FM 4-02.7 MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOR HEALTH SERVICE SUPPORT IN A CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR ENVIRONMENT (JULY 2009) - page 2

 

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FM 4-02.7 MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOR HEALTH SERVICE SUPPORT IN A CHEMICAL, BIOLOGICAL, RADIOLOGICAL, AND NUCLEAR ENVIRONMENT (JULY 2009) - page 2

 

 

actual medical casualties (the Goiania incident nonagent casualties outnumbered those
actually exposed to radiation
450:1). Commanders and HSS planners must have
procedures in place for CBRN casualty management. Effective care and management of
CBRN casualties require planning to treat large numbers of individuals as discussed in
Chapter III.
d. Planners must include a comprehensive, workable plan to decontaminate casualties
to be evacuated from the TO. Contaminated casualties must be decontaminated before
entering the strategic air evacuation system unless the CCDR and Commander, United
States Transportation Command (USTRANSCOM) direct otherwise.
e. When BW agents are a threat, decontamination, isolation, and processing
procedures must be in place to prevent the spread of contagious infections. Every attempt
should be made to contain contagious diseases within the AO. Adequate preplanning is
particularly critical when contagious casualties
(for example, smallpox or plague) are
anticipated. Preplanning coordination with USTRANSCOM on the use of air assets, and the
Department of State (DOS) for permission to fly contagious casualties over another nation’s
airspace, must be accomplished. Refer to Chapter IV of this manual; FM 8-284/NTRP 4-
02.23 (NAVMED P-5042)/AFMAN (I) 44-156/MCRP 4-11.1C; AFTTP 3-42.3; and AFTTP 3-
42.5 for more detailed information. The most current guidelines can be obtained from the
Commander, USTRANSCOM.
f.
The demand for PVNTMED and US Public Health Service (PHS) will increase
commensurate with the CBRN threat. Preventive medicine and public health personnel and
the command surgeon assist the CCDR in determining the health risks associated with
CBRN hazards, the safety of drinking water and ice, and the appropriate time for using
pretreatments, prophylaxis, immunizations, barrier creams, and other preventive medicine
measure (PMM). Preventive medicine and public health personnel must establish and
maintain medical and OEH surveillance programs. These programs are established before
deployment and continue after deployment.
To maintain combat effectiveness,
commanders and HSS personnel must continually evaluate capabilities and make
adjustments to conform to the CCDR’s priorities.
6. Preparation and Training for Chemical, Biological, Radiological, and
Nuclear Defense
a. Health service support encompasses a full spectrum of operational medical concepts
designed to establish future benchmarks for the military health system (MHS) challenges
delineated in Joint Vision 2020. Health service support is more than clinical medicine; it
involves enhanced methods of preventing casualties before, during, and after a military
operation. The tenets of FHP and HSS include—
(1) Emphasis on fitness, preparedness, and preventive measures.
(2) Improvements in monitoring and surveillance of threats and forces engaged in
military operations.
(3) Service members’ and commanders’ awareness of the health threat before it
can affect the force.
b. Medical readiness training is founded on the art of military medicine. The training
includes an understanding of how the combat environment (including CBRN) affects—
• Service members and the related preventive and clinical interventions required.
• Hazard exposures and regional diseases.
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15 July 2009
• Baseline clinical competence, including mass casualty management.
• Clinical knowledge and skills specific to combat-unique injuries, CBRN injuries,
and familiarity with platform-specific roles, supplies, and equipment.
• In addition to the training clinical skills in casualty management medical care
providers must be trained to survive in a CBRN environment.
• Medical planners must be trained to plan for operations in a CBRN environment.
• Collective training must include appropriate CBRN scenarios.
c. For more information on the efficiency and interoperability of medical support
planning for operations in CBRN environments refer to STANAG 2478.
7. Predeployment Procedures
a. Predeployment requires inclusion of detailed planning for FHP and HSS in a CBRN
environment. Health service support commanders and planners must look beyond
mobilization. They must be prepared to deploy their command at a short notice to a CBRN
environment and conduct their mission both in CONUS and OCONUS. They must project
the unit’s theater requirements and provide the required support. In preparing for
deployment, unit commanders should consider but not be limited to—
(1) Requesting information on the CBRN threat in the AO. Confirming all personnel
have up-to-date prescribed immunizations for CBRN threats and are physically fit for
deployment.
(2) Ensuring each person receives force health protection prescription products
(FHPPP) such as DOD-prescribed CBRN immunizations, prophylaxis, barrier creams, and
pretreatments.
(3) Ensuring personnel treat uniforms with approved insect repellent systems.
(4) Incorporating CBRN-related PMM into the standing operating procedure (SOP).
(5) Ensuring personnel have adequate personal hygiene supplies.
(6) Ensuring personnel have their chemical protective overgarment, gloves, over-
boots, protective mask, skin decontaminating kits
(SDKs), and individual equipment
decontamination kits.
(7) Distributing PVNTMED guidelines.
(8) Establishing a medical surveillance system.
(9) Establishing an OEH program.
(10) Ensuring units have authorized CPS systems and that personnel are trained on
their employment.
(11) Conducting just-in-time
(JIT) training on CBRN subjects according to the
projected operating environment.
(12) Ensuring commanders, as well as all deployable personnel, are trained in
Service-specific operational risk management methods.
b. Logistics requirements and sustainment operations are a critical concern to the
battlefield commander throughout the campaign. Deploying units must be self-sustaining for
a specified period of time after arrival within the theater. Pre-positioned logistics may
augment the supplies and equipment that accompany deploying units.
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c. Mobility strategy demands that forces are able to move personnel and materiel to the
scene of a crisis at a pace and in numbers sufficient to achieve quick, decisive mission
success. Air and sea lift users must supply a full and complete description of all air and sea
lift requirements in order for the USN and USAF to match transport assets against those
requirements. This is accomplished through the time-phased force and deployment data
(TPFDD) validation process. Medical planners must ensure CPS systems and medical
CBRN defense equipment are correctly reflected in the TPFDD. The TPFDD is the
supported CCDR’s statement of his requirements by unit type, time period, and priority for
arrival used in the joint mobility strategy. The TPFDD is both a force requirements
document and a prioritized transportation movement document. The TPFDD also defines
the CCDR’s nonunit-related cargo and personnel requirements to include civilians to sustain
his forces.
8. Predeployment Actions
a. The capability to defend against CBRN attacks and sustain combat operations in
CBRN environments requires forewarning and properly trained and equipped forces
throughout the theater. Casualty prevention initiatives using passive defense measures are
planned for early in the predeployment planning process. Passive defense measures
include consideration of the four Ss: Sense, Shape, Shield, and Sustain. Sense is action to
detect CBRN attack and include syndromic surveillance, clinical diagnosis, occupational and
environmental health surveillance and other medical indications and warnings. Shape is the
ability to form a medical or integrated CBRN COP and include CBRN casualty estimation,
health risk assessment, and medical asset and workload visibility. Shield is the ability to
protect personnel through vaccinations, pretreatments, collective and individual protection,
health risk education, and medical restriction and quarantine. Sustain is the ability to
recover and conserve the fighting strength through patient decontamination, treatment,
provision of psychological support, risk communication, and the application of medical
individual decon kits to include M291 Skin Decon Kits or reactive skin decon lotion (RSDL)
as well and medical unit operational and thorough decontamination.
b. The medical commander must ensure that the following actions are addressed
during the predeployment phase. For more information on predeployment health activities,
refer to DODI 6490.03.
(1) Medical Estimate of Situation. The HSS planner officer or noncommissioned
officer (NCO) or the designated medical intelligence officer, in conjunction with the medical
CBRN defense officer and the CBRN casualty management officer, will do the medical
estimate. Medical commanders will conduct predeployment vulnerability assessment of
PVNTMED concerns (validating NCMI-identified health threats). Assess vulnerabilities to
local food and water sources, potential epidemiological threats, local medical capabilities,
vector/pest threats, and hygiene of local billeting and public facilities. These assessments
will provide the necessary information to determine the initial force protection strategies and
resources required to mitigate risks to DOD personnel and assets.
(2) Casualty Prevention Measures (Shield). These actions must be done prior to
deployment:
(a) Immunizations:
• Department of Defense minimum requirements must be current (as
defined by the most recent Advisory Committee on Immunization
Practice vaccine-specific schedules) in tetanus-diphtheria, influenza,
hepatitis A, measles, mumps and rubella, and polio.
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15 July 2009
• Service-specific requirements. Refer to Army Regulation (AR) 40-562/
Bureau of Medicine and Surgery Instruction
(BUMEDINST)
6230.15A/Air Force Joint Instruction (AFJI) 48-110/Commandant, US
Coast Guard Instruction (CG COMDTINST) M6230.4F.
(b) Deployment-specific medical countermeasures. Based upon the geo-
graphical location, the CCDR will determine the need for—
• Additional immunizations
(for example, anthrax, meningococcus, or
Japanese encephalitis vaccine, smallpox).
• Chemoprophylactic medications (for example, mefloquine, chloroquine,
doxycycline).
• Other individual personal protective measures
(such as insect
repellent, insect netting, and uniform impregnation).
(c) Individual health assessment. Conduct predeployment health assess-
ments using the Department of Defense
(DD) Form
2795
(Pre-Deployment Health
Assessment) and ensure medical and dental requirements are current according to Service
policy, including—
Mandatory occupational health examination and training requirements
(for example, respirator exams and fit testing).
Dental Class I/II (refer to FM 4-02.19).
Significant health conditions (for example, medical profiles, pregnancy).
Collection of additional baseline biological samples as warranted by the
deployment health threat.
Human immunodeficiency virus (HIV) testing according to Service
policy or the supported combatant commander policy (serves dual pur-
pose: HIV screening and predeployment serum sample).
The most recent tuberculin skin test (TST) results must be documented
appropriately in the deployment health record. Currency (or periodicity)
of TST is established by Service-specific policies based upon analysis
of Service-unique risk factors. Thus, Service policies may permit more
than a 24-month period to elapse between TSTs.
(For previous puri-
fied protein derivative converters handle according to Service policy.)
Deoxyribonucleic acid sample on file. To confirm the unit/individual
status of DNA specimens on file, contact the DOD DNA Specimen
Repository (commercial telephone [301] 295-4379, facsimile [301] 295-
4380, or e-mail afrssir@afip.osd.mil).
Ninety to 180-day supply of prescription medications.
Required medical equipment (such as glasses, protective mask inserts,
hearing aids, or dental orthodontic equipment, and so forth).
Medical Record. Create or update the deployed medical record (DD
Form 2766 [Adult Preventive and Chronic Care Flowsheet]) with—
Blood type.
Medications/allergies.
Special duty qualifications.
Corrective lens prescription.
Immunization record.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
II-9
Completed DD Form 2795. Medical summary sheet identifying
medical conditions (such as glucose-6-phosphate dehydrogenase
[G6PD] deficiency, sickle cell trait, and so forth).
(d) Predeployment health threat brief. Provide information to deploying
personnel identifying health threats and countermeasures to include applicable
immunizations and other preexposure drugs such as pyridostigmine bromide.
(e) Medical CBRN defense briefing. Train all personnel in CBRN-related self-
aid, buddy care, and CLS skills to include immediate decontamination and the
administration of nerve agent antidotes, and the wear/care and inspection of protective
mask and clothing. Train all medical personnel in CBRN casualty triage and treatment.
Train WMD personnel in triage, emergency treatment in a CBRN environment, and how to
thoroughly decontaminate CBRN-contaminated casualties.
(3) Review of medical plans. All medical predeployment/deployment pertinent to
providing operational support (such as CCDR OPLANs, OPLAN Annex I, deliberate plans
from the beddown base, and CBRN passive defense plans) must be reviewed. This plan
will define how the medical force will arrive at the deployment location, set up, and achieve
initial operational capability (IOC) status.
(4) Coordinate service and support. Medical, civil engineering (CE), transportation
and logistics support personnel must work together to provide the base with a fully
integrated CBRN defense capability. The medical commander coordinates with CE
readiness support when integrating CBRN considerations into the beddown plan to prevent
duplication of effort. The medical commander and his staff coordinate with the logistics
planner to prioritize time-phased flow of medical materiel and personnel to accommodate
the most appropriate time to have resources and CBRN passive defense capabilities in
theater.
(5) Conducting risk assessments for all known health hazards in accordance with
JP 3-0., JP 2-01.3, and Service operational risk management guidance. Incorporate health
risk assessments into overall operational plans and specify requirements for risk control
decisions by the appropriate level in the command.
(6) Incorporating risk management and surveillance recommendations into the FHP
and HSS Appendix, Annex I (Medical) of the deliberate or crisis action plan.
9. Deployment Procedures
a. During deployment, commanders maintain vigilance to ensure CBRN preparedness
of their units that includes JIT training and individual and unit protective equipment
inspections. Refining the existing medical contingency response plan to reflect the current
mission, identification of CBRN threats and other factors will impact the health of the force
operating in a CBRN environment. Commanders must ensure—
(1) Up-to-date medical surveillance/documentation and OEH surveillance data in
accordance with applicable policies.
(2) Review of casualty prevention responsibilities, review of casualty care
responsibilities, review of decontamination capabilities and water supply for decontamination
and the review of resupply issues to include adequate supplies of antidotes,
anticonvulsants, bandages, mask filters, IPE for HSS staff and anticipated casualties, and
patient protective wrap (PPW) for anticipated casualties.
