,,transcriber',s ,,note ,italic text is denoted by underscores4 ,blank space in some sample documents in the text is also denoted by 4 ,bold text is denoted by equal signs4 ,superscripts are denoted by eg abc,,tm4 ,subscripts in chemical formulae are denoted by eg ,,co#b4 ,footnotes are all within a specific ,table1 including the ,table of ,contents4 ,they are positioned at the bottom of that ,table1 as in the original text1 and are denoted by 99 or 99994 ,obvious punctuation errors have been corrected after careful comparison with other occurrences within the text and consultation of external sources4 ,more detail can be found at the end of the book4 ,,fm #d-jb4g 7,,fm #h-aj-g7 ,,health ,,service ,,support ,,in ,a ,,nuclear1 ,,biological1 ,,and ,,chemical ,,environment ,,tactics1 ,,techniques1 ,,and ,,procedures ,,october #bjjb ,,headquarters1 ,,department ,,of ,,the ,,army ,,distribution ,,restriction3 ,approved for public release2 distribution is unlimited4 99,,fm #d-jb4g 7,,fm #h-aj-g7 ,,field ,,manual ,,headquarters ,,no4 #d-jb4g 7#h-aj-g7 ,,department ,,of ,,the ,,army ,washington1 ,,dc1 #a ,october #bjjb ,,health ,,service ,,support ,,in ,a ,,nuclear1 ,,biological1 ,,and ,,chemical ,,environment ,,tactics1 ,,techniques ,,and ,,procedures ,,table ,,of ,,contents ,page ,preface viii ,,chapter #a4 ,,nuclear1 ,,biological1 ,,and ,,chemical ,,warfare ,,aspect ,,of ,,the ,,medical ,,threat #a-a #a-a4 ,general #a-a #a-b4 ,medical ,threat #a-a #a-c4 ,nuclear1 ,biological1 ,chemical1 and ,radiological ,dispersal ,device ,threats--,the ,health ,service ,perspective #a-b ,,chapter #b4 ,,command ,,and ,,control #b-a #b-a4 ,general #b-a #b-b4 ,health ,service ,support ,command and ,control ,planning ,considerations #b-a #b-c4 ,health ,service ,support ,command and ,control ,appraisal of the ,support ,mission #b-b #b-d4 ,health ,service ,support ,units #b-b #b-e4 ,movement_/,management of ,contaminated ,facilities #b-c #b-f4 ,leadership on the ,contaminated ,battlefield #b-e #b-g4 ,homeland ,security #b-f ,,chapter #c4 ,,levels ,i ,,and ,,ii ,,health ,,service ,,support #c-a #c-a4 ,general #c-a #c-b4 ,level ,i ,health ,service ,support #c-b #c-c4 ,level ,,ii ,health ,service ,support #c-b #c-d4 ,forward ,surgical ,team #c-c #c-e4 ,actions ,before a ,nuclear1 ,biological1 or ,chemical ,attack #c-c #c-f4 ,actions ,during a ,nuclear1 ,biological1 or ,chemical ,attack #c-d #c-g4 ,actions ,after a ,nuclear1 ,biological1 or ,chemical ,attack #c-d #c-h4 ,logistical ,considerations #c-e #c-i4 ,personnel ,considerations #c-e #c-aj4 ,disposition and ,employment of ,treatment ,elements #c-f #c-aa4 ,civilian ,casualties #c-f #c-ab4 ,nuclear ,environment #c-g #c-ac4 ,medical ,triage #c-h #c-ad4 ,biological ,environment #c-h #c-ae4 ,chemical ,environment #c-i #c-af4 ,operations in ,extreme ,environments #c-aj #c-ag4 ,medical ,evacuation in a ,nuclear1 ,biological1 and ,chemical ,environment #c-aj ,,chapter #d4 ,,levels ,,iii ,,and ,,iv ,,hospitalization #d-a #d-a4 ,general #d-a #d-b4 ,protection #d-c #d-c4 ,decontamination #d-h #d-d4 ,emergency ,services #d-aj #d-e4 ,general ,medical ,services #d-aa #d-f4 ,surgical ,services #d-aa #d-g4 ,nursing ,services #d-ab #d-h4 ,conventional ,operations #d-ac ,,chapter #e4 ,,other ,,health ,,service ,,support #e-a ,section ,i4 ,preventive ,medicine ,services #e-a #e-a4 ,general #e-a #e-b4 ,disease ,incidence ,following the ,use of ,nuclear1 ,biological1 and ,chemical ,weapons #e-a #e-c4 ,preventive ,medicine ,section #e-c #e-d4 ,preventive ,medicine ,detachment #e-c ,section ,,ii4 ,veterinary ,services #e-d #e-e4 ,general #e-d #e-f4 ,food ,protection #e-d #e-g4 ,food ,decontamination #e-d #e-h4 ,animal ,care #e-e ,section ,,iii4 ,laboratory ,services #e-e #e-i4 ,general #e-e #e-aj4 ,level ,,ii #e-e #e-aa4 ,level ,,iii #e-e #e-ab4 ,level ,,iv #e-f #e-ac4 ,level ,v 7,continental ,united ,states7 #e-f #e-ad4 ,field ,samples #e-f ,section ,,iv4 ,dental ,services #e-g #e-ae4 ,general #e-g #e-af4 ,mission in a ,nuclear1 ,biological1 or ,chemical ,environment #e-g #e-ag4 ,dental ,treatment ,operations #e-g #e-ah4 ,patient ,treatment ,considerations #e-g #e-ai4 ,patient ,protection #e-h ,section ,v4 ,combat ,operational ,stress ,control #e-i #e-bj4 ,general #e-i #e-ba4 ,leadership ,actions #e-i #e-bb4 ,individual ,responsibilities #e-aj #e-bc4 ,mental ,health ,personnel ,responsibilities #e-aa ,section ,,vi4 ,health ,service ,logistics #e-aa #e-bd4 ,general #e-aa #e-be4 ,protecting ,supplies ,in ,storage #e-ab #e-bf4 ,protecting ,supplies ,during ,shipment #e-ab #e-bg4 ,organizational ,maintenance #e-ab ,section ,,vii4 ,homeland ,security ,response #e-ac #e-bh4 ,chemical1 ,biological1 ,radiological1 ,nuclear1 and ,high-,yield ,explosive ,response #e-ac #e-bi4 ,capabilities of ,response ,elements #e-ad ,,appendix ,a4 ,,medical ,,effects ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,weapons ,,and ,,toxic ,,industrial ,,material ,a-#a ,a-#a4 ,general ,a-#a ,a-#b4 ,physical ,effects of ,nuclear ,weapons ,a-#a ,a-#c4 ,physiological ,effects of ,nuclear ,weapons ,a-#d ,a-#d4 ,biological ,effects of ,thermal ,radiation ,a-#g ,a-#e4 ,physiological ,effects of ,ionizing ,radiation ,a-#h ,a-#f4 ,handling and ,managing ,radiologically ,contaminated ,patients ,a-#aj ,a-#g4 ,radiological ,patients in ,stability ,operations and ,support ,operations ,a-#ac ,a-#h4 ,effects of ,biological ,weapons ,a-#ad ,a-#i4 ,behavior of ,biological ,weapons ,a-#ae ,a-#aj4 ,management of ,biological ,warfare ,patients ,a-#af ,a-#aa4 ,effects of ,chemical ,weapons ,a-#ag ,a-#ab4 ,behavior of ,chemical ,weapons ,a-#ag ,a-#ac4 ,characteristics of ,chemical ,agents ,a-#ai ,a-#ad4 ,management of ,chemical ,agent ,patients ,a-#bc ,a-#ae4 ,management of ,toxic ,industrial ,material ,patients ,a-#bc ,,appendix ,b4 ,,sample_/,,specimen ,,collection ,,and ,,management ,b-#a ,section ,i4 ,introduction ,b-#a ,b-#a4 ,general ,b-#a ,b-#b4 ,sample_/,specimen ,background ,information ,b-#b ,b-#c4 ,sample_/,specimen ,collection and ,preservation ,b-#c ,b-#d4 ,chain of ,custody ,b-#h ,section ,,ii4 ,sampling ,techniques and ,procedures ,b-#i ,b-#e4 ,general ,b-#i ,b-#f4 ,expended ,material ,b-#aa ,b-#g4 ,environmental ,samples ,b-#aa ,b-#h4 ,collection of ,air and ,vapors ,b-#ab ,b-#i4 ,collection of ,water ,samples ,b-#ac ,b-#aj4 ,collection of ,soil ,samples ,b-#ae ,b-#aa4 ,collection of ,contaminated ,vegetation ,b-#af ,b-#ab4 ,medical ,specimens ,b-#af ,b-#ac4 ,collection of ,medical ,specimens ,b-#ag ,b-#ad4 ,post ,mortem ,specimens ,b-#ai ,b-#ae4 ,reporting1 ,packaging1 and ,shipment ,b-#bj ,b-#af4 ,handling and ,packaging ,materials ,b-#ba ,b-#ag4 ,collection ,reporting ,b-#bc ,b-#ah4 ,sample_/,specimen ,background ,documents ,b-#bg ,,appendix ,c4 ,,guidelines ,,for ,,operational ,,planning ,,for ,,health ,,service ,,support ,,in ,a ,,nuclear1 ,,biological1 ,,and ,,chemical ,,environment ,c-#a ,c-#a4 ,general ,c-#a ,c-#b4 ,predeployment ,c-#a ,c-#c4 ,mobilization ,c-#b ,c-#d4 ,establish a ,medical ,treatment ,facility ,c-#c ,c-#e4 ,operate a ,medical ,treatment ,facility ,receiving ,contaminated ,patients4 ,c-#d ,c-#f4 ,preventive ,medicine ,services ,c-#e ,c-#g4 ,veterinary ,services ,c-#f ,c-#h4 ,dental ,services ,c-#f ,c-#i4 ,combat ,operational ,stress ,control ,c-#f ,c-#aj4 ,medical ,laboratory ,services ,c-#f ,c-#aa4 ,health ,service ,logistics ,c-#g ,c-#ab4 ,homeland ,security ,c-#h ,,appendix ,d4 ,,medical ,,planning ,,guide ,,for ,,the ,,estimation ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,battle ,,casualties ,d-#a ,section ,i4 ,introduction ,d-#a ,d-#a4 ,general ,d-#a ,d-#b4 ,medical ,planners' ,tool ,d-#a ,section ,,ii4 ,medical ,planning ,guide for the ,estimation of ,nuclear1 ,biological1 and ,chemical ,battle ,casualties 7,nuclear7--,a,med,p-#h7;,a71 ,volume ,i ,d-#a ,d-#c4 ,general ,d-#a ,d-#d4 ,medical ,planning ,considerations ,d-#b ,d-#e4 ,triage ,d-#c ,d-#f4 ,evacuation ,d-#c ,d-#g4 ,in-,unit ,care ,d-#c ,d-#h4 ,hospital ,bed ,requirements ,d-#d ,d-#i4 ,medical ,logistics ,d-#d ,d-#aj4 ,medical ,force ,planning ,d-#d ,section ,,iii4 ,medical ,planning ,guide for the ,estimation of ,nuclear1 ,biological1 and ,chemical ,battle ,casualties 7,biological7--,a,med,p-#h7;,a71 ,volume ,,ii ,d-#d ,d-#aa4 ,general ,d-#d ,d-#ab4 ,medical ,planning ,considerations ,d-#f ,d-#ac4 ,triage ,d-#f ,d-#ad4 ,evacuation ,d-#f ,d-#ae4 ,in-,unit ,care ,d-#g ,d-#af4 ,patient ,bed ,requirements ,d-#g ,d-#ag4 ,medical ,logistics ,d-#g ,d-#ah4 ,medical ,force ,planning ,d-#h ,section ,,iv4 ,medical ,planning ,guide for the ,estimation of ,nuclear1 ,biological1 and ,chemical ,battle ,casualties 7,chemical7--,a,med,p-#h7;,a71 ,volume ,,iii ,d-#h ,d-#ai4 ,general ,d-#h ,d-#bj4 ,medical ,planning ,considerations ,d-#aj ,d-#ba4 ,triage ,d-#aa ,d-#bb4 ,evacuation ,d-#aa ,d-#bc4 ,in-,unit ,care ,d-#aa ,d-#bd4 ,patient ,bed ,requirements ,d-#ab ,d-#be4 ,medical ,logistics ,d-#ab ,d-#bf4 ,medical ,force ,planning ,d-#ab ,,appendix ,e4 ,,example ,x-1 ,,annex1 ,,to ,,hss ,,plan_/,,operation ,,order1 ,,medical ,,nbc ,,staff ,,officer ,,planning ,,for ,,hss ,,in ,,an ,,nbc ,,environment ,e-#a ,,appendix ,f4 ,,employment ,,of ,,chemical ,,and ,,biological ,,collective ,,protection ,,shelter ,,systems ,,by ,,medical ,,units ,f-#a ,section ,i4 ,introduction ,f-#a ,f-#a4 ,general ,f-#a ,f-#b4 ,types of ,collective ,protection ,shelter ,systems ,f-#a ,section ,,ii4 ,employment of the ,chemically and ,biologically ,protected ,shelter ,system ,f-#b ,f-#c4 ,establish a ,battalion ,aid ,station in a ,chemically ,biologically ,protected ,shelter ,f-#b ,f-#d4 ,division ,clearing ,station in a ,chemically ,biologically ,protected ,shelter ,f-#d ,f-#e4 ,forward ,surgical ,team in a ,chemically ,biologically ,protected ,shelter ,f-#f ,section ,,iii4 ,employment of the ,chemically ,protected ,deployable ,medical ,systems and ,simplified ,collective ,protection ,systems ,f-#h ,f-#f4 ,collective ,protection in a ,deployable ,medical ,system-,equipped ,hospital ,f-#h ,f-#g4 ,chemically_/,biologically ,protecting the ,international ,organization for ,standardization ,shelter ,f-#aa ,f-#h4 ,chemically_/,biologically ,protecting the ,vestibules ,f-#ab ,f-#i4 ,chemically_/,biologically ,protecting ,air ,handler ,equipment ,f-#ab ,f-#aj4 ,establish ,collective ,protection ,shelter ,using the ,m#bj ,simplified ,collective ,protection ,system ,f-#ab ,f-#aa4 ,casualty ,decontamination ,f-#ab ,section ,,iv4 ,operations1 ,entry1 and ,exit ,guidelines ,f-#ac ,f-#ab4 ,operations ,f-#ac ,f-#ac4 ,decontamination of ,entrance ,area ,f-#ac ,f-#ad4 ,procedures ,prior to ,entry ,f-#ad ,f-#ae4 ,entry_/,exit for the ,collective ,protection ,shelter ,system ,f-#ad ,f-#af4 ,resupply of ,protected ,areas ,f-#ag ,,appendix ,g4 ,,patient ,,decontamination ,g-#a ,section ,i4 ,introduction ,g-#a ,g-#a4 ,general ,g-#a ,g-#b4 ,immediate ,decontamination ,g-#b ,g-#c4 ,patient ,decontamination and ,thorough ,decontamination ,collocation ,g-#b ,g-#d4 ,patient ,decontamination at the ,battalion ,aid ,station 7,level ,i7 ,g-#e ,g-#e4 ,patient ,decontamination at the ,medical ,company ,clearing ,station 7,level ,,ii7 ,g-#e ,g-#f4 ,patient ,decontamination at a ,hospital 7,level ,,iii and ,,iv7 ,g-#e ,g-#g4 ,prepare ,hypochlorite ,solutions for ,patient ,decontamination ,g-#e ,g-#h4 ,classification of ,patients ,g-#f ,g-#i4 ,patient ,treatment ,g-#f ,section ,,ii4 ,patient ,decontamination ,procedures ,g-#g ,g-#aj4 ,decontaminate a ,litter ,chemical ,agent ,patient ,g-#g ,g-#aa4 ,decontaminate an ,ambulatory ,chemical ,agent ,patient ,g-#ad ,g-#ab4 ,biological ,patient ,decontamination ,procedures ,g-#ah ,g-#ac4 ,decontaminate a ,litter ,biological ,agent ,patient ,g-#ah ,g-#ad4 ,decontaminate an ,ambulatory ,biological ,agent ,patient ,g-#ai ,g-#ae4 ,decontaminate ,nuclear-,contaminated ,patients ,g-#bj ,g-#af4 ,decontaminate a ,litter ,nuclear-,contaminated ,patient ,g-#ba ,g-#ag4 ,decontaminate an ,ambulatory ,nuclear-,contaminated ,patient ,g-#ba ,,appendix ,h4 ,,field ,,expedient ,,protective ,,systems ,,against ,,nuclear1 ,,biological1 ,,and ,,chemical ,,attack ,h-#a ,h-#a4 ,general ,h-#a ,h-#b4 ,protection ,against ,radiation ,h-#a ,h-#c4 ,expedient ,shelters for ,protection ,against ,radiation ,h-#b ,h-#d4 ,expedient ,shelters ,against ,biological and ,chemical ,agents ,h-#e ,,appendix ,i4 ,,detection ,,and ,,treatment ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,contamination ,,in ,,water ,i-#a ,i-#a4 ,general ,i-#a ,i-#b4 ,detection of ,contamination in ,water ,i-#a ,i-#c4 ,procedures on ,discovery of ,contamination in ,water ,i-#a ,i-#d4 ,treatment of ,contaminated ,water ,i-#b ,,appendix ,j4 ,,food ,,contamination ,,and ,,decontamination ,j-#a ,j-#a4 ,general ,j-#a ,j-#b4 ,protection of ,food ,from ,contamination ,j-#b ,j-#c4 ,nuclear ,j-#c ,j-#d4 ,biological ,j-#d ,j-#e4 ,chemical ,j-#e ,,glossary ,glossary-#a ,,references ,references-#a ,,index ,index-#a ,,distribution ,,restriction3 ,approved for public release2 distribution is unlimited4 99 ,this publication supersedes ,,fm #h-aj-g1 #bb ,april #aiic4 ,change #a1 #bf ,november #aiif ,,preface ,the purpose of this field manual 7,,fm7 is to provide doctrine and tactics1 techniques1 and procedures for health service support 7,,hss7 units and personnel operating in a nuclear1 biological1 and chemical 7,,nbc71 radiological dispersal device 7,,rdd71 and toxic industrial material 7,,tim7 environment4 ,the manual provides information for use by commanders1 planners1 leaders1 and individuals in providing ,,hss under these adverse conditions4 ,the use of trade or brand names in this publication is for illustrative purposes only4 ,their use does not constitute endorsement by the ,department of ,defense 7,,dod74 ,the proponent of this publication is the ,united ,states 7,,us7 ,army ,medical ,department ,center and ,school 7,,ameddc,s74 ,send comments and recommendations directly to ,commander1 ,,us ,army ,medical ,department ,center and ,school1 ,,attn3 ,,mccs-,,fcd1 #adjj ,east ,grayson ,street1 ,fort ,sam ,houston1 ,texas #ghbcd-ejeb4 ,the use of the term level of care in this publication is synonymous with echelon of care and role of care4 ,the term echelon of care is the old ,north ,atlantic ,treaty ,organization 7,,nato7 term4 ,the term role of care is the new ,,nato and ,american1 ,british1 ,canadian1 and ,australian 7,,abca7 term4 ,the use of the term ,,tim in this publication is inclusive of ,,rdd4 ,the use of the term ,health ,service ,support in this publication is synonymous with ,combat ,health ,support as used in other publications4 ,health ,service ,support is the term used in ,joint ,publications to describe medical support to ,joint ,forces4 ,radiological and chemical detection devices discussed in this publication are currently being replaced through modernization or new device developments4 ,the users should adapt the application of doctrine as described to fit the new devices when issued_/authorized4 ,unless this publication states otherwise1 masculine nouns and pronouns do not refer exclusively to men4 ,this publication implements ,,nato ,standardization ,agreements 7,s,t,a,n,a,gs7 #bdge1 ,medical ,planning ,guide for the ,estimation of ,,nbc ,battle ,casualties 7,nuclear7--,allied ,medical ,publication 7,a,med,p7 #h7;,a71 ,volume ,i2 #bdgf1 ,medical ,planning ,guide of ,,nbc ,battle ,casualties 7,biological7--,a,med,p-#h7;,a71 ,volume ,,ii2 #bdgg1 ,planning ,guide for the ,estimation of ,,nbc ,battle ,casualties 7,chemical7--,a,med,p-#h 7,a71 ,volume ,,iii4 ,it is also in consonance with the following ,,nato ,s,t,a,n,a,gs and ,,abca ,quadripartite ,standardization ,agreements 7,q,s,t,a,gs73 ,,title ,,stanag ,,qstag ,warning ,signs for the ,marking of ,contaminated or ,dangerous ,land ,areas1 ,complete ,equipments1 ,supplies and ,stores #bjjb #eja ,emergency ,alarms of ,hazard or ,attack 7,,nbc and ,air ,attack ,only7 #bjdg #ahc ,interoperable ,chemical ,agent ,detector ,kits #fjh ,emergency ,war ,surgery #bjfh ,commander's ,guide on ,nuclear ,radiation ,exposure of ,groups #bjhc #hih ,reporting ,nuclear ,detonations1 ,biological and ,chemical ,attacks1 and ,predicting and ,warning of ,associated ,hazards and ,hazard ,areas--,,atp-#de7;,b7 #bajc #ahg ,friendly ,nuclear ,strike ,warning #bajd #ahi ,nuclear1 ,biological and ,chemical ,reconnaissance #baab ,,nato ,handbook on the ,medical ,aspects of ,,nbc ,defensive ,operations--,a,med,p-#f7;,b7 #bejj ,concept of ,operations of ,medical ,support in ,nuclear1 ,biological1 and ,chemical ,environments--,a,med,p-#g7;,a7 #bhgc ,medical ,aspects of ,,nbc ,defensive ,operations #accj ,principles of ,medical ,policy in the ,management of a ,mass ,casualty ,situation #bhgi ,medical ,aspects of ,mass ,casualty ,situations #haf ,guidelines for ,air and ,ground ,personnel ,using ,fixed and ,transportable ,collective ,protection ,facilities on ,land #bida #bjjj ,training of ,medical ,personnel for ,,nbc ,operations #bied ,,chapter #a ,,nuclear1 ,,biological1 ,,and ,,chemical ,,warfare ,,aspect ,,of ,,the ,,medical ,,threat #a-a4 ,general a4 ,after ,world ,war ,,ii1 the ,soviet ,union represented the principal threat to the national security interests of the ,,us4 ,during this period1 the military capability of the ,soviet ,armed ,forces grew enormously4 ,starting in the later years of the #aihjs1 the international security environment has undergone rapid1 fundamental1 and revolutionary changes4 ,with the collapse of ,soviet communism1 the ,soviet ,union disintegrated as a viable economic and political system4 ,the ,warsaw ,pact dissolved as a political and military entity4 ,the central ,soviet government was replaced by the ,commonwealth of ,independent ,states 7,,cis71 dominated by the ,russian ,republic4 ,the cohesion of ,soviet strategic military capability has been fractured by-- ,the dissolution of central ,soviet control4 ,the formation of the ,,cis4 ,the unpredictability associated with uncertain loyalties and low morale4 ,the ultimate outcome of these events in terms of ,,us national security interests is unclear4 ,the military capabilities of ,,cis like ,russia1 ,ukraine1 ,kazakstan1 and ,belarus remain formidable4 ,the capabilities include strategic nuclear and impressive conventional1 biological1 and chemical warfighting capabilities4 b4 ,from a global perspective1 the economic power and influence of developing and newly industrialized nations continue to grow4 ,centers of power 7global or regional7 cannot be measured solely in military terms4 ,nation states pursuing their own political1 ideological1 and economic interests may become engaged in direct or indirect competition and conflict with the ,,us4 ,more nations have acquired significant numbers of modern1 lethal1 combat weapon systems2 developed very capable armed forces2 and become more assertive in international affairs4 ,in the absence of a single1 credible1 coercive threat1 old rivalries and long repressed territorial ambitions will resurface1 causing increased tensions in many regions4 ,political1 economic1 and social instability and religious1 cultural1 and economic competition will continue to erode the influence of the ,,us over the rest of the world4 ,this erosion will also reduce the ,,us influence of traditional regional powers over their neighbors4 ,this environment will encourage the continued development1 or acquisition1 of modern armed forces and equipment by less influential nations2 thus raising the potential for the use of ,,nbc_/,,rdd weapons during internal conflict and armed confrontations in developing regions of the world4 c4 ,a third dimension to the threat is terrorist1 rogue groups1 and belligerents employing a number of chemical and biological agents and the possible use of ,,tim to injure or kill ,,us personnel4 ,the actions may be isolated or may be imposed by groups of individuals4 ,most will have the financial backing of nations1 large organizations1 or groups that have the desire to cause harm and create public distrust in our government4 #a-b4 ,medical ,threat ,medical threat is the composite of all ongoing or potential enemy actions and environmental conditions that will reduce combat effectiveness through wounding1 injuring1 causing disease1 and_/or degrading performance4 ,soldiers are the targets of these threats4 ,weapons or environmental conditions that will generate wounded1 injured1 and sick soldiers1 beyond the capability of the ,,hss system to provide timely medical care from available resources1 are considered major medical threats4 ,weapons or environmental conditions that produce qualitatively different wound or disease processes are also major medical threats4 ,added to the combat operational and disease and nonbattle injury 7,,dnbi7 medical threats are adversary use of the following types of weapons1 agents1 and devices3 ,biological warfare agents4 ,chemical warfare agents4 ,nuclear weapons4 ,toxic industrial materials4 ,radiological dispersal devices4 ,directed-energy devices_/weapons4 ,chemical1 biological1 radiological1 nuclear1 and high-yield explosives4 #a-c4 ,nuclear1 ,biological1 ,chemical1 and ,radiological ,dispersal ,device ,threats--,the ,health ,service ,perspective a4 ,nuclear ,weapons and ,radiological ,dispersal ,device ,threats4 ,since the breakup of the ,soviet ,union1 the number of countries with known nuclear capable military forces has almost doubled4 ,available information suggests that a number of countries in the ,middle ,east1 ,asia1 and ,africa have or may have nuclear weapons capability within the next decade4 ,table #a-a lists those countries known to have1 suspected of possessing1 or seeking1 nuclear weapons4 ,planners can expect1 as a minimum1 #aj to #bj percent casualties within a division-sized force that has experienced a nuclear strike4 ,in addition to the casualties1 a nuclear weapon detonation can generate an electromagnetic pulse 7,,emp7 that will cause catastrophic failures of electronic equipment components4 ,radiological dispersal devices1 comprised of an explosive device with radioactive material1 can be detonated without the need for the components of a nuclear weapon4 ,the ,,rdd can disperse radioactive material over an area of the battlefield causing effects from nuisance levels of radioactive material to life-threatening levels without