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15 July 2009
(3) Personnel must—
• Use work/rest cycles during the early stages of the deployment to become
acclimated to the AO (to include the ability to operate in MOPP Level 4),
mission permitting.
• Take prophylaxis and pretreatments as prescribed.
• Keep immunizations up to date.
• Use barrier creams (skin exposure reduction paste against chemical warfare
agents [SERPACWA]) when assuming MOPP Level 4.
• Use the insect repellent system.
• Practice good personal hygiene.
• Drink adequate amounts of water.
• Request PVNTMED support when needed.
• Practice good field sanitation processes or measures.
b. The supported CCDR will provide guidance and support to component commands
to—
(1) Develop individual protection and unit deployment policy for deploying
personnel to include which MCDM should be issued to individuals or to units in bulk.
(2) Develop policy on the storage and handling of bulk issued MCDM to ensure the
material remains effective throughout the operation. Each type of MCDM has unique
storage requirements needed to prolong its efficacy; however, storage considerations must
not outweigh the requirement for Service members to have the material available when
needed.
(3) Ensure subordinate medical activities conduct timely, standardized,
comprehensive surveillance, risk assessments, and prevention of health hazards.
(4) Ensure DOD health surveillance requirements are met for reporting and
archiving of health surveillance data and reports (DNBI, reportable medical events, and
OEH surveillance data). Ensure documentation in the individual medical records of all
individual health treatment provided at all Roles of care and any notable environmental and
occupational exposures. Special attention is needed to ensure individual exposure records
can be linked to individual health records.
(5) Ensure environmental health risk assessments are continuously reviewed and
updated throughout the deployment using data collected in theater. Significant newly
identified risks should be communicated to all appropriate organizations, including the DIA
through NCMI, combatant commands, Services, and Service occupational and
environmental health centers.
(6) The JTF/combatant command personnel readiness unit will ensure the Defense
Manpower Data Center is provided theater-wide rosters of all deployed personnel, their unit
assignments (company-sized or equivalent) and the unit’s geographic locations according to
the reporting requirements of DODI 1336.5. Accurate personnel deployment rosters are
required to assess the relative significance of medical disease/injury in terms of the rate of
occurrence among the deployed population. Without the means to identify the locations of
deployed personnel it will not be possible to accurately determine potential exposures to
HAZMAT and agents.
(7) Conduct pest control operations using the integrated pest management program
described in DODI 4150.07, DOD Pest Management Program. Document the types,
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
II-11
concentrations, amounts, application methods, dates and times, locations, and the
personnel potentially exposed to the hazardous substances. The DD Form 2766 is the DOD
standard form in the medical record for recording essential readiness indicators. This will be
the common location for minimum documentation by all Services, which may be
supplemented by other forms such as PHS Form 731 and Service-specific forms. The DD
Form 2766 will deploy with the individual.
10. Deployment Actions
a. The deployment phase consists of preattack, attack, and postattack postures. The
medical commander should be knowledgeable with the various capabilities of supporting
medical units that are assigned and available to the deployed location, as well as the
reachback capability of medical assets assigned to support the theater. The medical
commander should use all resources available to provide protective measures for all
assigned personnel and casualties. Detailed information on all phases of CBRN operations
is found in FM 3-11 (FM 3-100)/MCWP 3-37.1/NWP 3-11/AFTTP (I) 3-2.42 and AFTTP
3-42.3.
b. Preattack phase casualty prevention measures—
• Site selection.
• Health surveillance and DNBI reporting.
• Vulnerability assessments and surveillance plans.
• In-processing deployment Service members.
• Field hygiene and sanitation.
• Collective protection.
• Individual protective equipment.
• Medical sector CBRN detection and contamination control plan.
• Establishment of decontamination operations and HAZMAT waste areas.
• Coordination of logistics for adequate resupply of PPW (to include blower unit),
replacement mask filters, IPE, antidotes, anticonvulsants, and water supplies for
medical decontamination.
• Continued training of medical and WMD personnel in CBRN casualty
management.
• Preparation of hardened facilities depending on the threat condition.
• Coordination with CBRN staff for biological surveillance plan.
• Planning for sufficient patient movement item (PMI [ventilators]).
• Use of chemical agent detectors in patient treatment areas for unexpected
chemical casualties.
Note: Must use blower unit when using PPW.
c. Attack phase casualty prevention measures include—
• Alarm conditions.
• Donning of IPE.
• Understanding MOPP level.
• Operation of CPS.
• Knowing ATSO principles for an environment.
• Monitoring of CBRN JWARN.
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d. Postattack phase casualty prevention measures include—
• Surveillance for health risks and exposure symptoms requiring treatment.
• Detection of agents.
• Identification to determine the specific CBRN agent employed.
• Contamination avoidance.
• Continued protection measures.
• Contamination control/decontamination of personnel, equipment, supplies, and
food stores as indicated.
• Triage/treatment of CBRN and conventional casualties.
• Coordination of casualty disposition/evacuation.
• Disposition of contaminated equipment and supplies.
• Patient quarantine.
11. Actions Before a Chemical, Biological, Radiological, and Nuclear Attack
a. Given the disruption of transportation, communications, and operations during and
following a CBRN attack, it should be clear that preparation is the key to survival and
effectively providing HSS. Preparing a simple and complete tactical standing operating
procedure (TSOP) and FHP and HSS plan that integrates CBRN is the first step. Critical
training for medical personnel before a CBRN attack includes how to—
• Survive the attack individually and as a unit.
• Operate the Role 1 or Role 2 MTF in the environment.
• Effectively care for CBRN patients.
b. Even minimal site preparation
(nuclear hardening or chemical-biological
[CB]
protecting) may improve survival, greatly reduce contamination, and maintain the ability to
continue to provide HSS. The following discussion provides more information on each
environment.
As with other military personnel, HSS personnel must keep their
immunizations current; use available prophylaxis against suspect CB agents; use
pretreatments for suspect CW agents; use insect repellents; and have antidotes and
essential medical supplies readily available for known or suspected CBRN effects. The best
defense for HSS personnel is to protect themselves, their patients, and medical supplies
and equipment by applying contamination avoidance procedures. They must ensure that
stored medical supplies and equipment are in protected areas or in their storage containers
with covers in place. One method of having supplies and equipment protected is to keep
them in their shipping containers until needed. When time permits and warnings are
received that a CBRN attack is imminent or that a downwind hazard exists, HSS personnel
should employ their CPS (see Chapter XI) or seek protected areas (buildings, tents, or other
aboveground shelters for BW or CW attack; culverts, ravines, basements, or other shielded
areas for nuclear attack) for themselves and their patients. Other tasks include—
• Verifying CBRN defense FHP and HSS inventories are complete.
• Reviewing supported units CBRN plans, procedures, casualty collection points,
decontamination sites, and resources available to support the HSS mission.
• Coordinating with the intelligence staff officer
(S-2)/Army or Marine Corps
component intelligence staff officer (Army division or higher staff, Marine Corps
brigade or higher staff)
(G-2)/intelligence directorate of a joint staff
(J-2);
operations staff officer (S-3)/Army or Marine Corps component operations staff
officer (Army division or higher staff, Marine Corps brigade or higher staff) (G-
3)/operations directorate of a joint staff (J-3); logistics staff officer (S-4)/Assistant
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Chief of Staff for Logistics (G-4)/logistics directorate of a joint staff (J-4) of the
supported unit to develop the HSS COAs to obtain necessary materiel to support
extended operations without resupply (main supply route [MSR] contamination or
transportation support is not available).
• Coordinating with supported units for at least eight nonmedical augmentation
personnel to accomplish patient decontamination under medical supervision at
the Roles 1 and 2 MTFs. The USAF only coordinates for personnel support only
when not supported by an expeditionary medical decontamination team (EMDT).
The EMDTs will generally support a
10-bed or larger USAF Expeditionary
Medical Support (EMEDS) MTF in a CBRN environment.
12. Actions During a Chemical, Biological, Radiological, and Nuclear Attack
a. While it is possible that the CBRN attack will be a discrete short event, the more
likely scenario is the enemy will use CBRN throughout the conflict. The CBRN warning and
reporting system (CBRNWRS) will provide as much notice as is possible. Using the
information provided, HSS personnel will continue their mission by using the best available
protected areas. If warned of a CBRN attack, personnel should take up positions within the
best available shelter; and leadership will direct movement out of these positions when it is
safe.
For more information on CBRNWRS, see FM
3-11.3/MCRP
3-37.2A/NTTP
3-11.25/AFTTP(I) 3-2.56.
b. Redeployment procedures involve the transfer of units, individuals, or supplies from
one AO to—
• Another AO.
• Other locations within the area.
• Their home station/demobilization station for the purpose of further operational
employment.
• Demobilization.
c. Forces redeploy out of the operational area as quickly as mission, enemy, terrain
and weather, troops and support available-time available, civil considerations (METT-TC)
allow upon the achievement of objectives. However, the CCDR may have follow-on
operations or security concerns that require a well-planned sequence to the drawdown of
forces. The CCDR may order reconstitution operations to be completed prior to the
redeployment of all forces. The tactical commander must plan redeployment consistent with
the follow-on operational mission requirements. For more information on redeployment, see
JP 3-0 and JP 5-0.
d. Careful contingency planning that provides workable guidelines for the disposition of
casualties and remains must be conducted prior to the operation and prior to rotating troops
out of the AO. If BW agents have been used in the TO, redeployment planning must include
the health screening of troops before their movement out of the theater to prevent the
spread of disease. Planning must also incorporate close coordination with multinational unit
commanders, who have forces in the theater to ensure disease containment.
e. There are four phases to redeployment—
• Recovery, reconstitution, and redeployment planning activities.
• Movement to and activities at ports of embarkation.
• Movements to and activities at ports of debarkation.
• Reception, staging, onward movement, and integration (RSO&I).
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f.
Although many of the considerations for redeployment correspond to those for a
deployment, there are differences. During deployment, elements of a unit are configured for
strategic movement with the ultimate goal of reassembling the elements into an effective
force in theater. During redeployment, unless the unit is redeploying to a new theater, the
goal is to move forces home rather than building a force for theater operations. Therefore,
redeployment preparation involves reestablishing unit integrity and accountability of
personnel and equipment. In the reconstitution process, commanders reestablish the unit
by undoing organizational changes made to the unit for operations in the theater. The unit
may or may not redeploy to home station as a pure unit. Redeployment to new theaters
may require organizational modifications, as in the original deployment.
g. The CCDR must consider actions to attain specific CBRN-related objectives and
conditions particularly those associated with disabling or destroying enemy CBRN
capabilities. The CCDR must also ensure all personnel and equipment is decontaminated
before redeployment. Upon given notice from the CCDR, establishes when HSS
requirements and capabilities are drawn down or are no longer needed.
13. Actions After a Chemical, Biological, Radiological, and Nuclear Attack
a. After a CBRN attack, personnel should assess their own health status and those of
their subordinates. All personnel must survey their equipment to determine the extent of
damage and their capabilities to continue the mission. Initially, patients from nuclear
detonations will be suffering thermal burns or blast injuries. Also, expect patients and HSS
personnel to be disoriented. Nuclear blast and thermal injuries will immediately manifest;
most radiation-induced injuries will not be observed for several hours-to-days; however,
rudimentary assessment of radiation doses can be done by observing patient symptoms (for
example, time until onset of vomiting). Chemical warfare agent patients will manifest their
injuries immediately upon exposure to the agent, except for blister agents. Biological
warfare agent patients may not show any signs of illness for hours to days after exposure,
except for trichothecene mycotoxins. All patients arriving at Roles 1 and 2 MTFs must be
checked for CBRN contamination. Unit chemical defense equipment including Automatic
Chemical Agent Detector Alarm
(ACADA), improved chemical agent monitor
(ICAM),
AN/PDR-77 and AN/VDR-2 radiation, detection, indication, and computation (RADIAC) set
can be used for this purpose. In situations involving the rapid evacuation of casualties prior
to identification of CBRN contamination, these systems can be used as monitoring devices
in patient reception areas as they can be set to alarm when detecting contamination.
b. Patients are decontaminated before treatment (see Chapter V) to reduce the hazard
to HSS personnel, unless life- or limb-threatening conditions exist. Patients requiring
treatment before decontamination are treated in the EMT area of the patient
decontamination site (PDS). Examples of patient conditions that may require treatment at
the contaminated treatment station of the PDS are massive hemorrhage, respiratory
distress, and/or severe shock.
c. Incident reports
(including acute and/or catastrophic exposures to TIC/TIM and
CBRN warfare agents) with accompanying data must be accomplished—
• Initial reports must be made not later than 7 days after an incident or outbreak.
• Interim and final reports shall be forwarded not later than
7 days after
investigation and report completion.
• Combatant commands will forward copies of the reports to the
(Defense
Occupational and Environmental Health Surveillance (DOEHS) data portal for
archival.
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II-15
14. Other Chemical, Biological, Radiological, and Nuclear Defenses
a. It is advisable to assign PVNTMED and/or veterinary representatives to monitor the
breakout, preparation, and handling of food supplies in a contaminated environment. They
should also be involved in the monitoring of potable water supplies for contamination.
b. In a biological hazard environment, medical personnel are responsible for evaluating
biomedical samples for use in identification of the agent.
c. In radiological defense, medical personnel are responsible for recording the
accumulated radiological dose of each Service member, treating casualties from radiation
illness, and monitoring personnel who appear to have absorbed, inhaled, or ingested
radiological contamination.
d. Personnel may be given potassium iodide pills (as a pretreatment) if the fallout from
nuclear reactors is a threat.