the thermal and1 in most cases1 the blast effects of a nuclear detonation4 ,for nuclear weapons effects see ,appendix ,a4 ,table #a-a4 ,countries ,possessing or ,suspected of ,possessing ,nuclear ,weapons ,,known ,,to ,,possess ,,suspect ,,or ,,seeking ---------------------------------------- ---------------- ,,united ,,states ,,of ,,america ,,iraq ,,russia ,,north ,,korea ,,ukraine ,,iran ,,belarus ,,libya ,,kazakstan ,,algeria ,,people',s ,,republic ,,of ,,china ,,south ,,africa ,,france ,,israel ,,united ,,kingdom ,,pakistan ,,india b4 ,biological ,warfare4 7#a7 ,biological warfare 7,,bw7 is defined by the ,,us intelligence community as the intentional use of disease-causing organisms 7pathogens71 toxins1 or other agents of biological origin 7,,abo7 to incapacitate1 injure1 or kill humans and animals2 to destroy crops2 to weaken resistance to attack2 and to reduce the will to fight4 ,historically1 ,,bw has primarily involved the use of pathogens in assassinations or as sabotage agents in food and water supplies to spread contagious disease among target populations4 7#b7 ,for purposes of medical threat risk assessment1 we are interested only in those ,,bw agents that incapacitate1 injure1 or kill humans or animals4 7#c7 ,known or suspect ,,bw agents and ,a,b,os can generally be categorized as naturally occurring1 unmodified infectious agents 7pathogens72 toxins1 venoms1 and their biologically active fractions2 modified infectious agents2 and bioregulators4 ,see ,table #a-b for examples of known or suspected ,,bw threat agents4 ,also1 ,table #a-c presents possible developmental and future ,,bw agents4 ,table #a-b4 ,examples of ,known or ,suspect ,biological ,warfare ,agents ,,pathogens ,,toxins ---------------------------------------- -------------------- ,,bacillus ,,anthracis 7,,anthrax7 ,,botulinum ,,toxin ,,francisella ,,tularenius 7,,tularemia7 ,,mycotoxins ,,yersinia ,,pestis 7,,plague7 ,,enterotoxin ,,brucella ,,species 7,,brucellosis7 ,,ricin ,,vibrio ,,cholerae 7,,cholera7 ,,variola 7,,smallpox7 ,,viral ,,hemorrhagic ,,fevers ,table #a-c4 ,the ,future of ,biological ,warfare ,agents ,,current ,,threat ,,future ---------------------------------------- ------------------------------- ,,pathogens ,,modified ,,pathogens ,,limited ,,number ,,of ,,toxins ,,expanded ,,range ,,of ,,toxins 7,,organo-,,toxins7 ,,agents ,,of ,,biological ,,origin ,,protein ,,fractions ,,agents ,,of ,,biological ,,origin 7#d7 ,many governments recognize the industrial and economic potential of advanced biotechnology and bioengineering4 ,the same knowledge1 skills1 and methodologies can be applied to the production of second and third generation ,,bw agents4 ,naturally occurring infectious organisms can be made more virulent and antibiotic resistant and manipulated to render protective vaccines ineffective4 ,these developments complicate the ability to detect and identify ,,bw agents and to operate in areas contaminated by the ,,bw agents4 ,for biological agent characteristics and effects see ,appendix ,a4 ,the first indication that a ,,bw agent release_/attack has occurred may be patients presenting at a medical treatment facility with symptoms not fitting the mold for endemic diseases in the area of operations 7,,ao74 ,see ,appendix ,b for sampling requirements1 sampling procedures1 packaging and shipping1 and chain of custody requirements4 c4 ,chemical ,warfare4 7#a7 ,since ,world ,war ,i1 most western political and military leaders have publicly held chemical warfare 7,,cw7 in disrepute4 ,however1 evidence accumulated over the last #ej years does not support the position that public condemnation equates to limiting development or use of offensive ,,cw agents4 ,the reported use of chemical agents and biological toxins in ,southeast ,asia by ,vietnamese forces2 the confirmed use of ,,cw agents by ,egypt against ,yemen2 and later by ,iraq against ,iranian forces2 and the probable use of ,,cw agents by the ,soviets in ,afghanistan indicate a heightened interest in ,,cw as a force multiplier4 ,also1 an offensive ,,cw capability is developed as a deterrent to the military advantage of a potential adversary4 ,for a list of common chemical agents1 their characteristics1 behavior1 and effects see ,appendix ,a4 ,table #a-d lists those countries known or suspected of having offensive chemical weapons4 7#b7 ,the ,russian ,republic has the most extensive ,,cw capability in ,europe4 ,chemical strikes can be delivered with almost any type of conventional fire support weapon system 7from mortars to long-range tactical missiles74 ,agents known to be available in the ,russian inventory include nerve agents 7,o-ethyl methyl phosphonothiolate ,,vx1 thickened ,,vx1 ,sarin ,,gb1 and thickened ,soman ,,gd72 vesicants 7thickened ,lewisite,l and mustard-,lewisite mixture,,hl72 and choking agent 7phosgene74 ,although not considered ,,cw agents1 riot control agents are also in the ,russian inventory4 7#c7 ,the ,,us is in the process of destroying its stockpiles of ,,cw weapons4 ,many weapons have already been destroyed and the storage facilities have been rendered safe of all ,,cw agent residues4 ,table #a-d4 ,nations ,known or ,suspected of ,possessing ,chemical ,weapons ,,known ,,to ,,possess ,,suspected ,,of ,,possessing ---------------------------------------- -------------------------- ,,united ,,states ,,of ,,america ,,people',s ,,republic ,,of ,,china ,,russia ,,north ,,korea ,,france ,,egypt ,,libya ,,israel ,,iraq99 ,,ethiopia ,,iran ,,taiwan ,,syria ,,burma ---------------------------------------- -------------------------- 99 ,,following ,,the ,,persian ,,gulf ,,war 7#aiij-ia71 ,,the ,,united ,,nations 7,,un7 ,,began ,,destroying ,,cw ,,munitions ,,discovered ,,during ,,inspection ,,visits ,,to ,,iraq ,,by ,,un ,,arms ,,control ,,inspectors4 ,,included ,,among ,,the ,,cw ,,munitions ,,discovered ,,were ,,some #b1jjj ,,aerial ,,bombs ,,and #f1bjj ,,artillery ,,shells ,,filled ,,with ,,mustard ,,and ,,several ,,thousand #abb ,,millimeters 7mm7 ,,rocket ,,warheads ,,filled ,,with ,,nerve ,,agent 7,,gb74 ,,iraq ,,also ,,declared ,,surface ,,to ,,air ,,missile 7,,scud7 ,,warheads ,,filled ,,with ,,nerve ,,agent 7,,gb ,,and ,,gf74 ,,table #a-e ,,provides ,a ,,list ,,of ,,known ,,cw ,,agents4 ,table #a-e4 ,chemical ,warfare ,agents ,,nerve ,,vesicant ,,incapacitating ,,choking ,,blood ---------------------------------------- ------------------------------- ,,tabun7,,ga7 ,,sulfur ,,cns ,,depressant7,,bz7 ,,phosgene 7,,cg7 ,,hydrogen ,,mustard 7,,hd7 ,,cyanide 7,,ac7 ,,gb ,,hl ,,chlorine 7,,cl7 ,,diphosgene 7,,dp7 ,,cyanogen ,,gd ,l ,,chloropicrin 7,,ps7 ,,chloride 7,,ck7 ,,gf ,,phosgene ,d-,,lysergic ,,acid ,,oxime 7,,cx7 ,,vx ,,diethylamide 7,,lsd7 d4 ,toxic ,industrial ,materials4 ,toxic industrial materials can present a medical threat for deployed forces4 ,toxic industrial materials are comprised of toxic industrial biologicals 7,,tib71 toxic industrial chemicals 7,,tic71 and toxic industrial radiological 7,,tir7 materials4 ,these materials are found throughout the world and are used on a daily basis for commercial and private purposes4 ,large storage facilities1 transportation tankers 7over the road and railcars71 as well as smaller containers of material1 pose a danger to the health of personnel4 ,accidental spills or releases and terrorist actions can all lead to release of these materials into the environment causing potential casualty producing effects4 ,medical treatment facilities and nuclear power plants use radioactive materials that can pose a health hazard if accidentally released or used by hostile forces1 terrorists1 or others to contaminate an area4 ,biological materials used in medical research and pharmaceutical manufacturing may be used by hostile forces1 terrorists1 or others to produce casualties4 ,many ,t,i,cs produce the same effects on personnel as ,,cw agents4 ,as a matter of fact1 many ,t,i,cs are of the same chemical structure as ,,cw agents4 ,however1 there is quite a difference in their potency2 in most ,t,i,cs the potency is much lower4 ,for example1 chlorine used to treat water supplies has also been used as a ,,cw agent2 organophosphate pesticides can cause the same effects as some nerve agents4 ,hostile forces1 terrorists1 or others may use ,r,d,ds to produce casualties as well4 ,for detailed information on toxic industrial materials see ,,fm #h-ejj4 ,,chapter #b ,,command ,,and ,,control #b-a4 ,general ,the ,,us forces may be attacked by or exposed to ,,nbc1 ,,tim1 lasers1 advanced electronics1 high explosives1 fuel-air1 thermobaric1 and conventional weapons2 or a combination of these weapons_/materiel4 ,mass casualty situations will be the rule and not the exception4 ,mass casualty situations can occur anyplace on the battlefield4 ,combined ,,nbc and conventional weapons injuries may predominate4 ,command and control 7,c#b7 will be essential to prevent casualties and to provide effective ,,hss4 ,however1 ,c#b 7to include ,,hss ,c#b7 elements may be primary targets4 ,effective ,,hss in an ,,nbc environment can be accomplished1 but only if necessary preparations to survive and to be mission capable are taken4 ,increased ,,hss ,c#b actions are needed to maintain ,,hss proximity to the supported force2 to clear the battlefield2 to move and resupply the ,,hss units1 while managing multiple simultaneous mass casualty incidents2 and to rapidly evacuate patients4 ,health service support ,c#b units must push ,,hss augmentation to mass casualty sites1 clear the site1 evacuate the patients to ,medical ,treatment ,facilities 7,m,t,fs7 that can provide essential care or out of the ,,ao2 decontaminate and extract medical forces from ,,nbc contaminated areas and redistribute or redeploy the ,,hss forces4 ,within medical units1 ,c#b will be challenged by the use of protective clothing and equipment1 the need to move 7either to the patients or out of the contaminated area71 and obtaining additional support4 ,health service support advisers and staff officers must provide guidance to commanders on continued duty for personnel who have been exposed to ,,nbc weapons_/agents and ,,tim effects4 ,leaders must greatly increase coordinating1 preplanning1 using tactical standing operating procedures 7,t,s,o,ps71 and establishing multiple ,c#b mechanisms4 ,see ,appendix ,c for guidelines on operational planning for health service support in an ,,nbc or ,,tim environment4 ,see ,appendix ,d for medical planning guide on ,,nbc casualties4 ,see ,appendix ,e for a sample format of a medical ,,nbc staff officer appendix to annex ,q4 #b-b4 ,health ,service ,support ,command and ,control ,planning ,considerations a4 ,battle situational understanding is of great importance on the ,,nbc battlefield4 ,the number of casualties from each ,,nbc attack will overwhelm any single medical unit or ,,mtf causing the medical commander_/leader to take action4 ,to the extent possible1 the commander_/leader should be prepared for the requirement instead of reacting to it4 ,to ensure responsive ,c#b the ,,hss plan must consider3 ,likely targets 7,c#b nodes1 main supply routes 7,,msr71 supply nodes1 troop concentrations1 key terrain features1 key forces1 or other high value targets74 ,patient estimates 7conventional1 ,,nbc1 and ,,tim74 ,availability of ,,hss resources 7preestablished support plans74 ,availability of required nonmedical support 7patient decontamination teams74 ,ability to maintain operations if ,c#b is lost at any ,,hss level4 ,ability to maintain ,c#b operations when normal communication systems have been disabled due to ,,emp effects or other system failures4 ,ability to maintain ,c#b operations while the unit is operating in mission-oriented protective posture 7,,mopp7 ,level #d 7reduced audio and visual acuity74 ,the requirements for immunizations1 pretreatments1 barrier creams1 prophylaxis1 insect repellents1 and other medical countermeasures to protect the forces4 ,the resource requirements for treatment1 ,,medevac1 and hospitalization 7including care for enemy prisoners of war ,,epw74 b4 ,clearing the battlefield will require preplanning and close coordination at all levels4 ,early resuscitation1 stabilization1 and prompt medical evacuation 7,,medevac7 are mandatory for survival of the sick and wounded4 c4 ,for conventional operations ,c#b see ,,fm #h-aj4 ,field ,manual #h-ee provides ,,hss planning for conventional operations4 d4 ,provisions for emergency medical care of civilians1 consistent with the military situation4 ,all non-,,dod civilian care must be approved by the ,,ao ,commander in ,chief_/senior official and coordinated with the civil affairs unit and_/or country team4 ,for eligibility of care determinations guidance1 see ,,fm #h-aj4 e4 ,for additional information on planning operations in an ,,nbc environment see ,f,ms #h-aj1 #d-jb4aj1 #d-jb4d1 #d-jb4f1 #d-jb4bhc1 #h-i1 #h-aj-f1 #h-aj-bf1 #h-bhd1 and #h-bhe4 ,higher headquarters must distribute timely plans and directives to subordinate units to ensure that the subordinate unit's ,,hss plan supports their plan4 #b-c4 ,health ,service ,support ,command and ,control ,appraisal of the ,support ,minion ,the ,,hss personnel make an appraisal of the supported mission to determine the expected patient load4 ,once the appraisal has been accomplished1 ,,hss personnel prepare for the ,,hss mission by assigning personnel responsibilities4 ,using triage and ,,emt decision matrices for managing patients in a contaminated environment improves treatment proficiency4 ,see ,figure #b-a for a sample decision matrix4 ,training ,,hss personnel in the use of simple decision matrices should enhance their effectiveness and contribute to a more efficient battlefield ,,hss process4 ,prior training for designated nonmedical personnel in patient decontamination procedures will enhance their effectiveness in the overall patient care mission4 ,see ,appendix ,d for planning factors on the estimation of ,,nbc casualties4 #b-d4 ,health ,service ,support ,units ,health service support units must plan1 train1 and routinely practice mass casualty management4 ,the ,,nbc attack or ,,tim event will likely be in conjunction with enemy conventional operations4 ,but1 the ,,tim event may be caused by terrorist or belligerent action4 ,there will likely be increased conventional casualties in addition to the ,,nbc_/,,tim related casualties4 ,the supply and transportation units will be using the ,,msr in support of the combat commander's requirements2 thus1 impacting on patient ,,medevac and ,,hss unit resupply4 ,communications will be disrupted4 ,therefore1 ,,hss ,c#b must plan and prepare for conducting operations with limited or no communications with other ,,hss organizations4 ------------------------------------ ,,gather ,,data ,,nerve ,,agent ,,symptoms 7,,visual_/,,tactile--,,verbal_/,,nonver bal7 ----------------------------------- ---------------- ,,check ,,mopp ,,gear ---------------- ---------------------------- ------------- ------------- ,,not ,,intact ,,intact ------------- ------------- ------------- ------------- ,,administer ,,administer ,,antidote ,,antidote ------------- ------------- ------------- ----------- ,,secure ,,mopp ,,gear --------- --------- ------------- ,,individual ,,individual ,,can ,,cannot ----------- ,,function ,,function --------- --------- --------- --------- ------- ----------- ,,individual ,,individual ,,rtd ,,check ,,for ,,can ,,cannot -------- ,,other ,,function ,,function ---------------- ,,injuries --------- ---------- ----------- --------- -------------- ,,rtd ---------- ------------ ----------- ,,no ,,injuries ,,injuries ------------ ----------- ------------ ----------- ,,evac ,,provide ------------- ,,emt ----------- ----------- ,,evac ------------ ,figure #b-a4 ,sample triage and emergency medical treatment decision matrix4 #b-e4 ,movement_/,management of ,contaminated ,facilities ,operations in a contaminated area require the ,,hss commander_/leader to operate with contaminated or potentially contaminated assets4 ,the following provides guidance in determining how to operate with contaminated facilities3 a4 ,fulfill ,health ,service ,support ,principles4 ,in making his decision to move or continue to operate with contaminated facilities1 the commander_/leader must apply the principles of conformity1 proximity1 flexibility1 mobility1 continuity1 and control4 ,the unit's operation must conform to the tactical commander's operation plan 7,,oplan74 ,health service support must be provided to the tactical unit as far forward as possible2 this ensures prompt1 timely care4 ,additionally1 the ,,hss commander_/leader must be flexible2 his support must be tailored to meet the supported commander's ,,oplan requirements4 ,therefore1 ,,hss assets must be as mobile as the unit they support4 ,finally1 the ,,hss commander_/leader must control his assets4 ,dispersion on the integrated battlefield may enhance unit survivability2 but the ,,hss commander_/leader may not be able to maintain control of his assets1 they may become compromised4 b4 ,decision to ,move4 ,the ,,hss commander_/leader 7when deciding to move his unit to an uncontaminated area or in support of the tactical commander's plan7 must base his decision to move on several factors4 7#a7 ,protection available4 ,what type of protection is available in the new area8 ,will he need to establish the units' collective protection shelter 7,,cps7 systems1 or are indigenous shelters available 7for example1 buildings1 tunnels1 caves78 ,does the unit have sufficient individual protective equipment for unit personnel8 7#b7 ,persistency4 ,if his unit has been in a contaminated area1 is the contamination persistent or nonpersistent8 ,is the area he will move to contaminated or clean8 ,persistency determines the ,,mopp level2 the degree of threat2 and performance decrement caused by the protective measures used4 ,the level of contamination will determine whether employment of ,,cps is viable4 ,the ,,mtf may be able to continue to operate at the location by employing ,,cps4 ,personnel and patient decontamination must be accomplished before processing into the ,,cps4 7#c7 ,patients4 ,before moving the entire facility1 the ,,hss commander_/leader must consider the number and types of patients at the ,,mtf2 his ability to redirect en route patients to the new ,,mtf location2 and his ability to evacuate the patients currently on hand4 ,all patients should be stabilized before movement2 but1 ,,medevac must be continued4 7#d7 ,alternate facilities4 ,alternate facilities may be used 7if the facility can be configured to ensure continuity of care or provide a protected area for patients7 until the relocating activity is up and operating4 ,this is a viable consideration when ,,cps is not available or the current location is contaminated with a persistent agent4 ,patient decontamination cannot be performed in an area heavily contaminated with a persistent agent4 7#e7 ,medical evacuation4 ,consideration must always be given to the patient4 ,routes of ,,medevac must be disseminated to supported and supporting units4 ,the ability to evacuate patients during the move must continue4 ,all ,,medevac considerations must be addressed before any move4 7#f7 ,mobility4 ,an ,,mtf that is not #ajj percent mobile requires movement support4 ,thus1 the commander_/leader must coordinate movement support requirements with higher headquarters4 7#g7 ,mission4 ,the primary consideration is the support mission of the ,,mtf4 ,the tactical commander requires continuous ,,hss for his personnel2 when a move jeopardizes the quality of care1 the move may be delayed4 7#h7 ,sustainability4 ,hand-in-hand with the mission is sustainability 7the ability of the unit to continue its support mission74 ,if the current location of the ,,mtf hinders the unit's ability to sustain its support mission1 then the ,m,t,fs support to the unit is in question4 ,similarly1 if moving the ,,mtf will result in a disruption of support1 then the move may not be viable4 7#i7 ,decontamination4 ,when a nonpersistent agent hazard exists and a ,,cps is not available1 patients may be directed to another ,,mtf until the hazard is gone2 or the ,,mtf can move to a contamination free area4 ,certain facilities may be decontaminated1 patient protection procedures applied1 and the operation continued4 ,however1 an ,,mtf contaminated with a persistent agent requires time-consuming and resource-intensive decontamination operations2 it may include replacement of contaminated shelters4 c4 ,management of ,contaminated and ,clean ,facilities4 ,facilities contaminated with a persistent agent may be too resource intensive to decontaminate4 ,operating with a combination of contaminated assets and clean assets may be necessary4 ,mark contaminated assets with standard warning tags4 ,use these assets in contaminated environments and along contaminated routes4 ,keep clean assets in operation in clean areas4 ,of primary importance is proper marking and the avoidance of cross contamination4 d4 ,medical ,supplies and ,equipment for ,patient ,treatment4 ,are sufficient medical supplies and equipment available to perform the anticipated mission8 ,does the unit have special medical equipment sets available 7chemical agent patient decontamination and chemical agent patient treatment medical equipment sets78 #b-f4 ,leadership on the ,contaminated ,battlefield a4 ,operating on a contaminated battlefield will stress leadership4 ,heat stress from being in higher levels of ,,mopp for long periods of time may lead to dehydration4 ,the commander_/leader must ensure that his personnel rest1 drink1 and eat sufficiently to allow them to continue with the mission4 ,in the midst of activity1 rest1 hydration1 and nutrition are often overlooked2 however1 a good leader will ensure that his personnel needs are met4 ,see ,,fm #ba-aj for work_/rest cycles and water drinking requirements4 ,individuals may suffer hyperventilation because of the enclosed feelings4 ,personnel remaining in ,,mopp ,level #d around the clock may suffer from increased sleep loss4 ,use of ,,cps can reduce this problem by allowing the personnel to rest out of their ,,mopp gear4 ,leaders must share leadership responsibilities and delegate responsibilities as much as possible so that each one