15. Postdeployment Actions
a. The postdeployment actions consist of a continual monitoring for medical and OEH
surveillance and active collection of repository data. Actions will include—
• Completion of DD Form 2796 (Post-Deployment Health Assessment [PDHA]) for
exposures documentation.
• All environmental exposures should be highlighted and surveillance data stored
in the DOEHS Data Portal. Data must be sent and archived according to DODI
6490.03.
• Provider’s responsibilities to redeploying personnel by continuation of medical
treatment and documentation of casualties.
• Forwarding surveillance data to DOD as specified in DODI 6490.03.
• Disposition of contaminated equipment and supplies. Clean up of CBRN waste
from patient decontamination sites will need to be addressed during
decontamination operations and at their termination.
• Submission of FHP and HSS lessons learned in accordance with Service
requirements and the Joint Uniform Lessons Learned System.
b. Service members are identified in need of medical evaluation upon return to
home/processing station based on review of medical treatment received in theater, the post-
deployment health assessment form, and other pertinent health surveillance data. Reserve
Component (RC) members in need of a more detailed medical evaluation or treatment shall
complete DD Form 2697 (Report of Medical Assessment) and, with the Service member’s
consent, be retained on active duty pending resolution of his medical conditions as provided
in Section 12301 of Title 10, United States Code.
c. Medical debriefings are conducted with redeploying Service members on all
significant health events, CBRN and TIM exposures, and concerns (also identified on
postdeployment health assessments). Ensure these events and exposures are documented
in individual Service member’s health records. Medical debriefing ideally occurs within 5
days prior to departure from theater, but may be conducted within 5 days upon return to
CONUS/home station.
d. Significant OEH-related events/exposures are included in operational after action
reports
(AARs). This will include any disease outbreaks, location of TIMs sources,
contaminated sites (HAZMAT/wastes, CBRN, and other), presence of disease vectors, and
other operational factors that affected the overall health status (acute, chronic, or latent
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
effects) of the deployed Service members. Ensure AARs are provided to the intelligence
community (including NCMI) and Service centers for lessons learned to be incorporated into
future operational planning.
e. The Armed Forces Health Surveillance Center
(AFHSC) operates the DMSS
deployment health data repository. All deployment health surveillance information will be
forwarded to the DMSS for permanent archival and integration with DOD health information
systems. For more information on postdeployment health assessment, see DODI 6490.03.
Tri-Service reportable events guidelines and case definitions, blank pre- and
postdeployment health assessment forms, DNBI reporting forms, and DMSS contact
information are located on the AFHSC Web site at: http://afhsc.army.mil.
f.
Health service support commanders must accomplish the following at the home
station or processing station of the redeploying Service member—
(1) For deployments to high tuberculosis (TB) threat areas or operations, such as
those involving close contact with large refugee populations, conduct TB screening between
3 and 12 months after redeployment according to Service-specific requirements. For
deployments to low endemic TB threat areas, conduct TB screening according to Service-
specific policy. Interpretation of the TST results should be according to Service policy.
(2) Collect, when indicated by Service policy, a serum sample for HIV testing and
storage in the serum repository. Collect additional biological samples as warranted by the
events occurring in theater or postdeployment health assessment responses and
evaluations.
(3) Conduct additional health assessments and/or health debriefings when
indicated.
(4) Service members returning from a theater with deployment-related health
concerns will be evaluated using the Postdeployment Health Clinical Practice Guideline.
Health care providers should consult the DOD postdeployment health Web site,
http://www.pdhealth.mil, for further information on the clinical practice guidelines.
g. For postdeployment health reassessment, complete DD Form
2900
(Post-
Deployment Health Reassessment [PDHRA]) when required. A DD Form 2900 will be
administered to each redeployed individual within 90 to 180 days after return to home
station from a deployment that required completion of a postdeployment health assessment.
For individuals who received wounds or injuries that required hospitalization or extended
treatment before returning to home station, the reassessment will be administered 90 to 180
days following their return home. After the DD Form 2900 is completed, a trained health
care provider will discuss health concerns indicated on the form and determine if referrals
are required. Educate individuals on postdeployment health readjustment issues and
provide information on resources available for assistance. The original of the completed DD
Form 2900 must be placed in the deployed individual’s permanent medical record. Submit
copies of the completed DD Forms 2900 electronically to the DMSS. Services may require
submission of the forms to DMSS via their surveillance hubs.
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II-17
Chapter III
CASUALTY CARE AND MANAGEMENT
1. General
Operational casualty management strategies include effective care and efficient
management by HSS organizations. Organizations should be prepared to treat large
numbers of casualties in the event of CBRN weapon use. Casualties may include
combatants and noncombatants. Large numbers of individuals with psychological stress
reactions should also be expected. Each element of the medical evacuation and treatment
process must balance casualty care issues with the goal of conserving and restoring the
command’s combat capabilities.
2. Chemical, Biological, Radiological, and Nuclear Mass Casualty
a. Mass casualty is any large number of casualties produced in a relatively short period
of time, usually as the result of a single incident such as a military aircraft accident,
hurricane, flood, earthquake, or armed attack that exceeds local logistic support capabilities.
(Refer to JP 1-02 and FM 1-02/MCRP 5-12A).
b. With the employment of CBRN weapons/agents, a mass casualty situation can
present itself at any time and at any role of care. Treatment is often limited to life- or limb-
saving care and triage must be conducted within strict guidelines. It is important that all
patients be decontaminated before they are admitted into an uncontaminated area.
c. The roles of military units and organizations need to be defined for a successful
preparation, planning, and execution of decontamination operations.
(1) Individual responsibility. When a Service member becomes contaminated from
a CBRN attack, the following immediate decontamination procedures are carried out to
prevent him from becoming a casualty:
• Skin decontamination is a basic survival skill and should be performed
immediately by the individual or a buddy upon being contaminated.
• Personal wipe down should be performed as soon as possible (preferably
within 15 minutes of contamination). This is done to remove contamination
from individual equipment. Use detector paper or an ICAM to locate the
agent. Use a RADIAC set to locate radiological contamination and then
brush, wipe, or shake it off.
(a) Self-aid. Self-aid consists of measures that Service members can apply in
helping themselves. These include self-administration of antidotes (only for nerve agent
exposure) and assumption of the appropriate MOPP level.
(b) Buddy aid. Buddy aid consists of emergency actions to restore or maintain
vital body functions in a casualty who cannot administer self-aid. Mental confusion,
muscular incoordination, physical collapse, unconsciousness, and cessation of breathing
may occur so rapidly that the individual is incapable of providing self-aid. These actions
include—
• Decontaminating the casualty.
• Putting the remaining protective clothing on the casualty to preclude
further absorption of contamination through any exposed skin.
• Evacuating the casualty as soon as possible.
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III-1
(2) Contaminated unit responsibilities include—
(a) Operational and thorough troop/personnel decontamination is carried out
by contaminated units (with possible assistance from a decontamination unit). This may
include individual decontamination beyond the scope of immediate decontamination,
decontamination of mission-essential equipment, and limited terrain decontamination.
Operational and thorough decontamination reduces the level of contamination, thus
lessening the chance of spread and transfer. When combined with weathering, MOPP
levels may be reduced without further decontamination, depending on the surface or
material being decontaminated and the agent. See FM 3-11.3/MCRP 3-37.2A/NTTP 3-
11.25/AFTTP(I) 3-2.56 for more information on the decontamination of specific surfaces.
(b) The contaminated unit is responsible for setting up, operating, manning,
and closing the detailed equipment decontamination
(DED), detailed aircraft
decontamination (DAD), and detailed troop decontamination (DTD) area at the operational
and thorough decontamination site.
(c) The higher headquarters of the contaminated unit
(battalion, brigade,
division, or corps) will coordinate and provide nonmedical personnel augmentees to support
the medical unit/facility with patient decontamination. The USAF only coordinates with their
higher headquarters for support only when not supported by an EMDT. The EMDTs will
generally support a 10-bed or larger USAF EMEDS MTF in a CBRN environment.
(3) Chemical decontamination unit responsibilities include—
(a) Chemical, biological, radiological, and nuclear units
(battalion crew,
decontamination platoon) assist the contaminated unit with operational and thorough
troop/personnel decontamination. The CBRN unit determines the general location of the
DTD within the decontamination site and provides technical advice on setting up, operating,
and closing the DTD area. The supported unit is required to keep on-hand supplies to
conduct a DTD; however, the CBRN unit may supply the majority of the equipment and
supplies expended to conduct a DTD. The CBRN unit will be responsible for submitting a
complete CBRN 5 report after the site is closed.
(b) A supporting CBRN unit performs the DED or DAD. The DED and DAD
operations are conducted as part of a reconstitution effort during breaks in combat
operations. These operations require immense logistical support and are manpower-
intensive. The DED and DAD restore items so that they can be used without protective
equipment. As a safety measure, some Services require the use of protective gloves until
clearance decontamination has been completed. These operations require support from a
CBRN decontamination unit or element.
(4) Mortuary affairs responsibilities include—
(a) Mortuary affairs personnel are responsible for coordinating the disposition
of contaminated remains. This includes the decontamination of remains when required.
The joint mortuary affairs office acts as the theater central point of contact for coordination
for the mortuary affairs decontamination collection point (MADCP). Refer to JP 4-06 for
more information on the handling of contaminated human remains (HR).
(b) The CCDRs are responsible for searching for, recovering, tentatively
identifying, and evacuating remains from their areas of responsibility (AORs).
(c) Service component commanders are responsible for providing or arranging
for mortuary affairs support for their personnel.
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15 July 2009
(d) Subordinate commanders at all levels are responsible for the initial search
for, recovery, tentative identification, and evacuation of all deceased unit personnel within
their AO (see FM 4-20.64 and JP 4-06). If the threat of CBRN is suspected or present,
commanders will request MADCP support to perform recovery operations and the
subsequent decontamination of remains.
(e) The remains are placed in a CB HR pouch, if available, and care is taken
to minimize the spread of contamination. When a CB pouch is not available, the Type II-A
HR pouch should be used.
(f)
Mortuary affairs decontamination collection point responsibilities include—
• Establishing and operating the MADCP and adhering to the procedures
such as managing wastewater from decontamination operations and
ensuring adequate rest cycles are in place as outlined in JP 4-06.
• Coordinating to pick up contaminated remains from PDS, MTFs, and
troop DTD location for transport to MADCP.
(g) Personnel support is required after completing the evacuation mission to
the MADCP, such as thorough DTD. The conduct of detailed HR decontamination takes
about one hour per individual remains. The MADCP site will also receive support from a
supporting decontamination unit for a complete DTD or for decontamination of HR.
(h) When remains arrive at the MADCP without the DD Form 1380 (US Field
Medical Card [FMC]) or if it has not been reviewed and signed by a medical officer, the
MADCP will coordinate with the supporting medical company or the nearest MTF as
discussed in JP 4-06. The Armed Forces Medical Examiner (AFME) usually signs the DD
Form 2064 (Certificate of Death [Overseas]); however, current procedure in theater requires
the medical officer to sign the draft DD Form 2064 pending the AFME determination. The
AFME is currently located at Dover AFB instead of in theater.
Note: Transportation and handling of remains is a logistics function.
(5) Medical unit responsibilities include—
(a) Medical personnel supervise the patient decontamination operations. For
those MTFs not supported by an EMDT, augmentees from the supported units are usually
required to assist in the decontamination process and perform patient lifting and washing.
When a CBRN incident is expected, higher headquarters must plan, prepare, and
coordinate to augment the medical units with nonmedical personnel in support of patient
decontamination operation. Some basic information to consider when planning medical
CBRN support—
• Each Service has patient decontamination procedures, including
personnel and equipment requirements.
• Larger facilities, such as Roles 3 and 4, have more equipment and staff
to handle larger numbers of patients evacuated to them from smaller,
forward MTFs.
• No MTF is staffed to perform patient operational or thorough
decontamination while providing medical treatment.
• Patient treatment, patient evacuation and protecting its medical staff
from exposure to CBRN are the core mission of the medical personnel
during a CBRN incident.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-3
• Larger MTFs will require greater numbers of personnel as they will
need to process greater numbers of patients.
• Roles
1 and
2 medical units capable of conducting split-based
operations may collocate with CBRN decontamination units prior to an
expected CBRN attack. This allows the use of experienced CBRN
defense personnel to augment patient decontamination operations
prior to the arrival of units conducting operational or thorough
decontamination.
• In the US Army, the minimum number of personnel required for basic
PDS operation at a Roles 1 and 2 MTF is 8 nonmedical personnel and
20 nonmedical personnel at a Roles 3 and 4 facility.
(b) Additional personnel should be considered to allow for a work-rest rotation
of workers. These personnel are split into two categories to assist with either ambulatory
and litter decontamination.
(c) Medically trained personnel are located at the triage area, dirty side EMT
areas, litter and ambulatory decontamination areas, clean side of the hot line, and clean
treatment area.
(d) Patient decontamination must be performed by nonmedical personnel from
the supported units or units located within the base cluster or in vicinity of the MTF under the
supervision of the medical personnel (see Table III-1).
(e) Assigned medical units/personnel support the contaminated unit during
operational and thorough troop/personnel decontamination or DTD by providing medical
support to the site (see Table III-2).