gets sufficient rest to maintain unit effectiveness4 ,further1 leaders should concentrate on supervision or unit mission1 rather than on generation of new procedures during and after an attack4 ,the ,,nbc battlefield will1 therefore1 require more proactive and dedicated leaders who can balance the needs of their personnel and the mission4 ,further1 leaders will be challenged by an additional logistics burden of providing nontraditional respiratory protection for personnel against ,t,i,ms4 ,for detailed information on combat operational stress control 7,,cosc7 see ,,fm #h-ea and ,,fm #bb-ea4 ---------------------------------------- ----------- ,,danger ,the standard ,,nbc protective mask will not protect personnel from most ,t,i,cs4 ---------------------------------------- ----------- b4 ,leadership must plan for and establish procedures to maintain personnel performance during ,,nbc operations4 ,personnel performance while wearing ,,mopp is degrading4 ,at ,,mopp ,level #c or #d1 all but the most basic patient care procedures may have to be suspended because-- ,wearing gloves reduces the ability to grasp and manipulate small items 7fine motor skill74 ,,mopp impedes the ability to move about 7gross motor skills74 ,the mask reduces visual fields and acuity 7visual skills74 ,the mask and hood greatly reduces vocalization and hearing abilities 7auditory skills74 ,the ,,mopp creates significant heat and mental stress 7stamina74 ,heat injuries can occur in a very short period of time4 #b-g4 ,homeland ,security ,commanders and leaders must plan for and be prepared to support homeland security efforts2 especially1 for response to chemical1 biological1 radiological1 nuclear1 and high-yield explosive 7,,cbrne7 events4 ,depending upon the location of the event1 the response may be to a military installation in support of the weapons of mass destruction--installation support team 7,,wmd-,,ist7 or to an event site off a military installation4 ,response to a ,,cbrne event off a military installation will normally require a request for ,department of ,defense support to the event from the first responders to the event 7usually from the incident commander or lead federal agency ,federal ,bureau of ,investigation or ,federal ,emergency ,management ,agency74 ,see ,appendix ,c for planning considerations4 ,,chapter #c ,,levels ,i ,,and ,,ii ,,health ,,service ,,support #c-a4 ,general a4 ,the use of ,,nbc weapons is a condition of battle and ,,hss personnel must prepare to operate in these environments4 ,added is the dimension of ,,tim releases_/incidents in the operational area4 ,the importance of preventive medicine 7,,pvntmed7 measures and first aid 7self-aid1 buddy aid1 and combat lifesaver ,,cls support7 are even more critical4 ,heat and stress injuries related to ,,mopp wear are issues for the ,,hss leadership as well as the force he is supporting4 ,the stress load on personnel is increased by the concerns of being exposed to ,,tim releases4 ,considering that staffing of ,,hss units is based upon the minimum required to provide support on a conventional battlefield1 they will be challenged to provide the same level of ,,hss in these environments4 b4 ,the ,,hss leadership must quantify the ,,hss capability to their commanders4 ,the medical staff must review ,,oplans and make recommendations to reduce the number of patients4 ,medical ,,nbc training programs must stress the essential imperative of immediate decontamination1 the need to monitor your buddy for ,,nbc and heat or combat_/operational stress injury effects1 and the proper use of ,,nbc defense prophylaxis1 pretreatments1 insect repellents1 barrier creams1 and immunizations4 c4 ,maintaining close proximity to the supported force has been a major tenet of ,,hss doctrine and a critical factor in reducing the mortality rate4 ,maintaining this proximity and finding a place clean enough to provide necessary care requires intense coordination with the supported force4 ,alternate casualty collection points1 decontamination sites1 medical treatment sites1 and ,,medevac routes must be established1 coordinated and communicated to the lowest level practical4 ,communication will be much more difficult1 but must be maintained4 ,timely reports through the ,,hss technical channels will allow an optimal ,,hss response4 ,replacements for ,,hss front line losses must be rapidly filled after ,,nbc weapons are employed4 d4 ,contamination 7,,nbc and ,t,i,ms7 can significantly hinder ,,hss operations4 ,to maximize the unit's survivability and ,,hss capabilities and to avoid such contamination1 leaders must use-- ,contamination avoidance techniques4 ,alarms and detection equipment4 ,unit dispersion techniques4 ,overhead shelter1 shielding material1 protective cover1 and buildings of opportunity4 ,however1 these shelters may not provide protection from chemical vapor or ,,bw hazards4 ,collective protection shelters1 if available4 ,see ,appendix ,f4 ,chemical agent resistant coatings on equipment4 e4 ,on the ,,nbc battlefield1 as on the conventional battlefield1 ,,hss is focused on keeping soldiers in the battle4 ,effective and efficient ,,pvntmed measures1 triage1 emergency medical treatment 7,,emt71 decontamination1 advanced trauma management 7,,atm71 and contamination control in the ,,ao saves lives1 assures judicious ,,medevac1 and maximizes the return to duty 7,,rtd7 rate4 #c-b4 ,level ,i ,health ,service ,support a4 ,level ,i 7unit-level7 ,,hss may consist of a combat medic section1 a ,,medevac section1 and a treatment squad4 ,the treatment squad operates the ,level ,i ,,mtf 7battalion aid station ,,bas74 ,level ,i ,,hss is supported by first aid in the form of self-aid_/buddy aid and the ,,cls4 ,see ,,fm #d-jb4d for detailed information on conventional ,level ,i ,,hss4 b4 ,when operating under an ,,nbc threat or when ,,nbc attack is imminent1 the ,,bas must prepare for continuation of its mission4 ,should an attack occur or a downwind hazard exist1 the ,,bas must seek out a contamination free area to establish a clean treatment area1 or must establish collective protection to continue the mission4 ,some ,b,a,ss have ,chemically ,biologically ,protected ,shelter 7,,cbps7 ,systems4 ,when available1 these systems serve as the primary shelter for the ,,bas2 they are operated in the full chemical_/biological 7,,cb7 mode when attack is imminent or has occurred4 ,see ,appendix ,f for information on establishing a ,,bas in a ,,cbps system4 ,when operating in the ,,cb mode only patients requiring life- or limb-saving procedures are allowed entry at the ,,bas4 ,patients that have minor injuries that can be managed in the contaminated ,,emt area of the patient decontamination site will receive treatment in this area4 ,after treatment1 these patients will have the integrity of their ,,mopp restored by taping the damaged area and returned to duty4 ,patients with injuries that require further treatment1 but who can survive evacuation to the ,level ,,ii ,,mtf will have their ,,mopp spot decontaminated1 their injuries managed1 the integrity of their ,,mopp restored1 and be directed to an evacuation point to await transport to the ,level ,,ii ,,mtf 7example1 an individual with a splinted broken arm74 ,when patients or personnel are contaminated or are potentially contaminated1 they must be decontaminated before admission into the clean treatment area 7see ,,fm #c-e for personnel decontamination procedures and ,appendix ,g for patient decontamination procedures74 #c-c4 ,level ,,ii ,health ,service ,support a4 ,in the brigade1 ,level ,,ii ,,hss consists of-- ,evacuating patients from the ,,bas and ,,medevac on an area support basis from within the brigade support area 7,,bsa74 ,providing area support ,level ,i medical treatment4 ,operating the medical company clearing station 7hereafter referred to as the division clearing station ,,dcs71 which provides a patient holding capability for up to #dj patients for #gb hours4 ,see ,,fm #d-jb4f and ,,fm #h-aj-bd for detailed information on ,level ,,ii conventional operations4 ,providing limited dental service4 ,providing limited ,,pvntmed support in the areas of medical surveillance1 occupational and environmental health surveillance1 food service sanitation1 water quality control 7including ,,nbc contamination surveillance71 and communicable disease control4 ,providing limited ,,cosc2 these patients are returned to duty as far forward as their condition permits4 b4 ,in the division1 ,,hss is the same as for the brigade1 except patients may be evacuated from the ,,bsa ,,dcs1 but not evacuated from the ,,bas4 c4 ,when operating under an ,,nbc threat or when ,,nbc attack is imminent1 the ,,dcs must prepare for continuation of its mission4 ,should an attack occur or a downwind hazard exist the ,,dcs must seek out a contamination free area1 or must establish collective protection to continue the mission4 ,the ,,dcs in some medical companies have four ,,cbps ,systems2 they are complexed to provide space for ,,dcs operations4 ,these systems are operated in the ,,cb mode when attack is imminent or has occurred4 ,see ,appendix ,f for information on establishing a ,,dcs in ,,cbps ,systems4 ,when operating in the ,,cb mode only patients requiring life- or limb-saving procedures are allowed entry4 ,patients with minor injuries that can be managed in the contaminated ,,emt area of the patient decontamination site will receive treatment in this area4 ,after treatment1 these patients will have the integrity of their ,,mopp restored by taping the damaged area and returned to duty4 ,patients with injuries that require further treatment1 but who can survive evacuation to the ,level ,,iii ,,mtf will have their ,,mopp spot decontaminated1 their injuries managed1 and be directed to an evacuation point to await transport to the ,level ,,iii ,,mtf 7example1 an individual with a splinted broken arm74 ,when personnel and patients are contaminated or are potentially contaminated1 they must be decontaminated before admission into the clean treatment area 7see ,,fm #c-e for personnel decontamination procedures and ,appendix ,g for patient decontamination procedures74 #c-d4 ,forward ,surgical ,team ,forward surgical teams 7,,fst7 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 capability4 ,field ,manual #h-aj-be describes ,,fst operations4 ,however1 when forward deployed and ,,nbc contamination is imminent the ,,fst must employ collective protection in order to continue their support mission4 ,when operating in a contaminated area the ,,fst ,,cbps ,systems must be complexed with the ,,dcs ,,cbps4 ,the ,,fst cannot operate in an ,,nbc environment without the support of the ,,dcs4 ,they do not have the capability to decontaminate patients4 ,all patients are decontaminated in the ,,dcs patient decontamination area4 ,they are then processed into the ,,emt section of the ,,dcs2 where they are triaged and routed to the ,,fst for surgery1 if required4 ,see ,appendix ,f for ,,fst employment of collective protection procedures4 #c-e4 ,actions ,before a ,nuclear1 ,biological1 or ,chemical ,attack a4 ,given the disruption of transportation1 communications1 and operations during and following an ,,nbc attack1 it should be clear that preparation is the key to survival and effectively providing ,,hss4 ,preparing a simple and complete ,,tsop and ,,hss plan that really integrates ,,nbc is the first step4 ,critical training for medical personnel before an ,,nbc attack is how to-- ,survive the attack individually and as a unit4 ,operate the ,level ,i or ,level ,,ii ,,mtf in the environment4 ,effectively care for ,,nbc patients4 b4 ,even minimal site preparation 7nuclear hardening or ,,cb protecting7 may improve survival1 greatly reduce contamination1 and maintain the ability to continue to provide ,,hss4 ,see the discussion below for more information on each environment4 ,as with other military personnel1 ,,hss personnel must keep their immunizations current2 use available prophylaxis against suspect ,,cb agents2 use pretreatments for suspect chemical agents2 use insect repellents1 and have antidotes and essential medical supplies readily available for known or suspected ,,nbc effects4 ,the best defense for ,,hss personnel is to protect themselves1 their patients1 medical supplies1 and equipment by applying contamination avoidance procedures4 ,they must ensure that stored medical supplies and equipment are in protected areas or in their storage containers with covers in place4 ,one method of having supplies and equipment protected is to keep them in their shipping containers until actually needed4 ,when time permits and warnings are received that an ,,nbc attack is imminent1 or that a downwind hazard exists1 ,,hss personnel should employ their ,,cps 7see ,appendix ,f7 or seek protected areas 7buildings1 tents1 or other ,,above ground shelters for biological or chemical attack2 culverts1 ravines1 basements1 or other shielded areas for nuclear7 for themselves and their patients4 c4 ,other tasks include3 ,verifying ,,nbc defense ,,hss inventories are complete4 ,reviewing supported units ,,nbc plans1 procedures1 casualty collection points1 decontamination sites1 and resources available to support the ,,hss mission4 ,coordinating with the ,s#b_/;,g#b1 ,s#c_/;,g#c and ,s#d_/;,g#d of the supported unit to develop the medical courses of action2 to obtain necessary materiel to support extended operations without resupply 7,,msr contamination or transportation support not available74 ,coordinating with supported units for at least eight nonmedical personnel for patient decontamination augmentation at the ,level ,i and ,,ii ,m,t,fs4 #c-f4 ,actions ,during a ,nuclear1 ,biological1 or ,chemical ,attack ,while it is possible that the ,,nbc attack will be discrete short events1 the more likely scenario is the enemy will use ,,nbc throughout the conflict4 ,the warning and reporting system will provide as much notice as is possible4 ,using the information provided1 ,,hss personnel will continue their mission by using the best available protected areas4 ,if warned of a nuclear attack1 they take up positions within the best available shelter2 movement out of these positions will be directed by leadership when it is safe to do so4 #c-g4 ,actions ,after a ,nuclear1 ,biological1 or ,chemical ,attack ,all personnel must survey their equipment to determine the extent of damage and their capabilities to continue the mission4 ,initially1 patients from nuclear detonations will be suffering thermal burns or blast injuries4 ,also1 expect patients and ,,hss personnel to be disoriented4 ,nuclear blast and thermal injuries will immediately manifest1 most radiation-induced injuries will not be observed for several hours to days4 ,chemical agent patients will manifest their injuries immediately upon exposure to the agent1 except for blister agents4 ,biological agent patients may not show any signs of illness for hours to days after exposure1 except for trichothecene 7,t#b7 mycotoxins4 ,all patients arriving at ,levels ,i and ,,ii ,m,t,fs must be checked for ,,nbc contamination4 ,patients are decontaminated before treatment 7see ,appendix ,g7 to reduce the hazard to ,,hss personnel1 unless life- or limb-threatening conditions exist4 ,patients requiring treatment before decontamination are treated in the ,,emt area of the patient decontamination station4 ,examples of patient conditions that may require treatment at the contaminated treatment station of the patient decontamination area-- ,massive hemorrhage4 ,respiratory distress4 ,severe shock4 #c-h4 ,logistical ,considerations a4 ,health service logistics 7,,hsl7 personnel must train and prepare to operate in all battlefield situations4 ,operating in an ,,nbc environment requires the issue of chemical patient treatment medical equipment set and chemical patient decontamination medical equipment set4 ,expect disruption of ,,msr and communications systems and plan accordingly4 ,see ,,fm #d-jb4a and ,,fm #h-aj-i for details on ,,hsl operations4 b4 ,the medical platoon 7,level ,i7 is authorized two chemical agent patient treatment medical equipment sets and one chemical agent patient decontamination medical equipment set4 ,each chemical agent patient treatment medical equipment set has enough supplies to treat #cj patients4 ,each chemical agent patient decontamination medical equipment set has enough consumable supplies to decontaminate #fj patients4 ,,note ,the chlorine granules in the chemical agent patient decontamination set are used to prepare the hypochlorite solutions for use to decontaminate patients4 c4 ,the brigade1 divisional1 and nondivisional medical companies are authorized five chemical agent patient treatment medical equipment sets and three chemical agent patient decontamination medical equipment sets4 ,these medical equipment sets are for use at the ,,dcs patient decontamination station4 #c-i4 ,personnel ,considerations ,during ,,nbc actions1 ,,hss personnel requirements increase2 thus1 ,,hss reinforcement or replacements are necessary4 ,plans for ,,hss in a ,,nbc battlefield must include efforts to conserve available ,,hss personnel and ensure their best use4 ,,hss personnel will be fully active in providing ,,emt or ,,atm care2 they will provide more definitive treatment as time and resources permit4 ,however1 to provide care they must be able to work in a shirt-sleeved environment1 not in ,,mopp ,levels #c or #d4 ,nonmedical personnel conduct search and rescue operations for the injured or wounded2 they provide immediate first aid and decontamination4 ,see ,,fm #c-e1 for detailed information on personnel and equipment decontamination operations4 ,see ,f,ms #d-jb4bhc1 #h-bhd1 and #h-bhe for detailed information on treatment of ,,nbc patients4 #c-aj4 ,disposition and ,employment of ,treatment ,elements a4 ,select sites for the ,,bas and ,,dcs that are located away from likely enemy target areas4 ,cover and concealment is extremely important2 they increase protection for operating the ,,mtf4 b4 ,operating a ,,cbps ,system in the ,,cb mode at the ,,bas requires at least eight medical personnel4 ,the senior ,,nco performs patient triage and limited ,,emt and minor injury care in the patient decontamination area4 ,one trauma specialist supervises patient decontamination and manages patients during the decontamination process4 ,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 treatment4 ,they also manage the patients that are awaiting ,,medevac to the ,,dcs4 ,the physician1 physician assistant1 and two trauma specialists provide ,,atm in the clean treatment area or inside the ,,cbps4 ,see ,appendix ,f for ,,cps entry_/exit procedures4 c4 ,when the ,,bas or ,,dcs are receiving ,,nbc contaminated patients1 they require at least eight nonmedical personnel from supported units to perform patient decontamination procedures4 ,these facilities are only staffed to provide patient care under conventional operational conditions4 ,without the augmentation support1 they can either provide patient decontamination or patient care1 but not both4 d4 ,a patient decontamination station is established to handle contaminated patients 7see ,appendix ,g74 ,the station is separated from the clean treatment area by a hot line and is located downwind of the clean treatment area or ,,cps4 ,personnel on both sides of the hot line assume a ,,mopp level commensurate with the threat agent employed 7normally ,,mopp ,level #d74 ,the patient decontamination station should be established in a contamination-free area of the battlefield4 ,however1 it may be necessary to establish a patient decontamination station that is collocated with an ,,mtf that is employing a ,,cbps1 in a chemical vapor hazard area in order to decontaminate patients and clear the battlefield before moving the ,,mtf to a clean area4 ,when ,,cps systems are not available1 the clean treatment area is located upwind #cj to #ej meters of the contaminated work area4 ,when personnel in the clean working area are away from the hot line1 they may reduce their ,,mopp level4 ,chemical monitoring equipment must be used on the clean side of the hot line to detect vapor hazards due to slight shifts in wind currents2 if vapors invade the clean work area1 ,,hss personnel must re-mask to prevent low-level ,,cw agent exposure and minimize clinical effects 7such as miosis74 #c-aa4 ,civilian ,casualties ,civilian casualties may become a problem in populated or built-up areas1 as they are unlikely to have protective equipment and training4 ,the ,,bas and ,,dcs may be required to provide assistance when civilian medical resources cannot handle the workload4 ,however1 aid to civilians will not be undertaken without command approval1 or at the expense of health services provided to ,,us personnel4 #c-ab4 ,nuclear ,environment a4 ,the ,,hss mission must continue in a nuclear environment2 protected shelters are essential to continue the support role4 ,well-constructed shelters with overhead cover and expedient shelters 7reinforced concrete structures1 basements1 railroad tunnels1 or trenches7 provide good protection from nuclear attacks 7see ,appendix ,h74 ,armored vehicles provide some protection against both the blast and radiation effects of nuclear weapons4 ,patients generated in a nuclear attack will likely suffer multiple injuries 7combination of blast1 thermal1 and radiation injuries7 that will complicate medical care4 ,nuclear radiation patients fall into three categories3 ,the irradiated patient is one who has been exposed to ionizing radiation1 but is not contaminated4 ,they are not radioactive and pose no radiation threat to medical care providers4 ,patients who have suffered exposure to initial nuclear radiation will fit into this category4 ,the externally contaminated patient has radioactive dust and debris on his clothing1 skin1 or hair4 ,this radioactive debris can cause burns if not removed quickly4 ,this usually presents a housekeeping problem to the ,,mtf1 similar to the lice-infested patient arriving at a peacetime ,,mtf4 ,however1 an accumulation of radioactive debris1 from several patients admitted to the ,,mtf1 may present a threat to other personnel4 ,the externally contaminated patient is decontaminated at the earliest time consistent with required medical care4 ,lifesaving care is always rendered1 when necessary1 before decontamination4 ,the internally contaminated patient is one that has ingested or inhaled radioactive material1 or radioactive material has entered the body through an open wound4 ,the radioactive material continues to irradiate the patient internally until radioactive decay and_/or biological elimination removes the radioactive isotope4 ,attending medical personnel are shielded1 to some degree1 by the patient's body4 ,inhalation1 ingestion1 or injection of quantities of radioactive material sufficient to present a threat to health care providers is highly unlikely4 b4 ,medical units operating in a radiation fallout environment will face three problems3 ,the ,,mtf may be immersed in fallout1 requiring decontamination and relocation efforts4 ,patients may continue to be produced from continued radiation exposure4 ,the contaminated environment hinders ,,medevac4 c4 ,decontamination of most radiological contaminated patients and equipment can be accomplished with soap and water4 ,soap and water will not neutralize radioactive material4 ,however1 it will remove the material from the skin1 hair or material surface4 ,see ,appendix ,g for specific patient decontamination procedures4 ,the waste can become a concentrated point of radiation and must be managed and monitored4 d4 ,commanders and leaders must consider the radiation exposure levels for themselves1 their staffs1 and patients when operating in or determining if the unit will enter a radiologically contaminated area4 ,the commander and leader must establish an operational exposure guide for their unit and personnel4 ,the operational exposure guide 7,,oeg7 is established for either battlefield exposures as shown in ,table #c-a or for exposures in stability operations and support operations as shown in ,table #c-b4 ,the tables present radiation exposure status 7,,res7 categories2 however1 they can be used to establish ,o,e,gs based on the same exposure criteria4 ,table #c-a4 ,radiation ,exposure ,status ,categories for ,tactical ,operations ,,res-,o ,,the ,,unit ,,has ,,had ,,no ,,radiation ,,exposure4 ,,res-#a ,,the ,,unit ,,has ,,been ,,exposed ,,to ,,greater ,,than #j c,gy ,,but ,,less ,,than ,,or ,,equal ,,to #ge c,gy4 ,,res-#b ,,the ,,unit ,,has ,,been ,,exposed ,,to ,,greater ,,than #ge c,gy ,,but ,,less ,,than ,,or ,,equal ,,to #abe c,gy4 ,,res-#c ,,the ,,unit ,,has ,,been ,,exposed ,,to ,,greater ,,than #abe c,gy4 ,table #c-b4 ,radiation ,exposure ,status ,categories ,during ,stability ,operations and ,support ,operations ,,res-,o #j4je c,gy ,,res-#a;,a #j4je ,,to #j4e c,gy ,,res-#a;,b #j4e ,,to #e c,gy ,,res-#a;,c #e ,,to #aj c,gy ,,res-#a;,d #aj ,,to #be c,gy ,,res-#a;,e #be ,,to #ge c,gy #c-ac4 ,medical ,triage ,medical triage is the classification of patients according to the type and seriousness of illness or injury2 this achieves the most orderly1 timely1 and efficient use of ,,hss resources4 ,however1 the triage process and classification of nuclear patients differs from conventional injuries4 ,see ,,fm #d-jb4bhc for nuclear patient triage and treatment procedures4 #c-ad4 ,biological ,environment a4 ,a biological attack 7such as the enemy use of bomblets1 rockets1 spray or aerosol dispersal1 release of arthropod vectors1 and terrorist or insurgent contamination of food and water7 may be difficult to recognize4 ,frequently1 it does not have an immediate effect on exposed personnel4 ,all ,,hss personnel must monitor for ,,bw indicators such as-- ,increases in disease incidence or fatality rates4 ,sudden presentation of an exotic disease4 ,other sequential epidemiological events4 b4 ,passive defensive measures 7such as immunizations1 good personal hygiene1 physical conditioning1 using arthropod repellents1 wearing protective mask1 and practicing good sanitation7 will mitigate the effects of many biological agent intrusions4 c4 ,the ,,hss commanders and leaders must enforce contamination control to prevent illness or injury to ,,hss personnel and to preserve the facility4 ,incoming vehicles1 personnel1 and patients must be surveyed for contamination4 ,ventilation systems in ,m,t,fs 7without ,,cps7 must be turned off if ,,bw exposure is imminent4 d4 ,decontamination of most ,,bw contaminated patients and equipment can be accomplished with soap and water4 ,soap and water will not kill all biological agents2 however1 it will remove the agent from the skin or equipment surface4 ,see ,appendix ,g for specific patient decontamination procedures4 e4 ,treatment of ,,bw agent patients may require observing and evaluating the individual to determine necessary medications1 isolation1 or management4 ,see ,,fm #h-bhd for specific treatment procedures for ,,bw agent patients4 f4 ,medical surveillance is essential4 ,most ,,bw agent patients initially present common symptoms such as low-grade fever1 chills1 headache1 malaise1 and coughs4 ,more patients than normal may be the first indication of biological attack4 ,daily medical treatment summaries1 especially ,,dnbi1 need to be prepared and analyzed4 ,trends of increased numbers of patients presenting with unusual or the same symptoms are valuable indicators of enemy employment of ,,bw agents4 ,daily analysis of medical summaries can provide early warnings of ,,bw agent use1 thus enabling commanders to initiate preventive measures earlier and reduce the total numbers of troops lost due to the illness4 ,see ,,fm #d-jb4ag for information of medical surveillance procedures4 ,see ,,fm #h-bhd for preventive1 protective1 and treatment procedures4 #c-ae4 ,chemical ,environment a4 ,consider that all patients generated in a ,,cw agent environment are contaminated4 ,the vapor hazards associated with contaminated patients may require ,,hss personnel to remain at ,,mopp ,level #d for long periods4 ,the ,,mtf must be set up in clean areas or employ ,,cps4 ,if there is liquid agent contamination1 or a continued vapor hazard1 the ,,mtf should be moved and be decontaminated1 mission permitting4 b4 ,initial triage1 ,,emt1 and decontamination are accomplished on the dirty side of the hot line4 ,life-sustaining care is rendered1 as required1 without regard to contamination4 ,normally1 the senior health care sergeant performs initial triage and ,,emt at the ,,bas4 ,secondary triage1 ,,atm1 and patient disposition are accomplished on the clean side of the hot line4 ,when treatment must be provided in a contaminated environment outside the ,,cps1 the level of care may be greatly reduced because medical personnel and patients are in ,,mopp ,level #c or #d4 ,however1 lifesaving procedures must be accomplished4 ,see ,,fm #h-bhe for specific treatment of ,,cw agent patients4 c4 ,decontamination of most chemically contaminated patients and equipment requires the use of materials that will remove and neutralize the agent4 ,see ,,fm #c-e for equipment decontamination procedures and ,appendix ,g for specific patient decontamination procedures4 #c-af4 ,operations in ,extreme ,environments ,enemy employment of ,,nbc weapons or ,t,i,ms in the extremes of climate or terrain warrants additional consideration4 ,included are the peculiarities of urban terrain1 mountains1 snow and extreme cold1 jungle1 and desert operations in an ,,nbc environment with the resultant ,,nbc-related effects upon medical treatment and ,,medevac4 ,for a more detailed discussion on ,,nbc aspects of urban terrain1 mountain1 snow and extreme cold1 jungle1 and desert operations1 see ,f,ms #c-jf4aa1 #ca-ga1 #ij-c1 #ij-e1 and #ij-aj4 a4 ,in mountain operations1 passes and gorges may tend to channel the nuclear blast and the movement of chemical and biological agents4 ,ridges and steep slopes may offer some shielding from thermal radiation effects4 ,close terrain may limit concentrations of troops and fewer targets may exist2 therefore1 a lower patient load may be anticipated4 ,however1 the terrain will complicate patient evacuation and may require patients to be decontaminated1 treated1 and held for longer periods than would be required for other operational areas4 b4 ,the effects of extreme cold weather combined with ,,nbc-produced injuries have not been extensively studied4 ,however1 with traumatic injuries1 cold hastens the progress of shock1 providing a less favorable prognosis4 ,thermal effects will tend to be reinforced by reflection of thermal radiation from snow and ice-covered areas4 ,care must be exercised when moving chemically contaminated patients into a warm shelter4 ,a ,,cw agent on the patient's clothing may not be apparent4 ,as the clothing warms to room temperature1 the ,,cw agent will vaporize 7off-gas71 contaminating the shelter and exposing occupants to potentially hazardous levels of the agent4 ,a three-tent system is suggested for processing patients in extreme cold operations4 ,the first tent 7unheated7 is used to strip off potentially contaminated clothing4 ,the second 7heated7 is used to perform decontamination1 perform ,,emt and detect off gassing4 ,the third 7heated7 is used to provide the follow on care and patient holding4 c4 ,in rain forests and other jungle environments1 the overhead canopy will1 to some extent1 shield personnel from thermal radiation4 ,however1 the canopy may ignite and create forest fires and result in burn injuries4 ,by reducing sunlight1 the canopy may increase the persistency effect of ,,cw agents near ground level4 ,the canopy also provides a favorable environment for ,,bw agent dispersion and survival4 d4 ,in desert operations1 troops may be widely dispersed1 presenting less profitable targets4 ,however1 the lack of cover and concealment exposes troops to increased hazards4 ,smooth sand is a good reflector of nuclear thermal and blast effects2 generating increased numbers of injuries4 ,high temperatures will increase the discomfort and debilitating effects on personnel wearing ,,mopp1 especially heat injuries4 #c-ag4 ,medical ,evacuation in a ,nuclear1 ,biological1 and ,chemical ,environment a4 ,an ,,nbc environment forces the unit leadership to consider to what extent he will commit ,,medevac assets to the contaminated area4 ,if the battalion or task force is operating in a contaminated area1 most or all of the organic medical platoon ,,medevac assets will operate there4 ,however1 efforts should be made to keep some ambulances free of contamination4 ,for conventional ,,medevac operations see ,,fm #h-aj-f and ,,fm #h-aj-bf4 b4 ,we have three basic modes of evacuating patients 7personnel litter bearers1 ground vehicles1 and aircraft74 ,using litter bearers to carry the patients involves a great deal of stress4 ,cumbersome ,,mopp gear1 added to climate1 increased workload1 and the fatigue of battle1 will greatly reduce personnel effectiveness4 ,if personnel must enter a radiologically contaminated area1 an ,,oeg must be established 7see ,table #c-a74 ,radiation exposure records are maintained by the ,,nbc ,,nco and made available to the commander1 staff1 and medical leader4 ,the exposure is entered into the individual's medical record4 ,based on the ,,oeg1 the commander and leaders will decide which ,,medevac assets will be sent into the contaminated area4 ,again1 every effort is made to limit the number of ,,medevac assets that are contaminated4 ,medical evacuation considerations should include the following3 7#a7 ,a number of ambulances will become contaminated in the course of battle4 ,optimize the use of resources2 use those already contaminated 7medical or nonmedical7 before employing uncontaminated resources4 7#b7 ,once a vehicle or aircraft has entered a contaminated area1 it is highly unlikely that it can be spared long enough to undergo thorough decontamination4 ,however1 operational decontamination should be performed to the greatest extent possible4 ,this will depend upon the contaminant1 the tempo of the battle1 and the resources available to the ,,medevac unit4 ,normally1 contaminated vehicles 7air and ground7 will be confined to dirty environments4 ,see ,,fm #c-e for details on decontamination procedures4 7#c7 ,use ground ambulances instead of air ambulances in contaminated areas2 they are more plentiful1 are easier to decontaminate1 and are easier to replace4 ,however1 this does not preclude the use of aircraft4 ,if an air ambulance is deployed into a contaminated area1 use it for repeated ,,medevac missions rather than sending other clean aircraft into the area4 7#d7 ,the relative positions of the contaminated area1 forward line of own troops 7,,flot71 and threat air defense systems will determine where helicopters may be used in the ,,medevac process4 ,one or more helicopters may be restricted to contaminated areas2 use ground vehicles to cross the line separating clean and contaminated areas4 ,the ground ambulance proceeds to an ,,mtf with a patient decontamination station 7,,pds72 the patient is decontaminated and treated4 ,if further ,,medevac is required1 a clean ground or air ambulance is used4 ,the routes used by ground vehicles to cross between contaminated and clean areas are considered dirty routes and should not be crossed by clean vehicles1 if mission permits4 ,consider the effects of wind and time upon the contaminants2 some agents will remain for extended periods of time4 7#e7 ,keep the helicopter rotor wash in mind when evacuating patients1 especially in a contaminated environment4 ,the intense rotor wash will disturb the contaminants and further aggravate the condition4 ,the aircraft must be allowed to land and reduce to flat pitch before patients are brought near4 ,this will reduce the effects of the rotor wash4 ,additionally1 a helicopter must not land too close to a decontamination station 7especially upwind7 because any trace of contaminants in the rotor wash will compromise the decontamination procedure4 c4 ,immediate decontamination of rotor wing aircraft and ground vehicles is accomplished to minimize crew exposure4 ,units include decontamination procedures in their standing operating procedures 7,,sop74 ,a sample aircraft decontamination station that may be tailored to a unit's needs is provided in ,,fm #c-e4 d4 ,evacuation of patients must continue1 even in an ,,nbc environment4 ,the ,,hss leader must recognize the constraints ,,nbc places on operations2 then plan and train to overcome these deficiencies4 e4 ,to minimize the spread of contamination inside the ,,medevac aircraft1 plastic sheeting should be placed under the litter to catch any contaminant that drips off the patient or litter4 ,the plastic sheeting can be removed with the patient1 removing any contamination with it4 ,when plastic sheeting is not available1 placing a blanket under the litter will reduce the amount of agent that makes contact with the inside of the aircraft4 ,,note ,the key to mission success is detailed preplanning4 ,a ,,hss plan must be prepared for each support mission4 ,ensure that the ,,hss plan is in concert with the tactical plan4 ,use the plan as a starting point and improve on it while providing ,,hss4 f4 ,medical evacuation by ,united ,states ,air ,force 7,,usaf7 aircraft will be severely limited until runway repairs and decontamination has occurred4 ,aerial flights from contaminated areas into uncontaminated airspace and destinations may be impossible for extended periods of time2 some nations will not allow patients from contaminated areas to travel through or over their country4 ,therefore1 patient holding on-site 7or in theater7 for an extended period of time must be anticipated4 g4 ,patient protection during evacuation must be maintained4 ,patients that have been decontaminated at the ,,pds at an ,,mtf will have had their ,,mopp ensemble removed4 ,the forward deployed ,m,t,fs will not have replacement ,,mopp ensembles for the patients4 ,these patients must be placed in a patient protective wrap 7,,ppw7 before they are removed from the clean treatment area for evacuation 7see the ,,ppw instruction sheet_/,,ppw label for use of the ,,ppw74 ,the ,,ppw provides the same level of protection as the ,,mopp ensemble4 ,the patient does not have to wear a protective mask when inside the ,,ppw4 ,the patient is placed inside the ,,ppw that is on a litter4 ,the ,,ppw may also have a battery-operated blower that can provide a reduction of the body heat load and reduce the carbon dioxide level within the ,,ppw4 ,the ,,ppw will provide protection for the patient for up to #f hours and is a one-time use item4 ,the blower is reusable1 remove it and the attachment devices from the used ,,ppw and return it to the patient movement items inventory4 ,see ,,fm #d-jb4a for a discussion on patient movement items4 ---------------------------------------- ------------------ ,,warning ,,do ,,not place contaminated patients in the ,,ppw4 ,it is for use with uncontaminated_/decontaminated patients only4 ---------------------------------------- ------------------ ,,chapter #d ,,levels ,,iii ,,and ,,iv ,,hospitalization #d-a4 ,general a4 ,many factors must be considered when planning for ,levels ,,iii and ,,iv hospital support on the integrated battlefield4 ,the hospital staff must be able to defend against threats by individuals or small groups 7two or three7 of infiltrators and survive ,,nbc strikes or ,,tim incidents while continuing their mission4 ,this threat may include the introduction of ,,nbc or ,,tim in the hospital area1 the water or food supplies2 and the destruction of equipment and_/or supplies4 ,on the larger scale of surviving ,,nbc strikes and continuing to support the mission1 operating in a contaminated environment will present many problems for hospital personnel4 ,the use of ,,nbc weapons or ,,tim release can compromise both the quality and quantity of health care delivered by medical personnel due to the contamination at the ,,mtf2 constrain mobility and evacuation2 and contaminate the logistical supply base4 ,while providing hospital support1 consider the following assumptions3 7#a7 ,their location1 close to other support assets1 makes them vulnerable to ,,nbc strikes and release_/dispersion of ,t,i,ms4 ,command1 control1 communications1 computers1 and intelligence 7,c#d;,i7 infrastructure1 logistical nodes1 and base clusters are high value targets4 ,most ,,nbc weapons are designed for wide-area coverage4 ,chemical and biological agents may present a hazard some distance downwind from the area of attack2 also1 residual radiation may extend for hundreds of kilometers 7km7 from ground zero4 ,the large signature 7size1 heat1 infrared7 of a hospital makes it easy to find and target 7the assumption is that the hospital is very near the intended targets74 ,hospitals located near road networks and airfields for access to evacuation routes increase their exposure to tactical strikes of ,,nbc weapons and exposure to ,,tim releases4 ,there are ever-increasing numbers of countries and individuals with the ability to manufacture and deliver ,,nbc weapons_/agents4 ,this activity increases their use potential at all levels of conflict4 ,,note ,when using existing civilian hospitals1 the materials for an ,,rdd may be at these hospitals4 ,exploding the material in place is very practical for a small team of terrorists4 7#b7 ,large numbers of casualties are produced in a short period of time4 ,many of these casualties may have injuries that are unfamiliar to hospital personnel4 ,these injuries may include-- ,radiation casualties4 ,biological casualties4 ,chemical casualties4 ,toxic industrial biological casualties 7release of material from biological research facilities74 ,toxic industrial chemical casualties4 ,toxic industrial radiological casualties4 ,chemical agent antidote overdose casualties4 ,combined conventional and ,,nbc injuries4 ,stress casualties mimicking all the above4 7#c7 ,in addition to the wounding effects of ,,nbc weapons on troops1 their use will have other effects upon the patient care delivery system4 ,follow-on treatment may have to be delayed due to the need for patient and faculty decontamination4 ,the arrival of contaminated patients at the hospital will require hospital personnel to perform triage2 administer ,,emt procedures in the patient decontamination area2 supervise augmentation personnel performing patient decontamination2 and constantly monitor the hospital for contamination4 ,the combat support hospital ,,csh requires at least #bj nonmedical personnel from units within the geographic area_/base cluster of the hospital to perform patient decontamination under medical supervision4 ,see ,appendix ,g for patient decontamination procedures4 ,patients may have been triaged and decontaminated at a ,level ,i or ,level ,,ii ,,mtf4 ,however1 all patients must be triaged and checked for contamination as they arrive at the hospital ambulance drop off point4 ,triage ensures patients receive life- or limb-saving care in a timely manner4 ,if patients are arriving from a suspected ,,nbc contaminated area1 they must be decontaminated before admission into the clean treatment area of the hospital4 ,the patient decontamination area is established on the downwind side of the hospital4 ,when the hospital does not have collective protection1 the patient decontamination point must be at least #ej yards downwind of the hospital entry point4 ,when the hospital is located inside a base cluster1 the patient decontamination area may have to be established some distance from the hospital to prevent contamination of other units in the area4 ,should this be the case1 the patients may have to be transported by ambulance or other vehicle from the clean side 7hot line7 of the patient decontamination area to the receiving point of the hospital4 ,conditions may mandate the use of nonmedical vehicles to transport casualties to the ,,mtf4 ,the use of these vehicles limits or prohibits en route medical care1 but may be the only way to clear the battlefield and ensure timely care of patients at the hospital4 7#d7 ,mission-oriented protective posture reduces the efficiency of all personnel4 7#e7 ,without ,,cps systems1 hospitals may operate for a limited time in a nonpersistent agent environment1 but are incapable of operating in a persistent agent environment4 ,chemical_/biological filters for fixed site hospital ventilation systems will be a critical item of