Table III-1. Troop Decontamination Levels and Responsible Unit
Levels
Techniques
Responsible
Skin decontamination
Individual
Immediate
Personal wipe down
Individual/buddy
Operator wipe down
Individual/crew
Spot decontamination
Individual/crew
MOPP gear exchange
Unit
Operational
Battalion crew or
Vehicle wash down
decontamination platoon
Contaminated unit with
DTD
Thorough
assistance from CBRN unit
DED/DAD
Decontamination platoon
Clearance
Unrestricted use of
Supporting strategic resources
resources
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15 July 2009
Table III-2. Patient Decontamination Levels and Responsible Element
Levels
Techniques
Responsible
Immediate
Complete decontamination of
Individual/Buddy
(Patient)
contaminated areas of patient’s
MOPP prior to evacuation or RTD,
without removing MOPP.
Operational/
Decontamination at a PDS and
Augmentees supervised by
Thorough
treatment of conventional and
medical unit/personnel
(Patient)
chemical injuries at MTF prior to
transport using ground, water, and
air.
(6) The placement of the DTD or PDS depends upon METT-TC. The best scenario
is to collocate medical patient decontamination and nonmedical troop decontamination side-
by-side or in close proximity from each other for easy coordination. The PDS is for CBRN
casualties requiring medical treatment while the DTD is for CBRN casualties requiring
decontamination. Once it is determined that a CBRN casualty does not require medical
treatment at the PDS, this casualty is sent to the DTD and not through the PDS for
decontamination. Patient thorough decontamination involves decontamination procedures
for litter and ambulatory patients. This encompasses a series of specific steps for patient
medical stabilization, the removal of clothing, wash down, and mask removal before entry
into the MTF. There is no room or the time to take care of nonmedical casualties at the
PDS.
(7) The brigade level or equivalent is the lowest level that the DTD operation can be
effectively planned. However, decontamination support for other unique operational
organizations (for example, special operations forces) may require execution at a lower
level. The operation requires close coordination between the chemical officer, logistics
officer, command surgeon, and medical commander. The US Army field decontamination
equipment sets provide buckets, sponges, liquid soap, high test hypochlorite (HTH) for a
shuffle pit and hypochlorite solution preparation, litters, and litter stands. Decontamination
procedures are generally personnel- and labor-intensive operations.
(8) Afloat Casualty Treatment/Patient Decontamination. As with shore forces,
casualty decontamination should be performed separately from noncasualty
decontamination. A medical staging area or mass casualty area should be placed near the
decontamination area, but far enough away so that personnel will not be affected by any
contaminant.
3. Triage
a. Triage is the classification of patients according to the type and seriousness of illness
or injury. It must be remembered that triage refers to priority for medical or surgical care, not
priority for decontamination. Triage achieves the most orderly, timely, and efficient use of
HSS resources. However, the triage process and classification of CBRN patients differs
from conventional injuries.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-5
b. In CBRN mass casualty situations, the magnitude of the casualty situation will
necessitate that the conventional treatment priorities must be modified. This means a
radical departure from the traditional practice of providing early complete essential treatment
to each casualty on the basis of individual needs. For this concept of treatment, using
priorities designed to assist in providing the greatest benefit for the largest number of
patients without wasting specialist skill and medical resources, the following system of triage
is used (ID-ME):
(1) IMMEDIATE TREATMENT: To include those requiring emergency life- or limb-
saving surgery. These procedures should not be time-consuming and should concern only
those casualties with high chances of survival.
(Examples: respiratory obstruction,
accessible hemorrhage, and emergency amputation.)
(2) DELAYED TREATMENT: To include those badly in need of time-consuming
major surgery/resuscitation, but whose general condition permits delay in surgery/treatment
without unduly endangering life.
(Examples: Large muscle wounds; fractures of major
bones; intraabdominal and/or thoracic, head, or spinal injuries; uncomplicated major burns;
and some incapacitating effects of CBRN agents.) To mitigate the effects of often critical
delay in surgery/treatment, sustaining treatment (such as stabilizing intravenous (IV) fluids;
splinting; administration of antibiotics; catheterizations; gastric decompression; relief of pain;
and pharmacological and respiratory support for the effects of CBRN agents) is required.
(3) MINIMAL TREATMENT: To include those with relatively minor injuries who can
effectively care for themselves or who can be helped by untrained personnel.
(Examples:
Minor lacerations, abrasions, fractures of small bones, minor burns, and nonincapacitating
effects of CBRN agents)
(4) EXPECTANT TREATMENT: To include casualties who have received serious
and often multiple injuries, and whose treatment would be time-consuming and complicated
with a low chance of survival.
(Examples: Severe multiple injuries; severe head or spinal
injuries; large doses of radiation; widespread severe burns; and intractable CNS respiratory
effects of CBRN agents.) If fully treated, they make heavy demands on medical manpower
and supplies. Until the mass casualty situation is under control, they will receive supportive
care as allowed by manpower and resources available. Continued efforts to ensure their
comfort by use of appropriate doses of narcotic analgesics and retriage as more resources
become available is vital to manage these patients. The extent of treatment will depend on
available supplies and manpower and may involve the use of large doses of narcotic
analgesics. These casualties should not be abandoned, and every effort should be devoted
to their comfort. The possibility of survival should always be kept in mind, even with
alarming injuries. For more information on triage in a CBRN environment, refer to
Emergency War Surgery (Third United States Revision) and The Textbook of Military
Medicine, Medical Aspects of Chemical and Biological Warfare (Borden Institute).
c. Special categories of patients who do not easily fit into the above categories and
casualties who pose a risk to other casualties, medical personnel, and the treatment
facility—
(1) Retained, unexploded ordnance: these patients should be segregated
immediately.
(2) Enemy Prisoners of War (EPWs)/Detainees: although treated the same as
friendly casualties, it is essential that the threat of “suicide bombers” and “human booby
traps” be prevented by carefully screening all EPWs prior to moving into patient areas
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
including triage area. Refer to Field Manual-Interim (FMI) 4-02.46 for more information on
the medical treatment of detainees.
4. Mission-Oriented Protective Posture Levels
a. In a CBRN incident, not all casualties will be in MOPP gear. Military personnel will
likely care for civilians casualties. As MOPP levels increase, individual protective equipment
is added to the equipment worn at lower levels. Each increase in the MOPP level reduces
the time troops must take to attain MOPP-4 and full protection. When the threat of CBRN
use is high, commanders may establish a standing MOPP level (other than MOPP-0) for
troops during military operations. In the event of a CBRN attack, this effectively reduces the
time required to attain MOPP-4. The levels of MOPP are—
• MOPP Level 0—None of the protective clothing and equipment is worn, but it is
readily available.
• MOPP Level 1 (Suspected)—MOPP suit on (jacket and trousers), carry boots,
gloves, and mask.
• MOPP Level 2 (Possible)—MOPP suit on, boots on, carry gloves and mask.
• MOPP Level 3 (Probable)—MOPP suit on, boots on, mask on (with hood), carry
gloves.
• MOPP Level 4 (Imminent)—All MOPP gear on.
b. The protective overgarment and hood can cause body heat buildup, which can lead
to heat exhaustion in warmer weather. The protective mask and hood degrade the ability to
see, speak, and hear. The rubber gloves restrict air circulation and limit the sense of touch
and the ability to perform tasks requiring delicate manipulation. The wearing of full IPE or
personal protective equipment
(PPE) can cause psychological stress
(such as
claustrophobia) in some people. All of these problems can reduce the effectiveness of HSS.
Therefore, flexibility in adjusting the MOPP levels should be exercised to meet mission
requirements, environmental conditions, and the threat of CBRN exposure.
5. Civilian Casualties
Civilian casualties may become a problem in populated or built-up areas, as they are
unlikely to have protective equipment and training. Roles 1 and 2 MTFs may be required to
provide assistance when civilian medical resources cannot handle the workload. However,
aid to civilians will not be undertaken without command approval or at the expense of health
services provided to US personnel.
6. Taxonomy of Care
a. In JP
4-02, HSS offers seven distinctive and overlapping care capabilities that
enhance performance in a military force. These capabilities circumscribe the entirety of
HSS. They include the medical resources (personnel, materiel, facilities, and information)
and the organizational enabling capacity to deliver HSS. All seven care capabilities are
requisite to sustained health and are mutually supportive to that purpose. Each capability,
however, has unique attributes that can be identified, improved, and applied to attain the
desired well-being during a CBRN incident.
(1) Policy and Resource Acquisition Capability. All HSS CBRN capabilities are
dependent on sound policy and sufficient resource acquisition.
Policy provides
the framework from which the HSS community derives the direction and identifies the
requisite people, materiel, facilities, and information to promote, improve, conserve, or
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III-7
restore well-being. With policy as the guide, resource acquisition occurs through planning,
programming, budgeting, and disbursement of funds. This Title 10 United States Code
activity is foundational to the HSS community’s capability to organize, train, and equip
sustainment forces.
(2) Prevention and Protection Capability. Health service support can support the
warfighter in a CBRN environment by applying prevention and protection capabilities.
These capabilities are both wide-ranging and diverse and match the complexity of human
health needs. These capabilities are focused on the individual, while others are directed at
the Family, organization, or force. Additionally, the Services will develop and enforce
specific minimum standards; these standards will ensure Service members are free of
diseases or medical and dental conditions that are incompatible with expeditionary military
service.
(a) When focusing on the joint force, the medical portion of protection is
labeled FHP. It includes all measures taken by commanders, leaders, individual Service
members, and the MHS to promote, improve, or conserve the mental and physical well-
being of Service members across the range of military operations. These measures enable
a healthy and fit force, prevent injury and illness, and protect the force from health hazards.
(b) Members of the joint force have to be physically and mentally fit. This
requirement demands programs that promote and improve the capacity of the personnel to
perform military tasks at high levels under extreme conditions (for example, wearing of IPE)
and for extended periods of time. These preventive and protective capabilities include
physical exercise, nutritional diets, dental hygiene and restorative treatment, combat and
operational stress management, rest, recreation, and relaxation geared to the individual or
organization.
(c) Methods to prevent disease are best applied synergistically. Sanitation
practices, waste management, pest and vector control are crucial to protection from disease.
Regional spraying and the application of insect repellent to guard against hazardous flora
and fauna are examples of prevention methods. Prophylactic measures can encompass
human and animal immunizations, dental chemoprophylaxis and treatment, epidemiology,
optometry, counseling on specific health threats, and issuance of protective clothing and
equipment.
(d) Key to preventive and protective care is information the capacity to
anticipate the current and future health environment and its proper delivery to the affected
human population. Derived from robust health surveillance and medical intelligence, this
information addresses occupational, natural environmental, and enemy-induced threats from
industrial hazards; air and water pollution; endemic or epidemic disease; and CBRN and DE
devices/weapons. The HSS system must be capable of acquiring, storing, moving, and
providing information that is timely, relevant, accurate, concise, and applicable to the
intended human user. In summary, this information capability is crucial to HSS.
(3) First Responder Capability. More than any other care service; the first
responder capability is defined by its time requirements. It is this health care capability that
provides immediate medical care and stabilization to the patient in preparation for
evacuation to the next HSS capability in the continuum of care. This capability can offer
primary care outpatient services, emergent care services, medical subspecialty services,
and ancillary services.
(4) Forward Resuscitative Capability. This capability is characterized by the
capacity to perform advanced EMT as close to the point of injury as possible, to attain
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15 July 2009
stabilization of the patient, and to achieve the most efficient use of life- and limb-saving
medical treatment. The forward resuscitative care capability typically provides essential
care for stabilization to ensure the patient can tolerate evacuation. This capability covers
advanced emergency services, postsurgical inpatient services, surgical subspecialty
services, and ancillary services.
(5) Theater Hospitalization Capability. This capability delivers HSS via modular
hospital configurations and/or a hospital ship required to medically sustain forces in a
theater. This HSS capability involves hospitals purposely positioned to provide in-theater
support. Theater hospitalization capabilities deploy as modules or multiple individual
capabilities that provide incrementally increased medical services in a progressively more
robust theater. The theater hospitalization capability offers essential care to either return the
patient to duty (within the theater evacuation policy and/or stabilization to ensure the patient
can tolerate evacuation to a definitive care facility outside the theater.
(6) Definitive Capability. This capability is rendered to conclusively manage a
patient’s condition and is usually delivered from or at facilities in the homeland but may be
delivered in OCONUS facilities outside the homeland. For the Service member this care
capability normally leads to rehabilitation, RTD, or discharge from the Armed Forces. It
includes the full range of preventive, curative, acute, convalescent, restorative, and
rehabilitative medical care and it extends to the families of members of the armed forces
and Service retirees.
(7) En route Capability. The purpose of an en route capability is the continuation of
care during movement
(evacuation) within the HSS roles of care without clinically
compromising the patient’s condition. Patient movement involves transitory medical care,
patient holding, and staging capabilities during transport from the site of injury or onset of
disease, through successive capabilities of medical care, to an MTF that can meet the
needs of the patient. Each Service component has an organic patient movement capability
for evacuation from point of injury to initial treatment at an MTF.
(a) En route capability can take three forms. Casualty evacuation (CASEVAC)
involves the unregulated movement of casualties aboard ships, land vehicles, or aircraft.
Medical evacuation refers to dedicated medical evacuation platforms staffed and equipped
to provide en route medical care using predesignated tactical or logistic aircraft, boats,
ships, and other watercraft temporarily equipped and staffed with medical attendants for en
route care. Aeromedical evacuation (AE) specifically refers to USAF fixed-wing movement
of regulated casualties, using organic and/or contracted mobility airframes, with AE aircrew
trained explicitly for this mission.