supply4 ,controlled entry and exit point with sufficient space to permit placement of litter patients and_/or numbers of personnel that permit purge of vapors will have to be established4 ,all windows1 doors1 and other points that may have air leaks will have to be sealed 7use tape and plastic sheeting7 to enable the facility to have a positive overpressure to keep ,,cb agents out4 ,liquid chemical agents can penetrate the ,,temper in about #f hours or general purpose 7,,gp7 tentage in a shorter period of time4 ,these agents will penetrate the wrappings on medical supplies and equipment2 especially1 sterilized equipment and supplies1 paper-wrapped cotton sponges1 and open or lightly closed medications_/solutions4 ,they can also contaminate water_/food supplies4 ,therefore1 equipment and supplies must be stored in protected areas or under protective coverings4 ,without a ,,cps system1 treatment procedures involving open wounds or the respiratory tract in the presence of a ,,cb agent hazard is limited4 ,exposing open wounds and the respiratory tract to the agent increases the effects of these agents on the patient4 ,without hardened protection1 the hospital1 staff1 and patients are susceptible to the effects 7blast1 thermal1 radiation1 and missiling7 of nuclear weapons4 ,hospital electrical and electronic medical equipment is vulnerable to the effects of the ,,emp produced by nuclear weapons4 ,the ,,emp is not harmful to humans1 animals1 or plants1 but is very damaging to electronic equipment4 ,hospital equipment is very difficult to decontaminate4 ,aging 7allowing the agent to off-gas7 may be the only means of decontamination4 ,hospitals are not kept in reserve4 ,all personnel and equipment losses due to ,,nbc contamination or radiation will have to be replaced4 b4 ,there are currently two force modernization initiative hospital systems in the force structure4 ,the ,medical ,force #bjjj 7,,mf#b,k7 system consists of the ,,csh1 the field hospital 7,,fh71 and the general hospital 7,,gh74 ,the ,medical ,reengineering ,initiative 7,,mri7 consists of only one hospital system--the ,,csh4 ,the ,,mf#b,k ,,csh is a corps asset1 whereas1 the ,,fh and ,,gh are the echelon above corps hospital systems4 ,the ,,mri ,,csh will be located in the corps and at echelons above corps4 ,the ,,mri ,,csh will replace the ,,fh and ,,gh at echelons above corps4 ,see ,,fm #d-jb4aj1 ,,fm #h-aj-ad1 and ,,fm #h-aj-ae for detailed information on these hospital systems4 #d-b4 ,protection a4 ,protection of hospital assets requires intensive use of intelligence information and careful planning4 ,the limited mobility of hospitals makes their site selection vital to minimize collateral damage from attacks on other units4 ,hospitals must be located as close to the supported units as possible to provide responsive care in support of the tactical commander's plan4 ,however1 their limited mobility must be considered when selecting their locations4 ,protective factors 7distance from other support units and interposed terrain features7 must be balanced against the operational factors 7accessibility and time required for patient transport74 ,depending on the weapon systems used1 local topography1 and meteorological conditions1 relatively large portions of the tactical area may remain uncontaminated4 b4 ,many defensive measures will either impede or preclude performance of the hospital mission4 ,successful hospital defense against an ,,nbc threat is dependent upon accurate1 timely receipt of information via the nuclear1 biological1 and chemical warning and reporting system 7,,nbcwrs74 ,this information will allow the hospital to operate longer without the limitations and problems associated with the use of the ,,cps and personnel assuming ,,mopp ,levels #c and #d4 ,the detailed information 7provided in the ,,nbc #e and #f reports respectively7 on the areas affected and the types of agents used allows the hospital staff to-- ,project the number and types of patients to be expected4 ,establish a patient decontamination area4 ,request patient decontamination assistance4 7#a7 ,protective procedures4 7a7 ,because most hospital sections operate in sheltered areas 7tentage or hard-walled shelter71 some protection is provided against vapor1 liquid1 and particulate 7fallout7 hazards4 ,sealing all openings can increase the temporary protection from such hazards2 all entries and exits must be curtailed while operating in this mode4 ,liquid agents will eventually seep through the tent fabric and create a vapor hazard inside the shelter4 ,locating equipment1 such as trucks1 under trees or other cover provides similar effects4 ,setting up hospitals in existing structures 7concrete or steel buildings7 provides greater protection from hazards and eliminates many decontamination problems4 ,however1 without means to seal openings1 chemical agent vapors can enter the structure4 ,the addition of ,,cb filtration systems with air locks1 that provide overpressure1 can provide maximum protection for occupants4 ,entry and exit procedures must be established to prevent contamination being introduced by personnel and patients entering4 ,see ,appendix ,f for entry_/exit procedures when ,,cb filters and air locks are in use4 7b7 ,concealment and good operations security 7,,opsec7 will help prevent identification of a unit4 7c7 ,dispersion is a defensive measure employed by tactical commanders2 however1 hospital operations limit the value of this technique4 ,one technique that may be used is locating sections of the hospital1 such as the motor pool1 personnel billets1 laundry1 and logistical storage1 a greater distance from the hospital complex than normal4 ,this will increase dispersion without severely compromising the hospital mission4 7d7 ,the ,,mopp ensemble does not protect against all radiation effects of nuclear weapons4 ,however1 it provides some protection against alpha and beta radiation burns4 ,by covering all body surfaces1 especially hairy areas1 ,,mopp greatly expedites the decontamination process4 7#b7 ,nuclear4 7a7 ,most protective measures for hospitals against nuclear attack require engineer and_/or intensive logistic support4 ,this support includes placing sandbag walls around tents2 digging trenches for patient occupation2 or constructing earthen berms 7see ,appendix ,h74 ,occupying existing structures1 depending upon their strength and potential flammability1 may be the best protection against the effects of a nuclear strike4 ,the remainder of this section presents factors to consider when selecting the protective posture for the hospital against a nuclear attack4 ,leaving equipment packed and loaded until actually needed for operations will help protect materiel in an ,,nbc environment4 ,in any event the unit must have established an ,,oeg1 implemented radiation monitoring1 and have contingency plans if these radiation levels are approached or exceeded4 7b7 ,personnel and patient protection requirements will depend upon the threat 7blast1 thermal1 immediate radiation1 or fallout effects74 ,the ,,mopp ensemble will not protect against internal radiation1 but will provide some protection from external radiological contamination4 ,if the threat is nuclear fallout1 the hospital structure provides protection2 the fallout can be brushed or washed off4 ,this allows protection while permitting patient care to continue virtually uninterrupted4 ,a need to relocate the hospital will depend upon the degree of contamination2 the amount of decontamination possible2 and the projected stay before a normal move in support of operations4 ,hospital tentage alone offers little protection against blast and missiling effects4 ,if the patients are to remain in the tents1 they are placed on the floor4 ,place all equipment on the ground or as low as possible and secure all loose objects4 ,in ,,gp tents1 sandbags can be piled around the base of the tent poles to add stability4 ,the tent poles and patient beds should keep the canvas off the ground enough 7if the tent collapses7 to continue minimal patient care and evacuation2 however1 be aware of possible tent pole breakage4 ,hospital units are very susceptible to the thermal effect of a nuclear detonation4 ,tents will not provide protection against the thermal pulse4 ,if the thermal effect 7fire7 is an impending threat1 patients and personnel in tentage must move to trenches1 bunkers1 or other nonflammable areas4 ,protection factors that can reduce the overall radiation exposure rate for hospital personnel and patients are-- ,time4 ,reducing the exposure time to the radiation reduces the overall exposure proportionally 7cut the time of exposure in half and the overall exposure is cut in half74 ,,example3 ,an exposure time of #fj minutes to a dose rate of #ajj centigray 7c,gy7 is cut in half 7#cj minutes7 to an exposure rate of #ej c,gy4 ,distance4 ,increasing the distance from the radiation source reduces the exposure in an inverse square relationship 7double the distance factor by #b decreases the exposure factor by #d74 ,shielding4 ,placing material between personnel and patient and the radiation source decreases the dose 7the reduction factor is dependent on the type of radiation and the density of the shielding material74 ,placement of sandbags 7two feet wide7 around the hospital tents and shelters provides adequate shielding for protection from gamma and x-ray radiation2 the thicker the sandbag stacks the greater the protection factor4 ,tent material is a good shield for alpha particles and adequate shielding from beta particles4 ,see ,appendix ,h for field expedient shielding techniques4 7#c7 ,biological4 ,the most likely use of a biological agent 7such as anthrax7 is releasing the agent as an aerosol4 ,while such agents may produce large numbers of casualties1 initially patients may be seen at the ,,mtf in small numbers1 but the number of patients will rapidly increase within a few hours to days4 ,when a trend is identified1 the enemy use of a biological agent is suspected4 ,general protective measures are the same as for any infectious disease2 specific protective measures are used once the vector or method of transmission has been identified4 ,designating a single hospital to care for these patients 7from a patient care or disease transmission standpoint7 may not be necessary4 ,however1 if the agent is communicable1 consolidating them all at one facility maximizes the use of limited assets and aids in limiting the spread of the disease4 ,protective measures against biological attack are the same as those for chemical agents when bombs1 sprays1 or gases are used2 see 7#d7 below4 ,the difficulty in rapidly identifying biological agents may force the use of protective measures for longer periods of time4 ,faced with this situation1 a careful evaluation of the mask-only posture is necessary before implementing any level of ,,mopp4 ,see ,,fm #h-bhd for additional information on prevention1 protection1 and treatment of biological casualties4 7#d7 ,chemical4 7a7 ,individual protection4 ,when ,,cps systems are not available1 using the correct ,,mopp level is essential in hospital mission performance4 ,the level of ,,mopp assumed depends upon the level of threat4 ,an alternative approach for the hospital commander is the use of the mask-only posture4 ,this posture is acceptable when the hazard is from vapor only 7except mustard74 ,see ,,fm #c-d for a description of each ,,mopp level and mask-only procedures4 ,hospital warning system4 ,the hospital must have a warning system that alerts all personnel of impending or present hazards4 ,this system must include visual and auditory signals2 the signals must operate inside and outside the hospital complex4 ,there are numerous problems associated with warning personnel2 they include-- ,the wide area covered by the hospital operations4 ,some personnel will be asleep at all times of the day or night 7two or three shifts74 ,the considerable noise from mechanical support equipment2 such as the power generation and environmental control equipment4 ,tentage and equipment interrupts line of sight4 ,hospital personnel response4 ,when ,,nbc alarms are activated1 all personnel 7including off duty personnel7 report to their duty stations as soon as they are in the designated ,,mopp level4 ,this allows for #ajj percent personnel accounting and provides additional personnel to secure patients and materiel4 ,unprotected hospital areas4 ,areas of the hospital without ,,cps are at their best posture with all openings secured and the ventilation systems turned off4 ,for nonpersistent agents 7vapor hazards71 personnel and patients stay at the designated ,,mopp level until the all clear signal is given2 then normal operations are resumed4 ,,note ,patients with injuries that prevent their assuming a protective posture must be placed in a ,,ppw or immediately evacuated to a clean ,,mtf4 7b7 ,environmental protection4 ,as noted previously1 hospital complexes without ,,cps offer some protection against liquid or fallout contamination1 but little protection against vapor hazards4 ,when ,,mopp ,level #a must be assumed1 close and secure all tent flaps1 vents1 and doors to prevent the entrance of liquids or particles4 ,all hospital personnel outside of shelters assume ,,mopp ,level #d4 ,cover or move all equipment and supplies into shelters 7tents1 hard-walled shipping containers71 if possible4 ,placement under thick foliage trees is better than left out in the open4 ,the best policy is to keep all equipment and supplies not immediately needed covered or in closed containers4 ,when ,,mopp ,level #c or mask-only posture is assumed1 shut down the hospital's ventilation system to prevent drawing vapors or fallout contamination into the hospital4 ,this measure also provides some protection of the internal environment during the time required for the vapor to penetrate the tentage4 7c7 ,patient protection4 ,patient protection depends upon prior planning and timely warning of the chemical threat4 ,each patient's protective mask must be available and serviceable4 ,if the patient came from a contaminated area1 the mask must be decontaminated and the filters changed4 ,the mask decontamination and filter change may have to be performed by hospital personnel4 ,if ambulatory patients' medical conditions permit 7minimal care ward71 they may be able to perform this task4 ,the hospital supply staff must ensure that mask filters are available at the supporting logistics support facility and can be requisitioned to meet this requirement4 ,check all masks for serviceability as soon as the mission permits1 but always before they are needed4 ,do not wait until the warning has been received to begin checking the mask4 ,each area must have an established plan for operations 7to include assisting patients assuming ,,mopp or other protective posture7 in the ,,nbc environment4 ,appendix ,f provides additional information on patient protection4 ---------------------------------------- ---------------- ,,caution ,remember1 personnel must assume ,,mopp ,level #d before beginning any decontamination process or risk becoming a casualty themselves4 ---------------------------------------- ---------------- ,hospital staff always mask themselves first1 then assist patients in masking4 ,on minimal care wards1 most patients can put on their masks4 ,for those who cannot1 other patients can assist them after putting on their own masks4 ,on the intermediate care wards1 some patients will be able to put on their masks1 but many will require assistance4 ,intensive care and emergency room staff will have to assist their patients in masking4 ,many patients with head and neck wounds or who are on life-support devices will be unable to wear their individual protective masks2 these patients must be placed in a ,,ppw4 ,while the ,,ppw has two ports for intravenous or blood infusion lines1 the staff may have to adapt for other devices 7,foley catheters1 traction devices1 and cardiac monitor7 by using tape and other means to seal the gaps created in the seal around the edge of the ,,ppw4 ,patients requiring assisted ventilation are at extreme risk1 unless their air supply is protected4 ,the sequence of protecting everyone is mask yourself first2 assist those patients who can wear their protective masks2 and then place patients in the ,,ppw4 7d7 ,materiel protection4 ,protection of materiel1 especially expendable supplies1 requires covers and barriers4 ,all materiel not required for immediate use is kept in shipping containers1 medical chests1 or under cover 7tentage1 plastic sheeting1 and tarpaulin7 for protection against particulate or liquid hazard4 ,protection against vapor hazard may require multiple barriers through which the vapor must penetrate4 ,for example1 intravenous solutions are in their individual plastic bags1 in the cardboard shipping box1 on a covered pallet1 in a hard-walled shelter2 such as a military-owned demountable container 7,,milvan74 ,this presents four barriers against the vapor hazard4 ,these principles should be used to the maximum extent practical4 #d-c4 ,decontamination a4 ,decontamination of nuclear-contaminated personnel1 equipment1 and the operational site is as follows3 7#a7 ,monitoring equipment is used to detect contamination2 the contamination is then removed by brushing or scraping with brooms1 brushes1 or tree branches4 ,flushing hard surface contaminated areas with water is also effective in removing nuclear contamination4 ,however1 there remains a problem of containing and removing the contaminated water4 ,the best method of containment is to trench the area into a sump for collection of the contamination4 ,this will reduce the area of contamination2 however1 the level of concentrated radiation may be such that there is an increased hazard to personnel4 ,the collection area must be clearly marked using the standard nuclear hazard signs4 7#b7 ,nuclear contamination of the site may require relocating the hospital4 ,scraping #a or #b inches of topsoil from the area1 or covering the area with #a or #b inches of uncontaminated dirt will not be practical4 ,a need to relocate the hospital will depend upon the degree of contamination2 the amount of decontamination possible and the projected stay before a normal move in support of operations4 ,if the hospital is immersed in a high level of radioactivity1 the best option may be to abandon it for #dh to #gb hours4 ,after this period the area should be checked and if the radioactivity has decayed sufficiently the hospital may be reoccupied and continue operations or moved to a clean area4 ,the command ,,oeg must be followed if reoccupying or moving the facility4 b4 ,suspect biological agents should be removed from equipment as quickly as possible1 ,in the absence of agent-specific guidance1 clean exposed surfaces using a #e percent hypochlorite solution or copious quantities of soap and water 7preferably hot74 ,liberally apply the hot1 soapy water and scrub all surfaces with a brush4 ,then rinse the surfaces with hot water4 ,as previously discussed1 the soapy water used is contaminated and must be controlled and removed to a safe area4 ,supertropical bleach 7,,stb7 and decontaminating solution ,number #b 7,,ds#b1 ,,us ,army7 are effective against most known biological agents because of their caustic nature4 ,if anthrax 7or other spore formers7 is suspected1 repeat the entire decontamination process again to remove the spores4 ,other standard biological decontamination agents are described in ,,fm #c-e4 ---------------------------------------- -------------------------- ,,caution #a4 ,keep liquid decontaminants out of equipment with electronic or electrical circuits4 ,unplug electrical devices before attempting to decontaminate them2 prevent electric shock4 ,some electronic devices maintain an electric charge1 even after being unplugged1 use extreme care to prevent shock4 #b4 ,soap and water only mechanically remove ,,bw agents4 ,the soap and water solution must be contained to prevent spreading the agent to other personnel1 thus causing more casualties4 ---------------------------------------- -------------------------- c4 ,decontamination of chemical contamination is as follows3 7#a7 ,personnel use their soldier skills and their ,m#bie ,individual ,equipment ,decontamination ,kit to decontaminate their personal equipment4 ,the ,m#ac1 decontamination apparatus1 portable1 is used to decontaminate vehicles1 trailers1 and ,international ,organization for ,standardization 7,,iso7 shelters4 ,this apparatus uses ,,ds#b 7a highly caustic1 flammable solution that cannot be used to decontaminate tentage74 ,the ,,ds#b must be washed off after sufficient time has passed for decontamination 7see ,,fm #c-e for details74 ,water used for ,,nbc decontamination purposes becomes contaminated2 therefore1 it must be contained in sumps4 ,dig shallow trenches to channel the water into sumps4 ,this will be difficult in hospital areas because relatively flat sites are needed for hospital complexing1 but must be accomplished to reduce the contamination levels in the hospital area4 7#b7 ,when hospital tentage becomes contaminated1 decontamination operations must be considered immediately4 ,spot decontamination may be effective for small areas2 however1 gross contamination of ,,temper and ,,gp tentage is best decontaminated by aging4 ,without ,,cps and with persistent agent contamination that absorbs into the tentage and presents a continuing vapor hazard1 the hospital stops receiving patients and evacuates all patients as quickly as possible4 ,when large portions of the hospital are contaminated1 personnel decontaminate all equipment possible and relocate to a new site1 leaving the contaminated equipment to age or to be decontaminated by a specialized unit4 ,when small portions of the hospital are contaminated1 the contaminated portions are removed to another location for decontamination2 hospital operations are continued1 but at a lower operational level4 ,for detailed equipment decontamination procedures1 see ,,fm #c-e4 ,,note ,liquid decontamination material must not be used on electrical or electronic components of equipment4 ,liquid decontaminants can damage the equipment2 thus making it inoperable and not available for