(b) On today’s lethal battlefield, the reduced medical footprint forward, and the
evacuate and replace philosophy, place a high demand on the en route care capabilities of
all Services. Consequently, patient movement capabilities are even more critical than in the
past and Service medical elements must integrate with lift operations, as well as with the
associated capabilities of our Nation’s allies and coalition partners.
b. For more information on the taxonomy of care, refer to JP 4-02.
7. Roles of Care
a. The US military doctrine supports an integrated and capability-based health care
system to triage, treat, evacuate, and return Soldiers to duty in the most efficient time and
manner. The US Army uses roles of care (previously referred to as levels and echelons) to
denote differences in capability rather than the quality of care. Each role has the capability
of role forward of it and expands on that capability. The Army Medical Department
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III-9
(AMEDD) is using terminology of roles of care with some modifications on the definition to
meet US Army requirement. For information on the NATO definitions of roles of care, refer
to STANAG 2228/AJP-4.10 (A) and the Emergency War Surgery Handbook.
b. Role 1. Care consists of care rendered at the unit level. It includes self-aid, buddy
aid, and CLS skills, examination, and emergency lifesaving measures. Examples include
the maintenance of the airway, control of bleeding, prevention and control of shock, splinting
or immobilizing fractures, and the prevention of further injury. Treatment may include
restoration of the airway by invasive procedures; use of IV fluids and antibiotics; and the
application of splints and bandages. These elements of medical management prepare
casualties for RTD or for evacuation to a higher role of care. Supporting medical units are
responsible for coordinating the movement of patients from supported MTFs. The USMC
Role I capabilities include only first aid (self-aid, buddy aid) and emergency care provided by
a unit corpsman, battalion aid station (BAS), shock trauma platoon, and Marine wing support
group. In the USAF, the first two roles of care (Roles I and II) are normally provided at a
deployment location and emphasize self-aid and buddy care. Casualties become medical
patients when a medical diagnosis and treatment sequence have been determined.
c. Role 2. Care includes physician-directed resuscitation and stabilization and may
include advanced trauma management (ATM), EMT procedures, and forward resuscitative
surgery. Supporting capabilities include basic laboratory, limited x-ray, pharmacy, and
temporary holding facilities. Casualties are treated and RTD or are stabilized for movement
to an MTF capable of providing a higher role of care. Ground or air movement is
coordinated for transfer the patient to a facility possessing the required treatment
capabilities. Role 2 is the first role where Group O packed red blood cells (Rh+-) will be
available for transfusion. The medical battalion’s surgical company and the forward
resuscitative surgery system are the only units in the USMC that provide Role II care.
d. Role 3. Care is administered that requires clinical capabilities normally found in a
facility that is typically located in a reduced-level enemy threat environment. The facility is
staffed and equipped to provide resuscitation, initial wound surgery, and postoperative
treatment. This role of care may be the first step to restoration of functional health, as
compared to procedures that stabilize a condition to prolong life. Blood products available
may include fresh frozen plasma and Group A, B, and O liquid cells and may also include
frozen Group O red cells and platelets. The USMC care at Role III and above is provided by
other Services as determined by the JFC.
e. Role 4. In addition to providing surgical capabilities found at Role 3, this role also
provides rehabilitation and recovery therapy. Definitive care includes the full range of acute,
convalescent, restorative, and rehabilitation care and is normally provided in CONUS by
military and the Department of Veterans Affairs hospitals, or civilian hospitals that have
committed beds for casualty treatment as part of the National Disaster Medical System
(NDMS). On occasion, OCONUS military or allied/coalition and/or host nation hospitals
approved by the CCDR as safe havens may also be used. This role may include a period of
minimal care and increasing physical activity necessary to restore casualties to functional
health and allow them to RTD or to a useful and productive life.
8. Role 1 Health Service Support in a Chemical, Biological, Radiological, and
Nuclear Environment
a. When operating under a CBRN threat or when a CBRN attack is imminent, the MTF
must prepare for continuation of its mission. Should an attack occur or a downwind hazard
exist, the MTF must seek out a contamination free area to establish a clean treatment area
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
or must establish collective protection to continue the mission. Some MTFs have chemical
biological protective shelter (CBPS) systems. When available, these systems serve as the
primary shelter for the MTF; they are operated in the full CB mode when attack is imminent
or has occurred. See Chapter XI for information on establishing an MTF in a CBPS system.
When operating in the CB mode only patients requiring life- or limb-saving procedures are
allowed entry into the MTF. Patients that have minor injuries that can be managed in the
contaminated EMT area of the PDS will receive treatment in this area. Patients with injuries
that require further treatment, but can survive evacuation to the Role II MTF will have their
MOPP immediately decontaminated, their injuries managed, the integrity of their MOPP
restored, and be directed to an evacuation point to await transport to the Role II MTF. When
patients or personnel are contaminated or are potentially contaminated, they must be
decontaminated before admission into the clean treatment area (see FM 3-11.5/MCWP 3-
37.3/NTTP
3-11.26/AFTTP[I]
3-2.60 for personnel decontamination procedures and
Chapter V for patient decontamination procedures).
b. Select sites for Roles 1 and 2 MTFs that are located away from likely enemy target
areas. Cover and concealment is extremely important; they increase protection for
operating the MTF.
c. Operating a CBPS system in the CB mode at the BAS requires at least eight medical
personnel. The senior health care NCO performs patient triage, limited EMT, and minor
injury care in the PDS. One health care specialist supervises patient decontamination and
manages patients during the decontamination process. Two trauma specialists work on the
clean side of the hot line and manage the patients until they are placed in the clean
treatment area or are sent into the CBPS for treatment. They also manage the patients that
are awaiting medical evacuation to the Role 2 MTF. The physician, physician assistant, and
two health care specialists provide ATM in the clean treatment area or inside the CBPS.
See Chapter XI for CPS entry/exit procedures.
d. When Roles 1 and 2 MTFs are receiving CBRN contaminated patients, they require
at least eight nonmedical personnel augmentees from supported units to perform patient
decontamination procedures under medical supervision. These MTFs are only staffed with
medical personnel to provide patient care under conventional operational conditions.
Without the augmentation support, they can either provide patient decontamination or
patient care, but not both.
9. Role 2 Health Service Support in a Chemical, Biological, Radiological, and
Nuclear Environment
a. Role 2 HSS responsibilities include, but not limited to—
• Evacuating patients from the BAS and medical evacuation on an area support
basis from within the brigade sustainment area.
• Providing Role 1 medical treatment on an area support basis.
• Operating the medical company Role 2 MTF, which provides a patient holding
capability for up to
40 patients for
72 hours. See FM 4-02.6 for detailed
information on Role II conventional HSS operations.
• Providing limited dental service.
• Providing limited PVNTMED support in the areas of medical surveillance, OEH
surveillance, food service sanitation, water quality control
(including CBRN
contamination surveillance), and communicable disease control.
• Providing limited COSC; these patients are returned to duty as their condition
permits.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-11
b. In the division, corps, and echelons above corps (EAC), Role 2 MTFs are the same
as for the brigade, except patients may be evacuated from a forward Role 2 MTF, as well as
from a BAS.
c. When operating under a CBRN threat or when a CBRN attack is imminent, the
Role 2 MTF must prepare for continuation of its mission.
d. Forward Surgical Team (FST). Forward Surgical Teams are either organic to
divisional and nondivisional medical units or are forward deployed in support of divisional or
nondivisional medical companies to provide a surgical capability. Refer to FM 4-02.25 for
more information on FST operations. However, when forward deployed and CBRN
contamination is imminent, the FST must employ collective protection in order to continue its
support mission. When operating in a contaminated area, the FST CBPS system must be
complexed with the Role 2 MTF CBPS system. The FST cannot operate in a CBRN
environment without the support of the Role 2 MTF. They do not have the capability to
decontaminate patients. All patients are decontaminated in the Role 2 MTF PDS. They are
then processed into the EMT section of the Role II MTF, where they are triaged and routed
to the FST for surgery, if required.
10. Role 3 Health Service Support in a Chemical, Biological, Radiological, and
Nuclear Environment
a. Many factors must be considered when planning for Role 3 MTF support on the
integrated battlefield. The MTF staff must be able to defend against threats by individuals or
small groups (two or three) of infiltrators and survive CBRN strikes or TIMs incidents while
continuing their mission. This threat may include the introduction of CBRN or TIM in the
MTF area, the water or food supplies and the destruction of equipment and/or supplies. On
the larger scale of surviving CBRN strikes and continuing to support the mission, operating
in a contaminated environment will present many problems for hospital personnel. The use
of CBRN weapons or TIMs release can compromise the quality and quantity of health care
delivered by medical personnel due to the contamination at the MTF, constrain mobility and
evacuation, and contaminate the logistical supply base. While providing hospital support,
consider the following assumptions—
(1) Their location, close to other support assets, makes them vulnerable to CBRN
strikes and release/dispersion of TIMs.
• Command, control, communications, computers, and intelligence
infrastructure, logistical nodes, and base clusters are high value targets.
• Most CBRN weapons are designed for wide-area coverage. Chemical
warfare and BW agents may present a hazard some distance downwind
from the area of attack; also, residual radiation may extend for hundreds of
kilometers (km) from ground zero.
• The large signature (size, heat, or infrared) of a hospital makes it easy to
find and target (the assumption is that the hospital is very near the intended
targets).
• Medical treatment facilities located near road networks and airfields for
access to evacuation routes increase their exposure to tactical strikes of
CBRN weapons and exposure to TIMs releases.
(2) There are an ever-increasing number of countries and individuals with the ability
to manufacture and deliver CBRN weapons/agents. This activity increases their use
potential at all levels of conflict. Refer to Table I-5 for listed countries.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
Note: When using existing civilian hospitals, the materials for a RDD may be at
these hospitals. Exploding the material in place is very practical for a small
team of terrorists.
(3) In addition to the wounding effects of CBRN weapons on troops, their use will
have other effects upon the health care delivery system.
(a) Follow-on treatment may have to be delayed due to the need for patient
and facility decontamination.
(b) The arrival of contaminated patients at the MTF will require MTF personnel
to perform triage; administer EMT procedures in the patient decontamination area;
supervise augmentation personnel performing patient decontamination; and constantly
monitor the hospital for contamination. A Role 3 MTF requires at least 20 nonmedical
personnel from supported units within the geographic area/base cluster of the hospital to
perform patient decontamination under medical supervision.
(c) Patients may have been triaged and decontaminated at a Role 1 or Role 2
MTF. However, all patients must be triaged and checked for contamination as they arrive at
the Role 3 hospital ambulance drop off point. Triage ensures patients receive life- or limb-
saving care in a timely manner. If patients are arriving from a suspected CBRN
contaminated area, they must be decontaminated before admission into the clean treatment
area of the MTF. The patient decontamination area is established on the downwind side of
the MTF. When the MTF does not have collective protection, the patient decontamination
point must be at least 50 yards downwind of the hospital entry point. When the MTF is
located inside a base cluster, the patient decontamination area may have to be established
some distance from the MTF to prevent contamination of other units in the area. Should this
be the case, the patients may have to be transported by ambulance or other vehicle from
the clean side (hot line) of the patient decontamination area to the receiving point of the
hospital.
b. Medical treatment facilities are not kept in reserve. All HSS personnel and
equipment losses due to CBRN contamination or radiation will have to be replaced.
11. Management of Chemical, Biological, Radiological, and Nuclear Casualties
in a Medical Treatment Facility
a. Defense Planning Against Use of CBRN Weapons/Agents. Many factors must be
considered when planning for hospitalization on the battlefield. To the maximum extent
possible, MTFs are located away from tactical or logistical targets. The MTF staff must be
able to defend against a CBRN threat and survive CBRN strikes while continuing their
mission.
Note: Medical units should ensure that they have an ample supply of 7 mil butyl
rubber gloves available so that staff can continue to perform medical
procedures that require the ability to palpate and still have finger dexterity for
fine motor tasks.
b. Without a CBPS system, MTFs may operate for a limited time in a nonpersistent
agent environment, but are incapable of operating in a persistent agent environment.
(1) Chemical/biological filters will be a critical item of supply. Therefore logistics
activities must ensure that sufficient quantities of replacement filters are available or are on
order to meet mission requirements. Logistics will also be responsible for the safe disposal
15 July 2009
FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-13
of the filter and all of the contaminated equipment that cannot be decontaminated (tentage,
plastic sheets, blankets, linens, and contaminated uniform items).
(2) Liquid CW agents can penetrate the tent, extendable, modular, personnel
(TEMPER) in about six hours or the general purpose (GP) tentage in a shorter period of
time. These agents can penetrate the standard/packaging wrappings on medical supplies,
sterilized equipment and supplies, and medications/solutions that come in contact with
agent liquid, vapor, or contaminated dust. The vapor, liquid, and dust can also contaminate
open water/food supplies. It is critical that these items be in a covered area or covered
containers prior to an attack.
(3) Without a CPS, treatment procedures in an actively contaminated area involving
an open wound or the respiratory tract are limited. Exposing open wounds and the
respiratory tract can provide a route of entry for the CBRN agent. Without hardened
protection, the MTF, staff, and casualties are susceptible to the blast, heat, and missiling
effects of nuclear weapons.
(4) The MTF’s medical equipment is vulnerable to the effects of the EMP produced
by nuclear weapons. The EMP has no known harmful effects to humans, animals, or plants,
but is very damaging to electronic equipment. It is very difficult to decontaminate most
medical equipment. Decontamination may only be possible by aging (allowing the agent to
off-gas).
(5) Medical treatment facilities are not kept in reserve. All personnel and equipment
losses due to CBRN contamination will have to be replaced by out-of-theater resources. For
more information on CPS, refer to Chapter XI.
12. United States Marine Corps Operations Casualty Management
a. Casualty management in USMC operations poses some interesting challenges.
There are three scenarios
(shipboard, sustained operations ashore, and amphibious
operations) that must be addressed by USMC HSS resources.
b. Shipboard. Ships may become contaminated directly as a result of an actual hit or
nearby airburst. Clouds of vapor or aerosols which drift offshore may also contaminate
ships indirectly. Initial casualties, which will primarily be exposed deck personnel or
personnel within spaces contaminated by penetrating chemical munitions, should be moved
to a collection area where initial triage and hasty decontamination can be performed before
transfer to the ship’s medical department.
c. Sustained Operations Ashore. These operations are generally characterized by
established bases and logistical support.
d. Amphibious Operations. Casualties will be moved from the point of illness or injury
to different roles of care. Movement of the casualties may not progress through each role in
sequence. Depending on the tactical situation and degree of air superiority, casualties may
move from the point of illness or injury directly to Role III care. Nonambulatory casualties
should be placed in PPWs before transfer between roles. In the early stages of amphibious
operations, the assault force is extremely vulnerable because of the lack of established
support base ashore.
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15 July 2009
13. Protection of Medical Treatment Facilities
a. Use of Intelligence Data and Planning. Protection of MTF assets requires intensive
use of intelligence data and careful planning. The limited mobility of MTFs makes their site
selection vital to minimize collateral damage from attacks on other units.
(1) Medical treatment facilities must be located as close to the supported troops as
possible to provide responsive care. However, their limited mobility and a possible lack of
CPS systems must be considered when selecting their locations.
(2) Protective factors (distance from other units and interposed terrain features)
must be balanced against the operational factors
(accessibility and time required for
casualty transport).
(3) Regardless of the weapon system used, relatively large portions of any tactical
area will remain uncontaminated. Medical treatment facilities should avoid movement
through or operation in contaminated areas.
b. Planning for Defensive Measures. Many defensive measures will either impede or
preclude performance of the MTF mission. A successful MTF defense operation against a
CBRN threat is dependent on accurate, timely receipt of information via the CBRN reporting
system. This warning data will allow MTFs to operate longer without the limitations and
problems associated with MOPP use, and then adopt a defensive posture when absolutely
necessary. The detailed information on the areas affected and the types of agents used
allows the MTF staff to—
• Predict the number and types of casualties to be expected.
• Establish a casualty decontamination area.
• Request casualty decontamination assistance.
c. Protective Procedures. Because most MTF sections operate in sheltered areas
(tentage or ISO shelters), some protection is provided against vapor, liquid, and particulate
(fallout) hazards. Positioning equipment
(such as trucks) under trees or other cover
provides similar effects. Setting up MTFs in existing structures (concrete or steel buildings)
provides the maximum protection from hazards and eliminates many decontamination
problems.
Note: This paragraph implements STANAG 2931.
(1) Concealment and good operations security
(OPSEC) will help prevent
identification of a unit. However, camouflaging the MTF must be weighed against the loss of
Geneva Conventions protection. The NATO STANAG 2931 provides for camouflage of the
Geneva emblem on medical facilities where the lack of camouflage might compromise
tactical operations. Medical facilities on land, supporting forces of other nations, will display
or camouflage the Geneva emblem in accordance with national regulations and procedures.
(2) When failure to camouflage would endanger or compromise tactical operations,
the camouflage of medical facilities may be ordered by a NATO commander of at least
brigade level or equivalent. Such an order is to be temporary and local in nature and
countermanded as soon as the circumstances permit. It is not envisaged that large, fixed
medical facilities would be camouflaged. The STANAG defines medical facilities as medical
units, medical vehicles, and medical aircraft on the ground. Refer to STANAG 2931 and FM
4-02 for additional information.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-15
(3) Dispersion is a defensive measure employed by tactical commanders; however,
hospital operations limit the value of this technique. One technique that may be used is
locating sections of the MTF (such as the motor pool, personnel billets, laundry, and
logistical storage) further from the MTF complex than normal. This would increase
dispersion without severely compromising the HSS mission.
(4) The MOPP will not protect personnel from external gamma and neutron
radiation exposure. It will however protect personnel from external alpha particles and all
but most energetic beta particles. Standard MOPP Level 4 affords excellent radiological
contamination protection. Standard issue military protective masks (M-40 or equivalent)
provide excellent protection from inhalation and ingestion of radioactive material.
14. Chemical Environment
a. Consider that all patients generated in a CW agent environment are contaminated.
The vapor hazards associated with contaminated patients may require HSS personnel to
remain at MOPP Level 4 for long periods. The MTF must be set up in clean areas or
employ CPS. If there is liquid agent contamination or a continued vapor hazard, the MTF
should be moved and decontaminated, mission permitting.
b. Initial triage, EMT, and decontamination are accomplished on the dirty side of the hot
line.
Life-sustaining care is rendered, as required, without regard to contamination.
Normally, the senior medical personnel perform initial triage and EMT at the Role I MTF.
Secondary triage, ATM, and patient disposition are accomplished on the clean side of the
hot line. When treatment must be provided in a contaminated environment outside the CPS
the role of care may be greatly reduced because medical personnel and patients are in
MOPP Level 4. However, lifesaving procedures must be accomplished. See FM 4-02.285/
MCRP 4-11.1A/NTRP 4-02.22/AFTTP (I) 3-2.69; 8-500; and the Medical Management of
Chemical Casualties Handbook for specific treatment of CW agent patients. Decontami-
nation of most chemically contaminated patients and equipment requires the use of
materials that will remove and neutralize the agent. See FM 3-11.5/MCWP 3-37.3/NTTP
3-11.26/AFTTP(I) 3-2.60 for military equipment decontamination procedures and Chapter V
for specific casualty decontamination procedures.
WARNING
Cross-contamination of patients by decontamination
personnel can result in further injury to the patient.
Decontamination personnel handling patients must
not have been involved in decontamination operations
or be thoroughly decontaminated prior to handling
patients. Bleach requires contact time with agent for
complete neutralization dependent on the ambient
temperature. Ensure decontamination personnel have
waited a sufficient amount of time before handling
patients to allow for this contact time to neutralize
agent.
c. Chemical Protection.
(1) Individual protection. When CPS systems are not available, using the correct
MOPP level is essential in MTF mission performance. The level of MOPP assumed
depends upon the level of threat.
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15 July 2009
(a) An alternative approach for the MTF commander is the use of the mask-
only posture. This posture is acceptable when the hazard is from vapor only (such as
nonpersistent agents). Casualties and personnel in tents and expandable shelters are
protected from solid or liquid contamination (transfer hazards for a limited time). Personnel
can work efficiently and for longer periods in mask-only posture instead of MOPP Level 4.
However, the commander must weigh these factors against the potential contamination
transfer risk. This risk should be small, except in areas where casualties or materiel are
received from the outside. Individuals returning to or bringing materiel from the outside must
be extremely careful not to bring contamination into the mask-only area. When considering
this alternative, remember that except those casualties in PPW, the casualties must also be
at mask-only posture.
(b) Medical facilities must ensure that they have an adequate supply of new
replacement filters on hand for casualties as well as staff. Casualties who have gone
through decontamination will need to have their filters replaced immediately after
decontamination. Decontamination team members will need to have their filters replaced
frequently if they come in contact with large amounts of contamination. The MTF personnel
should plan for the safe storage and disposal of patient and medical staff’s contaminated
respirator filters.
(c) The MTF must have a warning system that alerts all personnel of
impending or present hazards. This system must include visual and auditory signals; the
signals must operate inside and outside of the MTF complex. There are numerous
problems associated with warning personnel; they include—
• The wide area covered by MTF operations.
• Some shift personnel will be asleep at all times of the day or night.
• The considerable noise from the power generation and environmental
control equipment.
• Tentage and equipment, which interrupts the line of sight.
(2) When the CBRN alarm is activated, all personnel (including off duty personnel)
report to their duty stations as soon as they are in MOPP. This allows for 100 percent
personnel accountability and provides additional personnel to secure casualties and
materiel.
(3) With all openings secured and the ventilation system turned off, the
nonchemically protected MTF is at its best posture. For nonpersistent agents (vapor
hazards), personnel and casualties stay at the designated MOPP level until the all clear
signal is given; then normal operations are resumed.
Note: Casualties with injuries that prevent them from assuming a protective posture
should be evacuated immediately to a clean treatment facility.
d. Casualty Protection.
(1) Casualty protection depends on prior planning and timely warning of the
chemical threat. Each casualty’s protective mask must be available and serviceable. If the
casualty came from a contaminated area, the mask must be decontaminated and the filter
changed. The mask decontamination and filter change may have to be performed by MTF
personnel. If ambulatory casualties’ medical conditions permit, they may be able to perform
this task. Check all masks for serviceability as soon as the mission permits, although this
should have been checked prior to deploying to the AO. Do not wait until the warning has
been received to begin checking the mask. Each area must have an established plan for
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-17
operations (to include assisting casualties assuming MOPP or other protective posture) in
the CBRN environment.
(2) Medical treatment facility personnel always mask themselves first and then
assist casualties in masking. On minimal care wards, most casualties can put on their own
masks. For those who cannot, other casualties can assist them after putting on their own
masks. On the intermediate care wards, some casualties will be able to put on their masks,
but many will require assistance.
(3) Many casualties with head and neck wounds or who are on life-support devices
will be unable to wear their individual protective masks; these casualties must be placed
in PPWs with blowers. While the PPWs have two ports for IV or blood infusion lines, the
staff may have to adapt for other devices (Foley® catheters, traction, and cardiac monitors)
by using tape and other means to seal the gaps created in the seal around the edge of the
PPW. Casualties requiring assisted ventilation are at extreme risk, unless their air supply
is protected. The sequence of protecting everyone is mask yourself first; assist those
patients who can wear their protective masks; and then place those patients who cannot
mask in the PPW. Specific treatment information for the treatment of radiological casualties
is found in FM
4-02.283/NTRP
4-02.21/AFMAN
44-161(I)/MCRP
4-11.1B, and the
AFRRI’s
Medical
Management
of
Radiological
Casualties
Handbook
(4) Materiel protection. Protection of materiel, especially expendable supplies,
requires covers and barriers. All materiel not required for immediate use is kept in shipping
containers, medical chests, or under cover (such as tentage, plastic sheeting, or tarpaulin)
for protection against particulate or liquid hazard. Protection against vapor hazard may
require multiple barriers through which the vapor must penetrate. For example, IV solutions
are in their individual plastic bags, in the cardboard shipping box, on a covered pallet, or in a
military van
(MILVAN). This presents four barriers against the vapor hazard. These
principles should be used to the maximum extent practical.
e. Environmental protection. As noted previously, the MTF offers some protection
against liquid or fallout contamination, but little protection against vapor hazards.
(1) When MOPP Level 2 posture must be assumed, close and secure all tent flaps,
vents, and doors to prevent the entrance of liquids or particles. All MTF personnel outside
of shelters assume command-directed MOPP level. Cover or move all equipment and
supplies into shelters if possible. Keep all equipment and supplies not immediately needed
covered or in closed containers.
(2) When MOPP Level 3 or mask-only posture is assumed shutdown the MTF
ventilation system if in a nonchemically protected facility to prevent drawing vapors or fallout
contamination into the MTF. This measure provides some protection of the internal
environment during the time required for the vapor to penetrate the tentage. For chemically
protected facilities keep the ventilation on to maintain positive airflow.
15. Biological Environment
a. A BW agent attack (such as the enemy use of bomblets, rockets, spray or aerosol
dispersal, release of arthropod vectors, and terrorist or insurgent contamination of food and
water) may be difficult to recognize. Airborne dissemination of BW agent exposure is the
likely means of delivery. While such agents may produce large numbers of casualties, initial
casualties may be seen at the MTF in small numbers. When a trend is identified, the use of
a BW agent may be suspected. General protective measures are the same as for any
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
infectious disease; specific protective measures are used once the vector or method of
transmission has been identified.
b. Designating a single MTF to care for these patients (from a casualty care or disease
transmission standpoint) may not be necessary. However, if there are a limited number of
cases, consolidating them all at one facility maximizes the use of limited diagnostic
laboratory and personnel assets. Biological warfare attack protective measures are the
same as the measures for CW agents when bombs, sprays, or aerosols are used. The
difficulty in rapidly identifying BW agents may force the use of higher levels of MOPP for
longer periods of time. Faced with this situation, a careful evaluation of the mask-only
posture is necessary before implementing any level of MOPP.
c. Quarantine, exposed personnel or isolation of casualties may be warranted in some
cases, particularly with infectious biological agent exposure. If these situations exist, then
quarantine and isolation procedures should be followed. For additional information, refer to
FM 8-284/NTRP 4-02.23/AFMAN (I) 44-156/MCRP 4-11.1C; AFTTP 3-42.3; AFTTP 3-42.22;
and current Air Force directives on isolation procedures.
d. Frequently, BW agent exposure does not have an immediate effect on exposed
personnel. All HSS personnel must monitor for BW agent indicators such as—
• Increases in disease incidence or fatality rates.
• Sudden presentation of an exotic disease.
• Other sequential epidemiological events.
e. Passive defensive measures
(such as immunizations, good personal hygiene,
physical conditioning, using insect repellents, wearing the protective mask, and practicing
good sanitation) will mitigate the effects of many BW agent intrusions.
f.