patient care or transport4 ,the use of liquids to decontaminate electronic equipment could also potentially result in injury or electrocution of personnel4 7#c7 ,each ,,us ,army hospital is issued five chemical agent patient treatment ,,mes and three chemical agent patient decontamination ,,mes1 ,chemical ,agents ,patient ,decontamination1 for use in decontaminating patients4 ,each hospital must decontaminate and treat its own personnel who become casualties2 chemical casualties from units in its general area2 or contaminated patients received from lower level ,m,t,fs4 ,see ,appendix ,g for patient decontamination procedures and for establishment of a patient decontamination and treatment station4 #d-d4 ,emergency ,services a4 ,providing emergency services will be complicated by several factors3 ,varying levels of treatment received prior to arrival at the hospital4 ,caring for combined conventional wounds and ,,nbc agent effects4 ,managing heat-related complications associated with ,,mopp_/,,ppw use4 ,controlling psychological effects caused by biological and chemical agents1 the impact of ,,nbc weapons1 or the isolation of ,,mopp gear or ,p,p,ws4 ,having ,,emt personnel working at the arrival point1 decontamination site1 and in the hospital ,,emt area4 ,conducting triage and providing patient care while in ,,mopp gear4 ,supervising supported units decontamination augmentation personnel4 ,these personnel will most likely be of any military occupational specially 7,,mos71 except medical4 ,they will use hospital equipment and supplies to decontaminate patients4 b4 ,contaminated patients must be triaged in the decontamination area that is established at the hospital4 ,contaminated patients ,,will ,,not be brought into the clean ,,emt area until decontaminated4 ,all patients are screened for contamination4 ,based on the findings1 the patient is routed to the contaminated triage station1 or to the clean triage station4 ,contaminated patients are triaged1 then routed to the decontamination area1 or to the contaminated treatment area4 ,patient admission to the clean treatment area may be delayed2 however1 life- or limb-saving care is provided in the contaminated treatment area before decontamination4 #d-e4 ,general ,medical ,services ,the provision of general medical services in the hospital will be continued with minimal interruptions in the ,,nbc environment4 ,the noninvasive nature of these services allows their continuation at most ,,mopp levels4 ,however1 some general medical services will be constrained by ,,mopp ,levels #c and #d and the mask-only posture4 ,these constraints may include1 but not be limited to-- ,communication limitations4 ,loss of the oral route for administering medications to patients4 ,limited ability to accurately evaluate the eyes1 nose1 and mouth of patients wearing a protective mask4 ,reduced ability to perform examination_/assessment of patients in ,,ppw or ,,mopp ,levels #c and #d4 ,inability to provide oxygen therapy or ventilator support to a patient in a vapor hazard environment1 unless a ,,cb filter-supported respirator is available4 ,logistical constraints based upon the fact that key areas such as dietetics1 supply1 and laundry are not in the ,,cps4 ,these services may be reduced or delayed in the ,,nbc environment4 ,see ,appendix ,f for ,information on patient feeding under ,,nbc conditions4 #d-f4 ,surgical ,services a4 ,surgical services will be severely limited in the ,,nbc environment4 ,at any level above ,,mopp ,level #j1 without a ,,cps system surgical services are halted except for life- or limb-saving expedient procedures4 ,surgery cannot be safely performed outside a ,,cps due to a variety of factors including-- ,lack of protected ventilation for patients during and after surgery4 ,inability to maintain a sterile field while using ,,mopp gear4 ,direct access for agents through open wounds to the circulatory and respiratory systems4 ,decreased dexterity and vision resulting from ,,mopp gear use4 ,inability to quickly place the patient in a ,,ppw should the need arise4 b4 ,due to the relatively high number of trauma cases1 hospital services may be severely constrained by ,,nbc contamination4 ,the hospital location and the possible need for relocation are two major planning considerations for the command staff4 c4 ,patient accounting and medical regulating are critical factors in the transfer of patients from a hospital without a ,,cps that must move out of an ,,nbc environment4 ,hospitals without ,,cps stop receiving patients when a persistent hazard is identified2 patients on hand are protected and transferred to a clean ,,mtf4 #d-g4 ,nursing ,services ,providing nursing care in a hospital without ,,cps is influenced by the amount of protective gear worn by the nursing staff and the patients4 ,the patients may be in their ,,mopp gear1 in a ,,ppw1 or wearing only their protective mask2 any of which will interfere with care4 ,the nursing staff will wear the same level of protection as the patients4 a4 ,direct assessment of a patient's vital signs is extremely limited at ,,mopp ,levels #c or #d2 however1 a carotid artery pulse can be taken by palpating the neck area4 ,the patient's respiratory rate and level of consciousness may be assessed visually4 ,palpitation of the blood pressure through a ,,ppw may be possible if it is relatively strong1 or at least in the normal range4 ,the patient's temperature cannot be monitored2 this is an area of concern due to the possibility of heat stress4 b4 ,only gross neurological signs can be assessed through the ,,ppw or when the patient is in ,,mopp ,levels #c or #d4 ,however1 even this assessment is complicated by the presence of miosis and by the health care provider's mask4 ,urinary output and cardiac monitoring is continued uninterrupted for patients wearing a mask only and for patients in the ,,ppw4 c4 ,oral hygiene and bathing are postponed until a safe environment is available 7,,mopp ,level #b or less74 ,all toileting will occur within the hospital complex using ,,iso contained latrines1 chemical toilets1 bedpans1 urinals1 buckets1 or containers with plastic liners4 ,waste from improvised containers must be placed in containers with covers or in plastic bags and sealed to control odors and prevent spread of infectious material within the facility4 d4 ,at ,,mopp ,levels #c and #d1 feeding must be postponed4 ,a nutritional assessment is needed to determine how long each patient can tolerate a fasting state when ,,mopp ,level #c or ,level #d remains in effect for over #bd hours4 e4 ,intravenous 7,,iv7 medications are mixed in a clean area and then transported in a protective wrap 7multilayers of plastic1 medical chest1 or layered cardboard7 to the user4 ,however1 ,,iv solutions1 blood1 and injections can be given to patients on an unprotected ward4 ,normally1 oral medications are only given at ,,mopp ,level #b or lower4 f4 ,treatment procedures that have the potential of contaminating the patient's pulmonary or circulatory systems are conducted only at ,,mopp ,level #b or below4 ,however1 ,,emt procedures may have to be performed in the contaminated treatment area1 or the patient decontamination area4 g4 ,continuous oxygen therapy requires a collective protection environment or a ,,cb filter supported respirator4 h4 ,delivery of nursing care at ,,mopp ,level #c or ,level #d is limited due to the sensory restrictions of ,,mopp gear4 ,time is taken to reassure the patients on a personal basis1 as much as possible1 and by routinely monitoring the ward environment4 ,communications are difficult and identities are masked4 ,maintain the identity of personnel by using handwritten name tags for staff and patients 7including patients in ,,ppw74 i4 ,as with all procedures1 the time required for record-keeping rises markedly at ,,mopp ,level #c or ,level #d4 ,contaminated paperwork cannot be evacuated with the patient4 ,transcribe essential information onto uncontaminated documents for evacuation with the patient4 ,a record of patient exposure time to a contaminated area is prepared to assess the cumulative risk to the patient4 #d-h4 ,conventional ,operations ,for conventional operations of hospitals in a field environment see ,,fm #d-jb4aj1 ,,fm #h-aj-ad1 and ,,fm #h-aj-ae4 ,,chapter #e ,,other ,,health ,,service ,,support ,section ,i4 ,,preventive ,,medicine ,,services #e-a4 ,general ,on the integrated battlefield1 ,,pvntmed services will be in greater demand than at any other time1 especially under ,,bw conditions4 ,preventive medicine personnel will be called upon to assist the commander in determining the health hazards associated with nuclear fallout2 the safety of drinking water in an ,,nbc environment2 as well as determining when to use prophylaxis1 pretreatments1 immunizations1 and other ,,pvntmed measures 7,,pmm7 associated with ,,nbc warfare4 ,preventive medicine personnel must be aware of the medical threat in the ,,ao4 ,they must continually update their medical surveillance activities to identify disease trends 7endemic and epidemic71 potential disease vectors1 and the susceptibility of troops to these diseases4 ,under ,,nbc conditions1 diseases may manifest that exist in the area1 but were not being transmitted to personnel4 ,however1 due to the reduced health status of personnel from exposures to or from stress-related ,,nbc conditions1 the troops begin to suffer their effects4 ,the appearance of diseases or arthropods not known to exist in the ,,ao are indicators that ,,bw agents have been used4 ,for details on ,,pvntmed operations1 see ,,fm #d-jb4ag4 #e-b4 ,disease ,incidence ,following the ,use of ,nuclear1 ,biological1 and ,chemical ,weapons a4 ,determining ,factors4 ,factors of prime importance in determining the nature and severity of the disease effects are-- ,immunization status of personnel4 ,population density4 ,degree of industrialization in the operational area4 ,availability of food supplies4 ,availability of water4 ,climate4 ,finally1 the manner and situation in which nuclear weapons are used are of importance4 ,a single weapon detonated in a socially stable area will have far less serious effects than a detonation in an area where combat has already disrupted the social stability4 ,at ,hiroshima and ,nagasaki1 ,japan 7excellent examples of the first type of situation71 the survivors who could get away were able to obtain food1 shelter1 and care from surrounding intact areas4 ,with prolonged combat operations1 such intact areas would not be available1 resulting in no food1 shelter1 or care for survivors4 ,there will be a breakdown in social order and there will be a lack of effective medical support2 including ,,pvntmed functions and facilities4 b4 ,disease ,incidence4 ,without ,,pvntmed capabilities1 increased incidence and morbidity from diseases will follow4 ,some diseases will predominate in incidence1 depending upon the geographical areas involved and the endemic diseases present4 7#a7 ,in urban areas in temperate climates1 several diseases are epidemic threats4 ,these epidemic threats may include-- ,dysentery 7due to a variety of pathogens74 ,rickettsial diseases1 particularly typhus and scrub typhus4 ,hepatitis4 ,tuberculosis4 ,sexually transmitted diseases4 ,malaria and cholera 7in many parts of the world74 7#b7 ,there are several reasons for the increased risk of disease including1 but not limited to-- ,crowding of surviving populations with limited sanitary facilities1 such as was seen in ,europe at the end of ,world ,war ,,ii4 ,a lack of prophylaxis and immunizations with resultant increases in the susceptible faction of a given population4 ,a lack of pest management4 ,the effect of irradiation on susceptibility to infection4 ,with the high levels of fallout covering wide areas1 a large number of people will sustain sublethal whole-body doses of irradiation4 ,the interaction of irradiation with infections is not clear2 but it may be the result of latent infections manifesting and decreased resistance to infection4 ,the result is an increased incidence of disease4 ,the ecological imbalance and host-parasite relationship following the use of nuclear weapons4 ,each class and order of animals has marked differences in sensitivity to irradiation4 ,arthropods1 for example1 are much more resistant than are vertebrates4 ,the normal balance between arthropods and birds that prey upon them in a given area may be severely upset1 producing a marked overgrowth of the arthropods4 ,if the arthropods include vectors of disease there would be a serious increase in disease hazards4 ,if there is an increase in arthropods that destroy vegetation there would be a serious destruction of food crops4 ,the introduction of a ,,bw agent in an ,,ao in which the disease organism is endemic or epidemic can increase the risk level for exposed personnel4 #e-c4 ,preventive ,medicine ,section ,the ,,pvntmed sections of the brigade1 divisional1 and nondivisional medical companies perform analysis on water sources and supplies to determine the presence or absence of ,,nbc_/,,tim contamination2 see ,appendix ,i for additional information4 ,based upon their findings1 the water is released for consumption1 or is restricted from use until it is treated 7usually by water production personnel using the reverse osmosis water purification unit ,,rowpu74 ,they also collect water samples for suspect biological agent contamination for supporting medical laboratory analysis 7see ,appendix ,b74 ,they conduct medical surveillance activities1 to include occupational and environmental health threat surveillance4 ,they conduct limited entomological surveys to determine the existence of disease-vectoring arthropods in the ,,ao4 ,they inspect food service facilities to determine the extent1 if any1 of ,,nbc contamination4 ,they evaluate the unit's-- ,immunization status4 ,use of prophylaxis for specific diseases 7such as antimalarial tablets7 7see ,,fm #d-jb4cc71 for nuclear radiation exposure 7such as granisetron for nausea and vomiting7 7see ,,fm #d-jb4bhc71 and for ,,bw agents 7such as ,ciprofloxacin for postexposure chemoprophylaxis for ,anthrax7 7see ,,fm #h-bhd74 ,use of nerve agent pyridostigmine pretreatment tablets 7see ,,fm #h-bhe71 if warranted4 ,application of personal hygiene and field sanitation procedures 7,,fm #ba-aj_/,,mcrp #d-aa4a;,d74 ,based upon their findings1 they provide recommendations for corrective actions to the commanders4 ,they assist in training ,,us ,army unit field sanitation teams 7,,fm #d-be4ab72 they are not members of the unit field sanitation team4 ,they conduct medical surveillance activities for their command 7,,fm #d-jb4ag74 #e-d4 ,preventive ,medicine ,detachment ,the ,,pvntmed detachment provides ,,pvntmed services on an area support basis to units within their assigned ,,ao4 ,these services include1 but are not limited to-- ,conducting water surveillance1 including ,,nbc contamination4 ,collecting water samples suspected of ,,nbc_/,,tim contamination for analysis by supporting medical laboratory 7see ,appendix ,b74 ,performing food service sanitary inspections4 ,conducting medical surveillance and providing epidemiological consultation4 ,conducting pest 7arthropod and rodent7 surveys and surveillance4 ,conducting arthropod control operations4 ,the aerial spraying missions are dependent upon availability of helicopter support4 ,conducting occupational and industrial hygiene surveys4 ,advising commanders on the application of ,,pmm4 ,training the supported units' field sanitation teams4 ,section ,,ii4 ,,veterinary ,,services #e-e4 ,general ,the ,,us ,army ,veterinary ,service is the ,executive ,agent for veterinary services to all ,services within the ,,dod4 ,they ensure that food and bottled water supplies are safe and provide veterinary medical and surgical care for government-owned animals throughout the ,,ao4 ,on the integrated battlefield1 their role is particularly important2 the potential for food supplies becoming contaminated with ,,nbc agents is high4 ,for detailed information on provision of veterinary services see ,,fm #h-aj-ah4 #e-f4 ,food ,protection ,food may become contaminated from enemy employment of ,,nbc weapons_/agents or from terroristic contamination of food procurement facilities and food supplies4 ,the ,,nbc agents may be introduced during production or in the storage area of the procurement facility2 while the product is in transit2 at the military storage facility2 or at the unit food service facility4 ,regardless of where the agent is used1 the effect is the same2 personnel will become ill or die if they consume the contaminated food4 ,to ensure food safety1 veterinary personnel inspect and monitor food from its procurement until it is issued to the consumer4 ,throughout the ,,ao1 all ,services 7,army1 ,navy1 ,marine1 and ,air ,force7 logistics and food service personnel must take precautions to protect subsistence from contamination4 #e-g4 ,food ,decontamination ,veterinary personnel are involved in the detection and monitoring of ,,nbc contaminated rations2 before use1 they must inspect all food suspected of being contaminated with ,,nbc agents4 ,appendix ,j provides guidance on food decontamination procedures4 ,veterinary personnel provide advice on the decontamination of food to unit personnel owning the food1 or personnel performing the food decontamination4 ,depending on the type of contamination and packaging1 the food may be-- ,consumed without being decontaminated4 ,decontaminated and then consumed4 ,destroyed4 ,some items may be held to allow time for natural decay of nuclear or chemical contamination before consumption4 ,the commander1 with advice from veterinary personnel1 makes the decision on the disposition of the food4 ,however1 veterinary personnel make the final determination of food safety4 #e-h4 ,animal ,care ,veterinary personnel are concerned with the protection of government-owned animals and animals being procured for consumption4 ,animals must be protected from ,,nbc contamination1 whenever possible4 ,animals should be moved into enclosures to protect them as much as possible from contamination4 ,protective equipment is not available for military working dogs2 however1 protection of the animal's feet and body must be considered4 ,when military working dogs must cross a contaminated area1 protect their feet by using butyl rubber material to improvise booties4 ,since ,,cps systems are not available1 animal treatment facilities must be established in contamination free areas4 ,veterinary treatment personnel must remain in ,,mopp ,level #d when caring for ,,nbc animal casualties until the animals have been decontaminated4 ,the treatment of military working dog ,,nbc casualties is outlined in ,,fm #h-aj-ah4 ,section ,,iii4 ,,laboratory ,,services #e-i4 ,general ,laboratory services must continue their support role even under ,,nbc conditions4 ,for the provision of clinical and diagnostic support1 the facility must be located in a contamination-free area or be inside collective protection4 ,designated laboratories within the theater will analyze ,,nbc samples_/specimens 7including in theater field confirmation identification of biological agents by evaluating specimens from symptomatic patients and animals and environmental samples collected from the ,,ao74 ,see ,appendix ,b for procedures in collecting biological samples_/specimens1 handling_/packaging1 maintaining chain of custody1 transporting samples_/specimens1 and analysis4 #e-aj4 ,level ,,ii ,laboratory support at this level is extremely limited2 it consists of laboratory procedures in direct support of ,,mtf and ,,fst activities4 ,laboratory personnel prepare collected suspect ,,nbc specimens for submission to the supporting laboratory for analysis2 the specimens are forwarded to supporting medical laboratories 7,appendix ,b74 #e-aa4 ,level ,,iii ,laboratory support in a ,,csh is intended for providing clinical laboratory support and is primarily in support of acute surgical cases1 blood services1 and statim 7,,stat7 services required for intensive care operations4 ,only extremely limited microbiology services 7parasitological exams and gram stains7 are provided4 ,in a mature theater1 the microbiology services may be augmented to include limited cultures and sensitivity testing4 ,patients with documented or suspected exposure to ,,nbc weapons_/agents will be medically evaluated1 specimens will be collected1 packaged1 and have chain of custody established4 ,the specimens will be forwarded through technical channels to the supporting medical laboratory 7such as the theater ,army medical laboratory ,,taml7 for analysis4 ,see ,appendix ,b for specimen collection1 packaging1 chain of custody1 and processing requirements4 #e-ab4 ,level ,,iv a4 ,clinical ,laboratories4 ,the clinical laboratories in the combat support1 field1 and general hospitals have the ability to perform a general1 but limited1 array of analytical procedures in hematology1 urinalysis1 chemistry1 microbiology1 serology1 and blood bank4 ,patient specimens of suspected biological or chemical agent exposures are forwarded through technical channels to the supporting medical laboratory4 ,see ,appendix ,b for sample_/specimen collection1 packaging1 chain of custody1 processing1 and transporting requirements4 b4 ,field ,laboratories4 7#a7 ,theater ,army ,medical ,laboratory4 ,the ,,taml is the specialized echelons above corps 7,,eac7 laboratory that provides clinical and nonclinical medical laboratory support4 ,when equipped and staffed1 the ,,taml provides in-theater field confirmation identification of ,,nbc samples or specimens4 ,using sophisticated equipment and methods1 the ,,taml has the capability to detect and identify ,,nbc agents in a variety of specimens_/samples 7such as human1 air1 soil1 water1 animals1 vegetation1 and food74 ,direct support from continental ,united ,states 7,,conus7-based laboratories aids the ,,taml with identification of ,,nbc agents4 ,command decision on use of protective_/preventive measures and patient care may be based on the ,,taml findings4 ,proper collection1 packaging1 and rapid shipment of specimens by ,m,t,fs and samples from other sources will ensure effective1 timely1 and accurate laboratory analyses4 7#b7 ,area ,medical ,laboratory4 ,the ,area ,medical ,laboratory 7,,aml7 is the specialized laboratory within the theater that provides nonclinical medical laboratory support4 ,the ,,aml can be deployed in the corps or to ,,eac for support missions4 ,when fielded1 the ,,aml will replace the ,,taml in the force structure4 ,the ,,aml provides in-theater field confirmation identification of ,,nbc samples or specimens4 ,using sophisticated equipment and methods1 the ,,aml has the capability to detect and identify ,,nbc agents in a variety of specimens_/samples 7such as human1 air1 soil1 water1 animals1 vegetation1 and food74 ,direct support from ,,conus-based laboratories aids the ,,aml with identification of ,,nbc agents4 ,command decision on use of protective_/preventive measures and patient care may be based on the ,,aml findings4 ,proper collection1 packaging1 and rapid shipment of specimens by ,m,t,fs and samples from other sources will ensure effective1 timely1 and accurate laboratory analyses4 #e-ac4 ,level ,v 7,continental ,united ,states7 ,designated ,level ,v medical laboratories perform analyses to provide definitive identification of suspect biological agents for the ,president and ,secretary of ,defense purposes4 ,the definitive identification of suspect biological agents also aids commanders in the ,,ao in maintaining the health of their command4 #e-ad4 ,field ,samples ,chemical corps personnel collect environmental1 air1 soil1 and vegetation samples4 ,preventive medicine personnel collect samples from drinking water sources and supplies4 ,veterinary personnel collect samples from food supplies and medical specimens from animals4 ,all other units collect soil1 vegetation1 and small animal samples for laboratory analysis4 ,samples are subjected to initial screening with rapid test kits and in-theater confirmatory identification at the supporting medical laboratory4 ,the ,president- and ,secretary of ,defense-required definitive identification is performed at the designated ,level ,v medical laboratory4 ,comprehensive databases will be maintained to provide historical testing results and will aid in the ,,ao commander's decisions to conduct operations in an ,,nbc environment4 ,see ,appendix ,b for specific procedures for sample collection1 packaging1 transporting1 maintaining chain of custody1 and analysis4 ,section ,,iv4 ,,dental ,,services #e-ae4 ,general ,dental service support is provided in the ,,ao at ,levels ,,ii1 ,,iii1 and ,,iv4 ,because of their location close to main supply routes and other support assets1 dental units are vulnerable to an ,,nbc strike4 ,nuclear1 biological1 and chemical operations have an impact at all levels2 thus1 dental units must be prepared to survive on the integrated battlefield4 ,defense against ,,nbc weapons must be included in the dental unit's ,,tsop4 ,individual and collective tasks must be intensely trained on a regular basis2 survival depends on the ability of personnel to use basic survival skills against an ,,nbc attack4 ,for details on provision of dental services1 see ,,fm #d-jb4ai4 #e-af4 ,mission in a ,nuclear1 ,biological1 or ,chemical ,environment ,the overall mission of dental units to provide dental services is greatly affected in the aftermath of an ,,nbc attack4 ,first1 the unit must survive the attack and rapidly recover from its effects4 ,secondly1 in the event of mass casualties1 the dental patient care effort must be redirected from dental treatment to the alternate wartime role of augmenting the adjacent ,,mtf4 ,dental units do not possess ,,cps2 therefore1 providing dental services in an ,,nbc environment will be limited to the treatment of maxillofacial emergencies requiring immediate attention4 ,this care will be provided at an ,,mtf with a ,,cps4 #e-ag4 ,dental ,treatment ,operations ,as a general rule1 in the aftermath of an ,,nbc attack1 dental treatment operations cease until deliberate decontamination of the unit and its equipment has been accomplished4 ,only maxillofacial injuries of an immediate life-threatening nature should be considered for treatment4 ,after an attack1 the resources of the dental treatment facility 7,,dtf7 are redirected toward support of any mass casualty situation that may have been generated at an adjacent ,,mtf1 or toward decontamination and relocation to a noncontaminated area4 #e-ah4 ,patient ,treatment ,considerations ,the only category of dental treatment appropriate in an ,,nbc environment is emergency2 and then1 only those emergencies of an extreme nature which demand immediate attention4 ,the most likely condition requiring such attention would be maxillofacial trauma and would most likely be treated at an ,,mtf rather than a ,,dtf4 ,although the likelihood of a requirement to treat dental patients in an ,,nbc environment is extremely low1 ,d,t,fs must have a plan in the event that such patients do present4 a4 ,patient ,decontamination4 ,decontamination of patients1 dental patients included1 is an absolute requirement before admission into a clean ,,mtf4 ,contaminated patients are triaged and decontaminated before treatment 7except for life- or limb-saving care74 ,both triage and decontamination should be accomplished as far forward as possible4 ,specific details on patient decontamination are in ,appendix ,g4 ,it is important to note that normally patient decontamination is not performed by medical or dental personnel4 ,initial decontamination at the basic skill level is accomplished at the casualty's unit4 ,detailed patient decontamination is accomplished by the patient decontamination teams 7made up of nonmedical personnel from the supported units7 that are supervised by medical personnel at the ,,mtf4 b4 ,patient ,decontamination at ,dental ,treatment ,facilities4 ,neither dental units nor their ,d,t,fs are equipped for patient decontamination4 ,any contaminated patients arriving at a ,,dtf requiring urgent attention must be directed or evacuated to the nearest ,,mtf with a patient decontamination capability4 #e-ai4 ,patient ,protection ,dental treatment facilities must also consider the need to protect patients in their care in the event of an ,,nbc attack1 or when the threat of an attack is high4 ,special consideration must be made for maxillofacial patients whose condition prevents them from wearing their protective mask4 a4 ,immediate ,response4 ,in the event of an attack or when the alarm sounds1 dental treatment providers immediately cease work and mask4 ,the patients should do likewise4 ,only after putting on their own masks1 do the dental treatment providers assist the patient1 if necessary1 by removing materials that impede the patient's masking4 ,only those materials that impede masking or may compromise the airway 7such as rubber dam frames or impressions7 are removed1 the rest are left in place until the all clear is sounded4 ,special attention must be given to patients who may have been medicated into a less than fully conscious state1 or are otherwise incapacitated4 b4 ,mission-,oriented ,protective ,posture ,considerations4 ,the ,,mopp level should be taken into account when determining the category and extent of dental treatment to be provided4 ,patients1 including those seated in the dental chair1 should be at the ,,mopp level prescribed for the ,,dtf by its parent headquarters4 ,dental treatment at ,,mopp ,levels #c and #d is1 of course1 impossible because of the requirement to wear the protective mask2 however1 treatment is still possible at ,,mopp ,levels #j1 #a1 and #b4 ,treatment at ,,mopp ,level #b should be limited only to emergency care requiring urgent attention4 ,at ,,mopp ,level #a1 most types of dental emergencies can be accommodated2 however1 only minimal essential treatment should be undertaken in order to reduce risk of the patient being caught in a compromised state4 ,at ,,mopp ,level #j1 the provision of dental treatment generally is not limited4 ,however1 the degree of the ,,nbc threat forecast for the area should be considered before undertaking extensive treatment4 c4 ,maxillofacial ,injuries4 ,patients with maxillofacial injuries that prevent proper fit and seal of the individual protective mask must be placed in a ,,ppw4 ,though patients with these types of injuries are most likely to be found only in ,,mtf channels1 ,d,t,fs should nevertheless be prepared in the event a patient presents to the ,,dtf4 ,since the ,,dtf does not have any ,p,p,ws2 these patients should be immediately evacuated to the adjacent ,,mtf for treatment4 ,section ,v4 ,,combat ,,operational ,,stress ,,control #e-bj4 ,general ,when operating under the threat of or under actual ,,nbc conditions1 soldiers will be at a high risk of suffering combat operational stress-related conditions4 ,the invisible1 pervasive nature of these weapons creates a higher degree of uncertainty and ambiguity1 presenting fertile opportunities for false alarms1 mass panic1 and other maladaptive stress reactions4 ,therefore1 commanders and leaders must take actions to prevent and reduce the numbers of combat operational stress cases in this environment4 ,the symptoms and physical signs caused by excessive stress are similar to some signs of true ,,nbc agent injury4 ,in ,world ,war ,i1 inexperienced units initially evacuated two stress cases for every one true chemical casualty4 ,some minor chemical casualties also had major stress symptoms4 ,therefore1 far forward triage is essential to prevent over evacuation and loss of the individual to the unit4 ,for details on provision of ,,cosc see ,,fm #h-ea and ,,fm #bb-ea4 #e-ba4 ,leadership ,actions a4 ,keep ,personnel ,informed of the ,situation4 ,keep information flowing1 dispel myths1 and control rumors by-- ,discussing the situation and its possible long-term implications honestly4 ,maintaining the perspective that the best chance for mission accomplishment is assured when the unit and the ,army stays mission focused4 b4 ,train ,soldiers to ,survive4 ,use training procedures that-- ,tell the lessons of history on ,,nbc weapons employment4 ,show that the enemy's use of ,,nbc weapons_/agents will not give him enough advantage to justify the risk to his forces4 ,increase the chance of surviving and winning should the enemy use ,,nbc weapons_/agents4 ,emphasize the buddy system as a means of keeping watch for each other4 ,personnel must always seek buddy aid before taking additional antidotes4 ,this will reduce the numbers of individuals using their antidotes when not needed2 and prevent the increased heat stress caused by the effects of atropine on the body's cooling capabilities4 c4 ,put ,nuclear1 ,biological1 and ,chemical ,defense in ,realistic ,perspective4 ,continuously strive to maintain a realistic perspective in the unit by-- ,comparing the risks of the threat with the increased risk of facing the conventional threat in varying levels of ,,mopp4 ,the decision to initiate a ,,mopp level should be like deciding how much cover is needed to protect a unit from conventional weapons4 ,choosing the lowest ,,mopp level that protects the unit1 yet permits accomplishment of the mission4 ,do not try to be #ajj percent safe from chemical attack if it means that there is-- ,only a small chance of mission accomplishment4 ,a high probability of being killed by the enemy4 ,a high personnel loss due to heat injury4 d4 ,train in the ,protective ,mask4 ,train in the protective mask often4 ,it takes repeated wear and time to acclimate and get over the claustrophobic feeling of wearing the mask4 ,the training can be conducted during a variety of activities4 ,have personnel wear the mask often in garrison or during lulls in other activities1 even at desk jobs4 ,if on average1 one person in five wears the mask1 on a rotational basis1 at any given time1 everyone will quickly become accustomed to wearing it4 ,periodic prolonged wear 7#h hours or more7 helps soldiers gain confidence and realize that they can tolerate the discomfort4 ,have personnel wear the mask while performing combat-related 7mission essential7 tasks4 e4 ,train in ,mission-,oriented ,protective ,posture ,level #d4 ,training in ,,mopp ,level #d 7or simulated ,,mopp #d1 which is to overdress while wearing the protective mask1 overboots1 and gloves7 will increase personnel confidence in their ability to wear the ensemble4 f4 ,ensure ,sleep ,plans are ,safely ,practiced4 ,have everyone practice wearing the mask while sleeping4 ,ensure personnel only sleep in safe places2 do not allow personnel to sleep under or near vehicles or other motorized machinery4 ,require ground guides for all vehicles in the unit bivouac area4 ,ensure that each individual get at least #d hours of uninterrupted sleep during every #bd-;hour period1 mission permitting 7,see ,,fm #ba-aj74 #e-bb4 ,individual ,responsibilities a4 ,follow ,orders4 ,by following orders1 individuals can increase their ability to cope with and prevent combat operational stress-related conditions4 ,coping with the stresses of an ,,nbc environment requires extra individual action4 ,concentrate on the positive aspects of survival1 not the negatives of illness or death4 b4 ,train4 ,use every opportunity to wear the protective mask or the entire ,,mopp ensemble during training1 when permitted4 ,you build self-confidence and endurance by frequently training with your protective mask1 or at ,,mopp ,level #d4 ,perform refresher training in basic ,,nbc survival skills4 c4 ,use ,buddy ,system4 ,use the buddy system to increase your ability to survive4 ,service members looking out for each other give a sense of security that relieves stress4 ,looking out for each other improves every individual's ability to perform his duties4 #e-bc4 ,mental ,health ,personnel ,responsibilities a4 ,staffing for ,combat ,operational ,stress ,control4 ,combat operational stress control is provided by the following activities or units3 ,brigade mental health section4 ,division mental health section4 ,area support medical battalion mental health section4 ,neuropsychiatric ward and consultation service of each ,,csh1 field hospital1 and general hospital4 ,medical detachment1 ,,cosc4 ,medical company1 ,,cosc4 b4 ,conduct ,preventive ,activities4 ,in an ,,nbc environment1 prevention is the most economical means of controlling combat operational stress reactions4 ,mental health personnel must begin consultation services before ,,nbc weapons_/agents have been employed4 c4 ,control ,stress ,reactions4 ,individuals with combat operational stress reactions require prompt intervention4 ,the evaluation of over-stressed personnel is difficult but not impossible when both the soldier and the evaluator are in ,,mopp4 ,the primary method of mental health evaluation is the interview and mental status examination4 ,for details on controlling stress reactions1 see ,,fm #h-ea4 ,section ,,vi4 ,,health ,,service ,,logistics #e-bd4 ,general ,as in all combat situations1 the protection of medical supplies and equipment on the integrated battlefield is a must4 ,without medical supplies and equipment1 ,,hss will be greatly diminished4 ,thus1 the flow of supplies must continue to forward units as they are requested1 including during ,,nbc operations4 ,for detailed information on providing health service logistics see ,,fm #d-jb4a and ,,fm #h-aj-i4 #e-be4 ,protecting ,supplies in ,storage ,protecting supplies can be accomplished by placing them under tents1 using plastic wraps1 or providing storage warehouses with ,,cb filtered-conditioned 7heated or cooled7 air systems4 ,wrapping supplies in two layers of plastic material provides protection from most agents for a short period of time2 the thicker the plastic material1 the longer the protection4 ,effectiveness of protective procedures can be checked by placing ,m#i tape on supplies and between layers of the covering4 ,protection from the thermal and blast effects of nuclear detonations requires much more elaborate measures4 ,placing the supplies in trenches1 inside earthen berms1 behind stonewalls1 or in other field expedient facilities will enhance the protective posture of supplies from the nuclear effects4 ,even when taking these protective measures1 a quantity of supplies will become contaminated and must be replaced4 ,plans should be in place for replacement of lost items4 #e-bf4 ,protecting ,supplies ,during ,shipment ,during shipment1 supplies are protected by placement inside ,m,i,l,v,a,ns1 in covered enclosed vehicles1 or by wrapping them in several layers of plastic1 in tarpaulins1 or in other protective material4 ,to monitor exposure of supplies to chemical agents during shipment1 place ,m#i detector paper between the wrappings4 ,if exposure is limited to the outer layer1 simple removal of this layer may be all that is required to eliminate the contamination4 ,decontamination is much easier when the supplies and equipment have been protected by multilayers of over-wraps4 #e-bg4 ,organizational ,maintenance ,maintenance on vehicles1 equipment1 and medical equipment will become much more complex under ,,nbc conditions4 ,most chemical agents are soluble in organic solvents such as gasoline1 motor oils1 and lubricants4 ,the agent may be removed from the equipment by these solvents1 but exposure to the contaminated solvents will produce the same effects as exposure to the agent on the equipment4 ,the agents may seep down around the threads of bolts1 in cracks and crevices of the equipment1 and inside the cabinets or enclosures of equipment4 ,these potential contamination sources produce an increased hazard to maintenance personnel4 ,decontamination of some items1 especially medical equipment1 may be a problem for maintenance personnel4 ,the use of standard decontamination agents will cause damage beyond repair to most medical equipment and electronic equipment4 ,in some instances1 removal of chemical agents will require aging 7off-gassing7 of the agent4 ,turning the equipment on and running it1 or just exposing the equipment to warm air will speed the off-gassing process4 ,maintenance personnel must perform all procedures in ,,mopp ,level #d until decontamination is completed4 ,radiation will penetrate the metal structures of vehicles and other equipment2 radioactive material will be absorbed into the lubricants and fuels4 ,decontamination of this type of contamination is very difficult1 if not impossible4 ,personnel must use radiation detection equipment to determine the extent of contamination and decontaminate the items as much as possible4 ,dusting or washing with water can remove any fallout on the surface of vehicles and nonelectrical_/electronic components of equipment4 ,removal of radioactivity absorbed into metals or mixed in lubricants and fuels is beyond the capabilities of unit personnel4 ,see ,,fm #c-e for decontamination procedures4 ,section ,,vii4 ,,homeland ,,security ,,response #e-bh4 ,chemical1 ,biological1 ,radiological1 ,nuclear1 and ,high-,yield ,explosive ,response ,although1 homeland security is not a specific military mission1 commanders must plan for and be prepared to support a lead federal agency 7such as the ,federal ,bureau of ,investigation or ,federal ,emergency ,management ,agency7 in response to ,,cbrne event4 ,when the ,,cbrne event occurs on a military installation1 the ,weapons of ,mass ,destruction--,incident ,support ,team 7,,wmd-,,ist7 is the lead federal agency in charge of responding and establishes an incident command center 7,,icc74 ,the installation medical authority 7,,ima7 provides the ,,hss initial response to the event site4 ,request for assistance from deployable ,,hss organizations and staffs are initiated by the ,,ima through military channels4 ,the incident commander will submit a request for ,,hss assistance to a ,,cbrne event off the military installation through the appropriate federal channels4 ,the ,president will direct any ,,dod response in support of a lead federal agency to a ,,cbrne event4 ,the ,presidential direction to assist will be passed down through military channels to the appropriate ,,hss organization for response4 ,the ,,hss response may be in the form of special medical augmentation teams 7,,smart7 support from ,,us ,army ,medical ,command resources or ,,hss 7table of organization and equipment ,,toe7 units may be directed to respond4 ,normally1 responding ,,toe units will provide ,,hss to nonmedical military responders4 ,however1 the ,,hss mission may be to provide support to the lead federal agency or civilian public health organizations1 emergency medical services 7ambulance crews71 or hospitals4 ,the ,,hss response will include1 but not be limited to-- ,providing medical care to casualties at the incident casualty decontamination site and supervising the casualty decontamination process to ensure that no further injury is caused to the casualty4 ,providing en route care for casualties from the incident site to an ,,mtf or designated location for further care4 ,normally1 ,,toe ,,medevac assets are not used1 but ,,hss personnel provide the en route care on locally provided transport vehicles4 ,providing guidance to local responders in the management of ,,cbrne casualties4 ,the guidance may be on the correct use of antidotes1 chemoprophylaxis1 prevention of contamination spread in the ,,mtf1 patient decontamination at the ,,mtf1 and other related medical management procedures4 ,identifying suspect chemical1 biological1 or radiological materials used in the event4 ,providing guidance on application of standard precautions for ,,cbrne1 especially preventive measures to prevent spread of contagious agents4 ,managing1 triaging1 and treating mass casualties4 #e-bi4 ,capabilities of ,response ,elements ,for detailed ,information on capabilities of ,s,m,a,r,ts see ,,fm #d-jb and ,,fm #h-db4 ,for detailed information on capabilities and functions of ,,toe ,,hss units see ,,fm #d-jb- and #h-series publications4 ,,appendix ,a ,,medical ,,effects ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,weapons ,,and ,,toxic ,,industrial ,,material ,a-#a4 ,general ,biological and chemical weapons_/agents may be employed by assassins1 terrorists1 rebels1 and insurgents1 as well as well-formed battle organizations1 across the continuum of operations4 ,in addition1 nuclear weapons will remain a threat on the future battlefield4 ,another weapon that