Health service support commanders and leaders must enforce contamination control
to prevent illness or injury to HSS personnel and to preserve the MTF. Incoming vehicles,
personnel, and patients must be surveyed for contamination. Ventilation systems in MTFs
(without CPS) must be turned off if BW agent exposure is imminent.
g. Decontamination of most BW agent contaminated patients and equipment can be
accomplished with soap and water. Soap and water will not kill all biological agents;
however, it will remove the agent from the skin or equipment surface. See Chapter V for
specific casualty decontamination procedures.
h. Treatment of BW agent patients may require observing and evaluating the individual
to determine necessary medications, isolation requirements, or medical management
procedures. See FM 8-284/NTRP 4-02.23 (NAVMED P-5042)/AFMAN (I) 44-156/MCRP 4-
11.1C and the USAMRIID’s Medical Management of Biological Casualties Handbook
[select
“download Bluebook
6th
Edition”]) for specific treatment procedures for BW agent contaminated patients.
i.
Medical surveillance is essential. Most BW agent patients initially present with
common symptoms such as low-grade fever, chills, headache, malaise, and coughing.
More patients than normal may be the first indication of BW agent attack. Daily medical
treatment summaries, especially DNBI reports, need to be prepared and analyzed. Trends
of increased numbers of patients presenting with unusual or the same symptoms are
valuable indicators of enemy employment of BW agents. Daily analysis of medical
summaries can provide early warnings of BW agent use, thus enabling commanders to
initiate preventive measures earlier and reduce the total numbers of troops lost due to the
illness. See Chapter 2 of this publication and DODI 6490.03 for information of medical
15 July 2009
FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-19
surveillance procedures. See Chapter VII for suspected specimen collection, packaging,
chain of custody documentation, and shipment to the supporting medical laboratory. See
FM 8-284/NTRP
4-02.23
(NAVMED P-5042)/AFMAN
(I)
44-156/MCRP
4-11.1C for
preventive, protective, and treatment procedures.
16. Nuclear Environment
a. The HSS mission must continue in a nuclear environment. Chemical, biological
protective shelters are essential to continue the support role. Well-constructed shelters with
overhead cover and expedient shelters (reinforced concrete structures, basements, railroad
tunnels, or trenches) provide good protection from nuclear attacks.
b. Most protective measures against nuclear attack require engineer and/or intensive
logistics support. This support includes placing sandbag walls around tents, digging
trenches for casualty occupation, or constructing earthen berms. Occupying existing
structures, depending upon their strength and potential flammability, may be the best
protection against the effects of a nuclear strike. Leaving equipment packed and loaded
until actually needed for operations will help protect materiel in a CBRN environment.
c. Personnel and casualty protection requirements will depend upon the threat.
(1) If the threat is nuclear fallout, the MTF structure provides protection; the fallout
can be brushed or washed off. This allows protection while permitting casualty care to
continue virtually uninterrupted. A need to relocate the MTF will depend upon the degree of
contamination, the amount of decontamination possible, and the projected stay before a
normal move in support of tactical operations.
(2) Medical treatment facility tentage alone offers little protection against blast and
missiling effects. If the casualties are to remain in the tents, they are placed on the floor.
Place all equipment on the ground or as low as possible and secure all loose objects. In GP
tents and TEMPER, sandbags can be piled around the base of the tent poles to add
stability. The tent poles and casualties cots/beds should keep the canvas off the ground
enough (if the tent collapses) to continue minimal casualty care.
(3) Medical treatment facilities are very susceptible to the thermal effect of a
nuclear detonation. Tents will not provide protection against the thermal pulse. If the
thermal effect (fires) is an impending threat, casualties and personnel in tentage must move
to trenches or other nonflammable areas.
d. Armored vehicles provide some protection against the blast and radiation effects of
nuclear weapons. Patients generated in a nuclear attack will likely suffer multiple injuries
(combination of blast, thermal, and radiation injuries) that will complicate medical care.
Nuclear radiation patients fall into three categories—
(1) The irradiated patient is one who has been exposed to ionizing radiation, but is
not contaminated. They are not radioactive and pose no radiation threat to health care
providers. Patients who have suffered exposure to initial nuclear radiation will fit into this
category.
(2) The externally contaminated patient has radioactive dust and debris on his
clothing, skin, or hair. This radioactive debris can cause burns if not removed quickly. This
usually presents a housekeeping problem to the MTF, similar to the lice-infested patient
arriving at a peacetime MTF. However, an accumulation of radioactive debris from several
patients admitted to the MTF may present a threat to other personnel. The externally
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15 July 2009
contaminated patient is decontaminated at the earliest time consistent with required medical
care. Lifesaving care is always rendered, when necessary, before decontamination.
(3) The internally contaminated patient is one that has ingested or inhaled
radioactive material or radioactive material has entered the body through an open wound.
The radioactive material continues to irradiate the patient internally until radioactive decay
and/or biological elimination removes the radioactive isotope. Attending medical personnel
are shielded, to some degree, by the patient’s body. Inhalation, ingestion, or injection of
radioactive material sufficient to present a threat to health care providers is highly unlikely.
e. Medical units operating in a radiation fallout environment will face three problems:
• The MTF may be immersed in fallout, requiring decontamination and relocation
efforts.
• Patients may continue to be produced from continued radiation exposure.
• The contaminated environment hinders medical evacuation operations.
f.
Decontamination of most radiologically contaminated patients and equipment can be
accomplished with soap and water. Soap and water will not neutralize radioactive material
however; it will remove the material from the skin, hair, or material surface. The waste can
become a concentrated point of radiation and must be managed and monitored. One way
to mitigate waste is coordinate with the CBRN officer and the supporting engineer unit to
construct containment areas for the contaminated wastewater.
17. Medical Treatment Facility Contamination Control
a. The MTF must designate a hot line that delineates the area of possible liquid
contamination
(between the hot zone and warm zone). Contaminated casualties are
evacuated across the hot line to the warm zone for triage and decontamination. After
decontamination, the casualties are moved across the hot line to the cold zone for continued
care and evacuation. The hot line (away from the MTF) is considered contaminated by
liquid agent. The patient decontamination site is located in this area. The area on the other
side of the hot line, near the MTF is considered the clean area and should be free from
liquid contamination. No individual is to cross the hot line until decontaminated. See
Chapter V for detailed information and for layout of the zones of contamination.
b. The hot line must be manned by personnel who can provide security to ensure that
contaminated individuals do not enter the clean treatment facility or clean treatment area.
c. Engineering controls, such as concertina wire or other sturdy fencing material should
be used when available to restrict travel across the hot line to the clean area, except through
guarded ECPs.
d. At these ECPs, casualties are checked for contamination using the ICAM/CAM, M8
paper, or other detection devices.
e. Providing emergency services will be complicated by several factors—
• Varying levels of treatment received prior to arrival at the MTF.
• Combined conventional wounds and CBRN agent effects.
• Heat-related complications associated with MOPP use.
• Increased numbers of psychological casualties who must be triaged quickly to
allow for treatment of those who need emergency management.
• The need to have EMT personnel at the patient drop off point for triage—
• EMT in the dirty area.
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III-21
• Care in the decontamination area.
• Triage and care at the hot line.
• Care in the MTF in the clean area.
• The potential of having to triage and provide casualty care while in MOPP gear.
• Reduced ability for EMT personnel to communicate between the various phases
of the decontamination/treatment process.
• The need to provide supervision/guidance to the nonmedical decontamination
augmentation personnel from the supported units.
f.
Contaminated casualties must be triaged in the decontamination area that is
established at the MTF. Contaminated casualties will not be brought into the clean EMT
area until decontaminated. All casualties are screened for contamination. Based on the
initial screening, the casualty is routed to the contaminated triage station or to the clean
triage station. Contaminated casualties are triaged, and then routed to the decontamination
area or to the contaminated treatment area. Casualty admission to the clean treatment area
may be delayed; however, life- or limb-saving care is provided in the contaminated
treatment area before decontamination.
g. The provision of general medical services in the MTF will be continued with minimal
interruptions in the CBRN environment. The noninvasive nature of these services allows
their continuation at most MOPP levels. General medical services will be constrained by
MOPP Levels 3 and 4 and the mask-only posture. Most of these constraints will be—
• Communication limitations.
• Loss of the oral route for administering medications to casualties.
• Limited ability to accurately evaluate the eyes, nose, and mouth of casualties
wearing a protective mask.
• Reduced ability to perform examination/assessment of casualties in PPW or
MOPP Levels 3 and 4.
• Inability to provide oxygen therapy or ventilator support to a casualty in a vapor
hazard environment, unless a CB filter mask is available.
• Logistics constraints based upon the fact that key areas such as dietetics,
supply, and laundry are not in inclined in the CPDEPMEDS. These services may
be reduced or delayed in the CBRN environment.
h. Surgical Services.
(1) Surgical services will be severely limited in the CBRN environment outside of a
CPS. At any level above MOPP 0, surgical services are halted if performed in an
unprotected, contaminated area except for life- and limb-expedient procedures. These
emergency procedures may be performed with limited contamination risk to the casualty if
performed in a relatively contamination-free area (such as an EMT area that has not been
contaminated by a CBRN attack) where MOPP gear is worn by staff only as a precautionary
measure. Surgery cannot be safely performed outside a CPS in a contaminated area due to
a variety of factors including—
• Lack of protected ventilation for casualties during and after surgery.
• Inability to maintain a sterile field while using MOPP gear.
• Direct access for the CBRN agent through open wounds to the circulatory
and respiratory systems.
• Decreased dexterity and vision resulting from MOPP gear use.
• Inability to quickly place the casualty in a PPW should the need arise.
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15 July 2009
(2) Due to the relatively high number of trauma cases, MTF services may be
severely constrained by CBRN contamination. The MTF location and the possible need for
hasty relocation are two major planning considerations for the commander and staff.
(3) Casualty accounting and medical regulating are critical factors in the transfer of
casualties from an MTF without CPS that must move out of a CBRN environment. Medical
treatment facilities without CPS should stop receiving casualties when a persistent hazard is
identified. Casualties should be transferred to a clean MTF.
i.
Nursing Services.
(1) Providing nursing care in a contaminated medical treatment area without CPS is
influenced by the amount of protective gear worn by the nursing staff and the casualties.
The casualties may be in MOPP gear, in a PPW, or wearing only their protective mask; any
of which will interfere with care. Nursing personnel may be at any MOPP level or in
protective mask only.
(2) Direct assessment of a casualty’s vital signs is extremely limited at MOPP Level
3 or 4; however, a carotid artery pulse can be taken by palpating the neck area. The
casualty’s respiratory rate and level of consciousness may be assessed visually. Palpitation
of the blood pressure through a PPW may be possible if it is relatively strong or at least in
the normal range. The casualty’s temperature cannot be monitored; this is an area of
concern due to the possibility of heat stress.
(3) Only gross neurological signs can be assessed through the PPW. However,
even this assessment is complicated by the presence of miosis and by the health care
provider’s mask. Cardiac and urinary output monitoring is continued uninterrupted for
casualties wearing a mask only and for casualties in the PPW.
(4) Oral hygiene and bathing are postponed until a safe environment is available
(MOPP Level 2 or less). All toileting will occur within the MTF complex using a bedpan, a
urinal, a bucket, a container with a plastic liner, or a chemical toilet.
(5) At MOPP Level 3 or 4, feeding must be postponed. A nutritional assessment is
needed to determine how long each casualty can tolerate a fasting state when the MOPP
Level 3 or 4 remains for over 24 hours.
(6) Intravenous medications are mixed in a CPS area or in a clean area and then
transported in a protective wrap (such as multilayers of plastic, medical chest, or layered
cardboard) to the user. However, IV solutions, blood, and injections can be given to
casualties in an unprotected ward. Normally, oral medications are only given at MOPP
Level 2 or lower.
(7) Treatment procedures that have the potential of contaminating the casualty’s
pulmonary or circulatory systems are conducted only at MOPP Level 2 or below. However,
EMT procedures may have to be performed in the contaminated treatment area or the
casualty decontamination area.
(8) Continuous oxygen therapy requires a collective protection environment or a CB
filter-supported respirator.
(9) Delivery of nursing care at MOPP Level 3 or 4 is limited due to the sensory
restrictions of MOPP gear. Time is taken to reassure the patients on a personal basis, as
much as possible, and by routinely monitoring the ward environment. Communications are
difficult and identities are masked. Use of handwritten name tags for staff and casualties
(including casualties in PPW) is required to ensure the identity of all personnel.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-23
(10) As with all procedures, the time required for recordkeeping rises markedly at
MOPP Level 3 or 4. Contaminated paperwork cannot be evacuated with the casualty.
Transcribe essential information onto uncontaminated documents for evacuation with the
casualty. A record of casualty exposure time to a contaminated area is prepared to assess
the cumulative risk to the casualty.
(11) Dressing changes cannot be performed while the casualty is in a PPW or at
MOPP Level 3 or 4.
(12) Chest tubes and nasogastric tubes in a contaminated environment should be
managed in a way similar to the administration of IV fluids. Casualties with these tubes will
require close monitoring.
(13) Nursing staff should be monitoring the patient’s psychological status.
Casualties may require additional monitoring for stress reactions when placed in a PPW or
MOPP suit.
j.
Dental Services.
(1) General. Dental service support is provided at the AO at Roles 2, 3, and 4.
Since dental units have a bigger footprint and are collocated with other support assets, they
are vulnerable to a CBRN strike. The CBRN operations have an impact at all levels; thus,
dental units must be prepared to survive on the integrated battlefield. Defense against
CBRN weapons must be included in the dental unit’s SOP. Individual and collective tasks
must be intensely trained on a regular basis. Survival depends on the ability of personnel to
use basic survival skills against a CBRN attack.
(2) Mission in a CBRN Environment. The overall mission of dental units to provide
dental services is greatly affected in the aftermath of a CBRN attack. First, the unit must
survive the attack and rapidly recover from its effects. Secondly, in the event of mass
casualties, care must be redirected to the alternate wartime role of augmenting the adjacent
MTF. Dental units do not posses CPS therefore, providing dental services in a CBRN
environment will be limited to treatment of maxillofacial emergencies requiring immediate
attention. This care will be provided at an MTF in a CPS.
(3) Dental Treatment Operations. As a general rule, in the aftermath of a CBRN
attack, dental treatment operations will cease until deliberate decontamination of the unit
and its equipment has been accomplished. Only maxillofacial injuries, of an immediate life-
threatening nature, should be treated. After a CBRN attack, the resources of the dental unit
are redirected toward support of any mass casualty situation that may have been generated
at an adjacent MTF or toward decontamination and relocation to a noncontaminated area.
Although the likelihood to treat dental patients in a CBRN environment is extremely low,
dental units must have plans for providing dental services.
(4) Patient Decontamination.
Decontamination of patients is an absolute
requirement before admission into a clean MTF or dental facility. Contaminated patients are
triaged and decontaminated before treatment (except for life- or limb-saving care). Both
triage and decontamination should be accomplished as far forward as possible. Specific
details on patient decontamination are in Chapter V. It is important to note that medical or
dental personnel do not normally perform patient decontamination.
Immediate
decontamination at the basic skill level is accomplished in place or at the casualty’s unit.
Thorough patient decontamination is accomplished by the patient decontamination teams
(made up of nonmedical personnel
[augmentees] from the supported units) that are
supervised by medical personnel at the MTF. For more information, refer to Chapter V.
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15 July 2009
(5) Patient Decontamination at Dental Treatment Facilities (DTFs). Neither dental
units nor their DTFs are equipped for patient decontamination. Contaminated patients
arriving at a DTF requiring urgent attention must be directed or evacuated to the nearest
MTF with a patient decontamination capability.
(6) Patient Protection Status. Dental treatment facilities must also consider the
need to protect patients in their care in the event of a CBRN attack or when the threat of an
attack is high. Special consideration must be made for maxillofacial patients whose
condition prevents them from wearing protective masks.
(a) Immediate Response. In the event of an attack or when the alarm sounds,
dental providers and patients immediately cease work and mask. Only after putting on their
own mask, do the dental treatment providers assists the patient, if necessary, by removing
material that impede the patients masking. Only those materials that impede masking or
may compromise the airway (such as rubber dam frames or impressions) are removed. The
rest are left in place until the all clear is sounded. Special attention must be given to
medicated patients in less than a fully conscious state or that are incapacitated.
(b) Mission-Oriented Protective Posture Considerations. The MOPP level
should be taken into account when determining the category and extent of dental treatment.
Patients should be at the MOPP level prescribed for the dental facility by its parent
headquarters. Dental treatment at MOPP Levels 3 and 4, of course, is impossible because
of the requirement to wear the protective mask. However, treatment is still possible at
MOPP Levels 0, 1, and 2. Treatment at MOPP Level 2 should be limited only to emergency
care requiring urgent attention. At MOPP Level 1, most types of dental emergencies can be
accommodated. However, only minimal essential treatment should be undertaken to reduce
the risk of the patient being caught in a compromised state. At MOPP Level 0, the provision
of dental treatment generally is not limited. The degree of the CBRN threat forecast for the
area should be considered before undertaking extensive treatment.
(c) Oral and Maxillofacial Injuries. Patients with maxillofacial injuries that
prevent proper fit and seal of the individual protective mask must be placed in a PPW.
Though patients with these types of injuries are most likely found in MTFs, DTFs should
nevertheless be prepared for patients presenting to the DTF. Since the DTF does not have
any PPWs, these patients should be immediately evacuated to the adjacent MTF for
treatment.
18. Medical Treatment Facility Decontamination
a. The decontamination of MTFs and mission-essential surfaces and equipment
requires a well-thought-out process. Fixed-site decontamination capabilities must be
planned, coordinated, tested, and adapted for each MTF prior to a CBRN incident. Mobile
decontamination equipment capabilities may be available at a fixed site to decontaminate
buildings, equipment, roads, ramps, and helipads. Loading docks, entries and exits, and
building exteriors can be decontaminated with more conventional methods such as using
super tropical bleach (STB) and soap and water. Commanders should identify all systems
that are capable of contributing to the decontamination effort (for example, water hydrant,
fire hoses, fire trucks, steam cleaners, and water pumps). The commander should
designate and train teams that can perform decontamination for fixed-site operations.
b. The decontamination of an MTF consists of two parts: interior and exterior.
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
III-25
(1) Interior. When conducting decontamination of the interior of an MTF, the
following activities must occur—
• Secure the area or facility.
• Sample to confirm and determine the extent of the contamination.
• Evaluate the sampling results.
• Isolate the areas to prevent the spread of the contamination.
• Remove critical objects for special decontamination procedures.
• Ensure that contamination is not spread or transferred during movement.
• Decontaminate localized areas of the contamination.
• Properly manage the contaminated waste from the decontamination
process.
• Continue monitoring and protecting against low-level exposure risks.
• Document and record the decontamination operations.
(a) Medical Equipment. Moisture, dust, and corrosive decontamination
materials can damage unsealed electronic equipment circuitry (such as x-ray machines,
electrocardiogram, or respirators). Most field electronic equipment is watertight for
environmental protection which provides good protection against CBRN contamination.
Contamination will probably not penetrate gasket-equipped protective covers and sealed
components on electronic equipment; but if exposed, the contaminants may be present on
the outside of cases containing the electronic equipment. The outside portions of the
equipment case must be wiped down with a designated decontaminant. After
decontaminating the outside, the equipment must be wiped down with water or an approved
solvent to remove traces of decontaminant solutions. If equipment seals appear damaged
or the penetration of CBRN contamination into the inside of the equipment is suspected,
then the unit should be treated as if it was unsealed. Under no circumstances should
electronic equipment be immersed in a decontaminant solution or subjected to high-
pressure application of decontaminant solutions.
(b) Optics. Optical systems are extremely vulnerable to decontamination
materials that might scratch or adversely affect the lenses. Wipe optical systems with a soft,
nonabrasive material such as a lens-cleaning tissue, cotton wadding, or a soft cloth dipped
in hot, soapy water. Wipe the optical system with decontaminants. Do not immerse it.
(c) Medical Supplies. Some medical supplies tend to absorb CW agents and
may not be decontaminated and reused. Decontamination is difficult. It may be necessary
to burn or bury them if they are heavily contaminated with a CW agent. Either STB dry mix
or slurry may be used. Slurry is more effective. In many cases, weathering and rinsing with
soap and water may be the preferred decontamination technique if the medical supplies are
sealed. If the nonexpendable medical items
(such as surgical instruments) must be
decontaminated, boiling for
1 hour in soapy water is the preferred decontaminant for
chemical and biological contamination. Radioactive contamination can be removed by
brushing and then washing. It may also be vacuumed. If CBRN protective covers (tarps or
poncho) were used to protect the medical supplies from contamination during a CBRN
incident/attack. These covers should be decontaminated, buried or destroyed after use.
(2) Exterior. Many materials may absorb contamination and may not be completely
decontaminated. The removal or sealing (painting) of these surfaces may be required to
reduce the hazard. Continue monitoring the decontaminated surfaces until the detector
indicates there is no more off-gassing. As temperatures rise, off-gassing of previously
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FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009
contaminated surfaces may occur at detectable levels. A point detection device
(for
example, ICAM/CAM) should be used to monitor contaminated surfaces.
(a) Structures. Wood and concrete tend to absorb liquid agents and they may
give off toxic vapors for days or weeks. Building decontamination is very difficult and
requires large quantities of decontaminants. Covering the contamination with plastic sheets,
STB slurry, sodium silicate, or other substances that cover or absorb the agent can reduce
the hazard. Even though a particular part of a building is not intended for occupation, it may
still need to be decontaminated to prevent the contamination from spreading.
(b) Ramps, roads and helipads. Ramps, roads and helipads also absorb liquid
agents and then give off toxic vapors when heated by the sun. These surfaces may need to
be decontaminated several times to reduce hazards. Streets, sidewalks, or other porous
surfaces are best decontaminated by weathering if the time and the situation permit.
(3) Weathering. Weathering can increase the evaporation of liquid contamination.
In a hot, sunny environment, at least
99 percent of the contamination would have
evaporated within a few hours. Therefore, external building wash down may not be
necessary. As a result, vapor concentrations will be high but should not last long. If liquid
contamination soaks into soft, porous soil (such as loose sand), evaporation is not as quick.
Strong winds also increase the evaporation rate. Low temperatures during the night have a
reverse effect and tend to increase the persistency of chemical and biological
contamination. The sandblasting effect of sandstorms may remove contamination from
surfaces facing the storm. Sunlight and high temperatures will destroy many CB agents
without additional decontamination measures if time permits. Rain can help the
decontamination process by washing away contamination on exposed surfaces. Rain can
also hydrolyze some agents. However, runoff may contaminate the soil. For more detailed
information on fixed facility decontamination procedures, types of contamination and how to
decontaminate them, and decontamination of specific surfaces and materials, refer to FM 3-
11.5/MCWP 3-37.3/NTTP 3-11.26/AFTTP(I) 3-2.60 and FM 3-11.4 (FM 3-4)/MCWP 3-
37.2/NTTP 3-11.27/AFTTP (I) 3-2.46.
19. Training and Exercises
a. Individual and joint unit decontamination training across the force ensures the
readiness to fight and win should an adversary employ CBRN weapons. Training is a
responsibility shared by combatant commands, Services, and a number of DOD agencies.
Training and exercise programs must incorporate the principles for operations in CBRN
environments and include realistic consideration of CBRN weapons effects on sustained
combat operations.
b. Training opportunities exist both internally and externally and should include the
following:
• Initial and sustainment training.
• Individual, collective, and unit training.
• Intraagency and interagency training.
c. Exercises provide the opportunity to interact with other units or services and federal,
state, or local agencies. Exercises developed by non-DOD agencies provide an opportunity
to improve military capabilities for support of homeland security operations with minimal
resources. These exercises emphasize interoperability requirements and stress staff
coordination. They also serve to identify shortfalls in communications or other capabilities
that must be corrected.
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III-27
20. Restriction of Movement, Isolation, and Quarantine
a. To prevent the spread of an infectious disease or contagious illness, public health
authorities use different strategies. Three of these strategies are: restriction of movement
(ROM), isolation, and quarantine. These are common practices in public health and aim to
prevent and control exposure to potentially infected or infectious persons. These measures
may be voluntarily, implemented or be a directive by public health authorities or by military
commanders.
b. The three strategies differ in that ROM restricts persons to stop the spread of illness;
isolation applies to persons who are known to have an illness; and quarantine applies to
those who have been exposed to an illness but who may or may not become ill. During a
declared public health emergency, a commander, in consultation with the public health
executive officer, may exercise special powers relating to persons necessary to prevent the
spread of communicable diseases. To the extent necessary for protecting or securing
military property or places and associated military personnel, such special powers may also
include persons other than military personnel who are present on a DOD installation or other
area under DOD control. For more information, refer to DODI 5200.8.
(1) Restriction of Movement. The ROM refers to potentially infected persons and
the restriction of their movement to stop the spread of that illness. Restrictions of movement
may be implemented to prevent the spread of communicable diseases. In the case of
military personnel, restrictions of movement, including isolation or quarantine, or any other
measure necessary to prevent or limit transmitting a communicable disease may be
implemented. In the case of persons other than military personnel, restrictions of movement
may include limiting ingress and egress to, from, or on a military installation.
(2) Isolation. Isolation refers to the separation of persons who have a specific
infectious illness from a healthy population. Isolation allows for the target delivery of
specialized medical care to people who are ill, while protecting healthy people from getting
sick. Infected people in isolation may be cared for in their homes, in hospitals, or in
designated MTFs. Isolation is a standard procedure used in hospitals for patients with TB
and certain other infectious diseases. Although in most cases, isolation is voluntary;
however, many levels of government (federal, state, and local) especially the DOD have
basic authority to compel isolation of sick people to protect the public.
(3) Quarantine. Quarantine refers to the separation and ROM of persons who,
while not yet ill and have not shown signs and symptoms of the disease, have been
exposed to an infectious agent and therefore may become infectious. Quarantine involves
the confinement and active, continued health surveillance of an individual who is suspected
of having been exposed to an infectious agent until determined that they are free of
infection. Quarantine is medically very effective in protecting the public from disease.
(4) Protective Sequestration. Protective sequestration is a form of reverse isolation
where uninfected Service members are isolated from the infected population or
contaminated environment as a tactical or strategic reserve. Protective sequestration is a
measure or option that commanders may use after a CBRN incident.
21. Worried Well
a. During a CBRN incident, many people are fearful of having been exposed to a CB
warfare agent, even though they are either at very low risk or have tested negative for
exposure. The common term used to describe people in this situation is worried well. This
term generally refers to people who are worried (or convinced) that they have been exposed
III-28
FM 4-02.7/MCRP 4-11.1F/NTTP 4-02.7/AFTTP 3-42.3
15 July 2009

 

 

 

 

 

 

 

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