may be used is the ,,rdd4 ,the ,,rdd can cause significant damage and present health hazards to fighting forces by exposing them to radiation without the thermal and full blast effects of nuclear weapons4 ,the ,,rdd can disperse radioactive material over an area of the battlefield2 the area covered is dependent upon the amount of radioactive and explosive material used4 ,in order to detonate a nuclear weapon1 an adversary must first obtain access to the appropriate weapons-grade material4 ,however1 an ,,rdd can be produced and used by anyone with access to industrial or medical radioisotopes and explosives4 ,biological agents are easy to disperse on the battlefield without immediate detection2 however1 their effects on exposed troops can change the course of the battle4 ,some nations consider chemical weapons as a component of their munitions for the battlefield4 ,as more nations enter the arena of developing biological and chemical weapons1 their potential effects on our troops will increase4 ,the enemy's use of ,t,i,ms as weapons or collateral damage to ,,tim storage faculties can severely affect the unit personnel's ability to continue the mission4 ,the signs and symptoms of some ,,tim exposure can be the same as those presented from exposure to ,,nbc weapons4 ,considerations of both the physical and biological effects of these weapons are required for ,,hss operations4 ,field ,manual #d-jb4bhc provides additional information on nuclear and radiological effects2 ,,fm #h-bhd provides additional information on biological agent effects2 ,,fm #h-bhe provides additional information on ,,cw effects2 ,,fm #h-ejj provides detailed information on hazardous material 7,,tim7 effects4 ,a-#b4 ,physical ,effects of ,nuclear ,weapons a4 ,the principal physical effects of nuclear weapons are blast1 thermal radiation 7heat71 and nuclear radiation4 ,these effects are dependent upon the yield 7or size7 of the weapon expressed in kilotons 7,,kt71 the physical design of the weapon 7such as conventional and enhanced71 and the method of employment4 ,the distribution of energy 7,figure ,a-#a7 from the detonation of a moderate-sized 7#c to #aj ,,kt7 weapon is as follows3 7#a7 ,fifty percent as blast4 7#b7 ,thirty-five percent as thermal radiation2 made up of a wide spectrum of electromagnetic radiation1 including infrared1 visible1 and ultraviolet light and some soft x-ray radiation4 7#c7 ,fourteen percent as nuclear radiation1 #d percent as initial ionizing radiation composed of neutrons and gamma rays emitted within the first minute after detonation1 and #aj percent as residual nuclear radiation 7fallout74 7#d7 ,one percent as ,,emp4 b4 ,larger weapons are more destructive than smaller weapons1 but the destructive effect is not linear4 ,table ,a-#a presents a comparison of three aspects of nuclear weapons effects with yield4 ,illustration3 ,figure ,a-#a4 ,distribution of energy4 c4 ,the altitude at which the weapon is detonated determines the blast1 thermal1 and nuclear radiation effects4 ,nuclear blasts are classified as air1 surface1 or subsurface bursts4 7#a7 ,an airburst is a detonation in air at an altitude below #cj1jjj meters1 but high enough that the fireball does not touch the land or water surface4 ,the altitude is varied to obtain the desired tactical effects4 ,initial radiation will be a significant hazard1 but there is essentially no local fallout4 ,however1 the ground immediately below the airburst may have a small area of neutron-induced radioactivity4 ,this may pose a hazard to troops passing through the area4 7#b7 ,a surface burst is a detonation in which the fireball actually touches and vaporizes the land or water surface4 ,in this case1 the area affected by blast1 thermal radiation1 and initial nuclear radiation will be smaller than for an airburst of comparable yield4 ,however1 in the region around ground zero1 the destruction will be much greater and a crater is often produced4 ,additionally1 all the material that was within the fireball becomes fallout and will be a hazard downwind4 ,a surface burst is the most likely type of terrorist detonation4 7#c7 ,a subsurface burst is an explosion in which the detonation is below the surface of land or water4 ,cratering usually results4 ,if the burst does not penetrate the surface1 the only hazard is from the ground or water shock4 ,if the burst penetrates the surface1 blast1 thermal1 and initial nuclear radiation will be present1 though less than for a surface burst of comparable yield4 ,local fallout will be heavy over a small area4 7#d7 ,a high altitude burst occurs above #cj1jjj meters4 ,radiation and physical effects do not reach the ground and there is no local fallout4 ,this is the only detonation where the effects of the ,,emp are significant4 ,nonhardened electronic equipment including many medical devices may become inoperative4 ,the ,,emp damage is a moot point with other types of detonations1 as its range is primarily limited to the area of intense physical destruction4 ,table ,a-#a4 ,comparison of ,weapons ,effects 7,radii of ,effects in ,kilometers--,airburst7 #a ,,kt #bj ,,kt #ajj ,,kt #a ,,mt #aj ,,mt ---------------------------------------- ---------------------- ,,nuclear ,,radiation #j4ga #a4c #a4f #b4c #c4g 7#a1jjj c,gy7 ---------------------------------------- ---------------------- ,,blast 7#ej ,,incidence ,,of ,,translation ,,with ,,subsequent ,,impact #j4bh #a4j #a4d #c4h #aa4g ,,with ,a ,,non-,,yielding ,,surface7 ---------------------------------------- ---------------------- ,,thermal 7#ej ,,incidence ,,of #b,,nd-,,degree ,,burns ,,to #j4gg #a4h #c4b #d4h #ad4e ,,bare ,,skin1 #aj ,,km ,,visibility7 ,a-#c4 ,physiological ,effects of ,nuclear ,weapons ,the physiological effects of nuclear weapons are the result of exposure to the blast2 thermal radiation2 ionizing radiation 7initial or residual7 effects2 or a combination of these4 ,for smaller weapons 7less than #aj ,,kt71 ionizing radiation is the primary creator of casualties requiring medical care1 while for larger weapons 7greater than #aj ,,kt71 thermal radiation is the primary creator of casualties4 a4 ,the rapid compression and decompression of blast waves on the human body results in transmission of pressure waves through the tissues4 ,resulting damage is primarily at junctions between tissues of different densities 7bone and muscle71 or at the interface between tissue and airspace4 ,lung tissue and the gastrointestinal system 7both contain air7 are particularly susceptible to injury4 ,the tissue disruptions can lead to severe hemorrhage or to an air embolism2 either can be rapidly fatal4 ,direct overpressure effects do not extend out as far from the point of detonation as the drag force and are often masked by the drag force effects4 ,a typical range of probability of lethality1 with variations in overpressure for a #a ,,kt weapon1 is shown in ,table ,a-#b4 ,table ,a-#b4 ,range of ,lethality of ,peak ,overpressure ,,lethality ,,peak ,,overpressure ,,distance ,,from 7,,approximate 7 7,,atmospheres7 ,,ground ,,zero2 ,,meters ---------------------------------------- ---------------------- #a #b4c-b4i #aej #ej #b4i-d4a #abc #ajj #d4a #aaj 7#a7 ,the significance of the data is that the human body is relatively resistant to static overpressure compared to rigid structures such as buildings4 ,for example1 an unreinforced cinder block panel will shatter at #j4a to #j4b atmospheres4 7#b7 ,overpressure lower than those in ,table ,a-#b can cause nonlethal injuries such as lung damage and eardrum rupture4 ,lung damage is a relatively serious injury1 usually requiring hospitalization1 even if not fatal2 whereas eardrum rupture is a minor injury1 often requiring no treatment at all4 7a7 ,the threshold level of overpressure for an unreinforced unreflected blast wave that can cause lung-damage is about #a4j atmosphere4 7b7 ,the threshold level for eardrum rupture is around #j4b atmospheres2 the overpressure associated with a #ej percent probability of eardrum rupture is about #a4a atmospheres4 7#c7 ,casualties requiring medical treatment from direct blast effects are produced by overpressure between #a4j and #c4e atmospheres4 ,however1 other effects 7such as indirect blast injuries and thermal injuries7 are so predominate that patients with only direct blast injuries make up a small part of the patient workload4 b4 ,the drag forces 7indirect blast7 of the blast winds are proportional to the velocities and duration of the winds4 ,the winds are relatively short in duration1 but can reach velocities of several hundred km per hour4 ,injury can result from missiles impacting on the body or from the physical displacement of the body against objects and structures4 7#a7 ,the distance from the point of detonation at which severe indirect injury occurs is greater than that for equally serious direct blast injuries4 ,a high probability of serious indirect injury can occur when the peak overpressure is about #j4b atmospheres4 ,this range will increase with the increased size of the weapon2 for a #a ,,kt weapon1 the range is #j4bb km1 whereas for a #bj ,,kt weapon1 the range is #j4gf km4 ,at greater ranges injuries will occur and casualties will be generated1 but not consistently4 7#b7 ,the drag forces of the blast winds produced by a nuclear detonation are so great that almost any form of vegetation or structure will be broken up or fragmented into missiles4 ,thus1 multiple1 varied missile injuries will be common1 increasing their overall severity and significance4 ,table ,a-#c lists ranges at which significant missile injuries can be expected4 ,table ,a-#c4 ,ranges for ,probabilities of ,serious ,injury from ,small ,missiles ,,ranges 7km7 ---------------------------------------- ------------------------- ,,yield #a ,,probability ,,of #ej ,,probability ,,of #ii ,,probability ,,of 7,,kt7 ,,serious ,,injury ,,serious ,,injury ,,serious ,,injury ---------------------------------------- ------------------------- #a #j4bh #j4bb #j4ag #aj #j4gc #j4eg #j4dd #bj #j4ih #j4gf #j4eh #ej #a4d #a4a #j4hd #ajj #a4i #a4e #a4a #bjj #b4e #a4i #a4e #ejj #c4f #b4g #b4a #a1jjj #d4h #c4f #b4g ---------------------------------------- ------------------------- #a ,,incidence ,,of ,,injury ,,based ,,on ,,skin ,,and ,,tissue ,,perforation4 #b ,,missiles ,,used ,,were #aj ,,gram 7gm7 ,,in ,,weight4 7#c7 ,the velocity to which missiles are accelerated is the major factor in causing injury4 ,the probability of a penetration injury increases with increasing velocity1 particularly for small1 sharp missiles such as glass fragments4 ,small1 light objects are accelerated to speeds approaching the maximum 7wind7 velocity4 ,table ,a-#d shows data for probability of penetration related to size and velocity of glass fragments4 ,table ,a-#d4 ,probability of ,glass ,fragments ,penetrating the ,abdominal ,cavity ,,mass ,,of ,,glass #a #ej #ii ,,fragments 7gm7 ,,impact ,,velocity 7,,meters ,,per ,,second7 ---------------------------------------- --------------- #j4a #gh #acf #bdc #j4f #ec #ia #afa #a4j #df #hb #adc #aj4j #ch #fj #aah 7#d7 ,heavy1 blunt missiles may not penetrate1 but can result in significant injury1 particularly fractures4 ,the threshold velocity for skull fractures from a #d4e milligram 7mg7 missile is about #d4f meters per second 7m_/sec74 7#e7 ,the drag forces of the blast winds are strong enough to displace large objects 7such as vehicles71 or cause large structures to collapse 7such as buildings7 resulting in serious crushing injuries4 ,man himself can become a missile resulting in injuries 7called translational injuries74 ,the velocity at which the body is displaced will determine the probability and the severity of injury4 ,assuming a displacement of #c4j meters1 the impact velocity associated with various degrees of injury is shown in ,table ,a-#e4 ,the velocities in ,table ,a-#e can be correlated against yield4 ,the ranges at which such velocities can occur and the probability of injury are given in ,table ,a-#f4 ,table ,a-#e4 ,translational ,injuries ,a4 ,,blunt ,,injuries ,,and ,,fractures ,,probability ,,of ,,injury ,,velocity 7m_/sec7 ---------------------------------------- -------- #a #b4f #ej #f4f #ii #af4e ---------------------------------------- -------- ,b4 ,,fatal ,,injuries ,,probability ,,of ,,fatality ,,velocity 7m_/sec7 ---------------------------------------- -------- #a #f4f #ej #ag4j #ii #ci4g ,table ,a-#f4 ,ranges for ,selected ,impact ,velocities of a #gj-,kilogram ,human ,body ,displaced by ,blast ,wind ,drag ,forces for ,different ,yield ,weapons ,,weapon ,,yield ,,velocities 7m_/sec7 7,,kt7 #b4f #f4f #ag4j ---------------------------------------- ------ ,,ranges 7km7 ---------------------------------------- ------ #a #j4ch #j4bg #j4ai #aj #a4j #j4ge #j4ec #bj #a4c #j4ii #j4ga #ej #a4i #a4d #a4j #ajj #b4e #a4i #a4d #bjj #c4b #b4e #a4i #ejj #d4f #c4f #b4g #a1jjj #e4i #d4h #c4f ,a-#d4 ,biological ,effects of ,thermal ,radiation ,the thermal radiation emitted by a nuclear detonation causes burns in two ways--by direct absorption of the thermal energy through exposed surfaces 7flash burns72 or by the indirect action of fires in the environment 7flame burns74 ,indirect flame burns can easily outnumber all other types of injury4 a4 ,thermal radiation travels outward from the fireball in a straight line2 therefore1 the amount of energy available to cause flash burns decreases rapidly with distance4 ,close to the fireball all objects will be incinerated4 ,the range for #ajj percent lethality will vary with yield1 height of burst1 weather1 environment1 and immediacy of treatment4 ,the critical factors determining the degree of burn injury are the flux 7calories per square centimeter_/second cal_/cm#b_/sec7 and the duration of the thermal pulse4 ,the total amount of thermal radiation needed to cause a flash partial thickness burn on exposed skin will vary with the yield of the weapon and the nature of the pulse 7,table ,a-#g74 ,most burn patients will come from the zones where partial thickness burns occur4 ,in areas where radiation1 blast1 and thermal intensity are highest1 burn victims surviving long enough to reach medical care will be rare4 ,,note ,the battle dress uniform 7,,bdu71 ,,mopp gear1 or any other clothing will provide additional protection against flash burns4 ,the airspace between the clothing significantly impedes heat transfer and may prevent or reduce the severity of burns1 depending on the magnitude of the thermal flux4 ,table ,a-#g4 ,factors for ,determining the ,probability of ,partial ,thickness ,burns ,,yield ,,of ,,weapon #a ,,kt #aj ,,kt #ajj ,,kt #a ,,mt #aj ,,mt ---------------------------------------- -------------------------- ,,range 7km7 ,,for ,,production ,,of ,,partial ,,thickness ,,burns #j4gh #b4a #d4h #i4a #ad4e ,,on ,,exposed ,,skin ---------------------------------------- -------------------------- ,,duration ,,of ,,thermal ,,pulse ,,in ,,seconds #j4ab #j4cb #j4i #b4d #f4d ---------------------------------------- -------------------------- ,cal_/cm#b_/sec ,,required ,,to ,,produce ,,partial ,,thickness #d4j #d4e #e4c #f4c #g4j ,,burns ,,on ,,exposed ,,skin b4 ,indirect 7flame7 burns result from exposure to fires caused by the thermal effects in the environment1 particularly from ignition of clothing4 ,the larger-yield weapons are more likely to cause firestorms over extensive areas4 ,there are too many variables in the environment to predict either incidence or severity of casualties4 ,expect the burns to be far less uniform 7in degree7 and not limited to exposed surfaces4 ,for example1 the respiratory system may be exposed to the effects of hot gases produced by extensive fires4 ,respiratory system burns cause high morbidity and high mortality rates4 c4 ,the initial pulse of radiation in the optical and thermal bands can cause injuries in the forms of flash blindness and retinal scarring4 ,the initial brilliant flash of light produced by the nuclear detonation causes flash blindness4 ,this flash swamps the retina1 bleaching out the visual pigments and producing temporary blindness4 ,during daylight hours1 this temporary effect may last for about #b minutes4 ,at night1 with the pupil dilated for dark adaptation1 flash blindness will affect personnel at greater ranges and for greater durations4 ,partial recovery can be expected in #c to #aj minutes1 though it may require #ae to #ce minutes for full night adaptation recovery4 ,retinal scarring is the permanent damage from a retinal burn4 ,it will occur only when the fireball is actually in the individual's field of view and should be a relatively uncommon injury4 ,the location of the scar will determine the degree of interference with vision4 ,because night vision apparatus electronically amplifies an image1 it cannot transmit the flash intensity and will not cause eye injury4 ,a-#e4 ,physiological ,effects of ,ionizing ,radiation ,a nuclear burst results in four types of ionizing radiation3 neutrons1 gamma rays1 beta1 and alpha radiation4 ,the initial burst is characterized by neutrons and gamma rays while the residual radiation is primarily alpha1 beta1 and gamma rays4 ,the effect of radiation on a living organism varies greatly by the type of radiation to which the organism is exposed4 ,see ,table ,a-#h for characteristics of nuclear radiation4 a4 ,alpha particles are extremely massive1 charged particles 7four times the mass of a neutron72 they are a fallout hazard4 ,because of their size1 alpha particles cannot travel far and are fully stopped by the dead layers of the skin or by the uniform4 ,alpha particles are a negligible external hazard1 but if inhaled or ingested1 can cause significant internal damage4 ,illustration3 ,figure ,a-#b4 ,threshold distance for minimal chorioretinal burn and flash blindness versus yield 7airburst7 at night4 ,table ,a-#h4 ,characteristics of ,nuclear ,radiation ,part #a ---------------------------------------- ------------------------ ,,name ,,and ,,what ,,is ,,it ,,source ,,energy ,,and ,,symbol ,,speed ---------------------------------------- ------------------------ ,,energy ,,varies3 ,,helium ,,decay ,,of ,,uranium ,,speed ,,varies ,,alpha ,,nucleus ,,and ,,plutonium ,,from #a_/bj ,,to #a_/aj ,,particle ,,speed ,,of ,,light ---------------------------------------- ------------------------ ,,high-,,speed ,,decay ,,of ,,fission ,,beta ,,speed ,,products ,,and ,,varies ,,particle ,,electron ,,neutron ,,induced ,,elements ---------------------------------------- ------------------------ ,,electromagnetic ,,decay ,,of ,,fission ,,energy ,,varies3 ,,gamma ,,energy ,,products ,,and ,,travels ,,at ,,the ,,ray ,,neutron ,,induced ,,speed ,,of ,,light ,,elements ---------------------------------------- ------------------------ ,,uncharged ,,fission ,,and ,,particle ,,fusion ,,reactions ,,varies ,,neutron ---------------------------------------- ------------------------ ,part #b ---------------------------------------- ------------------------ ,,name ,,and ,,range ,,in ,,range ,,in ,,shielding ,,biological ,,symbol ,,air ,,tissue ,,required ,,hazard ---------------------------------------- ------------------------ ,,none1 ,,unless #e cm ,,cannot ,,none ,,ingested ,,or ,,alpha ,,penetrate ,,inhaled ,,in ,,particle ,,the ,,epidermis ,,sufficient ,,quantities ---------------------------------------- ------------------------ ,,several ,,stopped ,,by ,,beta #e ,,meters ,,layers ,a ,,few cm ,,of ,al ,,superficial ,,particle ,,of ,,skin ,,or ,,moderate ,,skin ,,injury ,,clothing ---------------------------------------- ------------------------ ,,up ,,to #ejj ,,very ,,dense ,,whole ,,body ,,gamma ,,meters1 ,,but ,,penetrating1 ,,material1 ,,such ,,injury1 ,,many ,,ray ,,is ,,energy ,,but ,,is ,,energy ,,as ,,concrete1 ,,casualties ,,dependent ,,dependent ,,steel ,,plate1 ,,possible ,,earth ---------------------------------------- ------------------------ ,,less ,,than ,,very ,,hydrogenous ,,whole ,,body ,,gamma1 ,,but ,,penetrating1 ,,materials1 ,,injury1 ,,many ,,neutron ,,is ,,energy ,,but ,,is ,,energy ,,such ,,as ,,casualties ,,dependent ,,dependent ,,water ,,or ,,possible ,,damp ,,earth ---------------------------------------- ------------------------ b4 ,beta particles are very light1 charged particles that are found primarily in fallout radiation4 ,these particles can travel a short distance in tissue2 if large quantities are involved1 they can produce damage to the basal stratum of the skin4 ,the lesion produced is similar to a thermal burn 7called a beta burn74 c4 ,gamma rays1 emitted during the nuclear detonation and in fallout1 are uncharged radiation similar to ,x rays4 ,they are highly energetic and pass through matter easily4 ,because of its high penetrability1 radiation can be distributed throughout the body1 resulting in whole body exposure4 d4 ,neutrons1 like gamma rays1 are uncharged1 are only emitted during the nuclear detonation1 and are not a fallout hazard4 ,however1 neutrons have significant mass and interact with the nuclei of atoms1 severely disrupting atomic structures4 ,compared to gamma rays1 they can cause #bj times more damage to tissue4 e4 ,when radiation interacts with atoms1 energy is deposited resulting in ionization 7electron excitation74 ,this ionization may involve certain critical molecules or structures in a cell1 producing its characteristic damage4 ,two modes of action in the cell are direct and indirect action4 ,the radiation may directly hit a particularly sensitive atom or molecule in the cell4 ,the damage from this is irreparable2 the cell either dies or is caused to malfunction4 ,the radiation can also damage a cell indirectly by interacting with water molecules in the body4 ,the energy deposited in the water leads to the creation of toxic molecules2 the damage is transferred to and affects sensitive molecules through this toxicity4 f4 ,the most radiosensitive organ systems in the body are the male reproductive1 the hematopoietic1 and the gastrointestinal systems4 ,the relative sensitivity of an organ to direct radiation injury depends upon its component tissue sensitivities4 ,cellular effects of radiation1 whether due to direct or indirect damage1 are basically the same for the different kinds and doses of radiation4 ,the simplest effect is cell death4 ,with this effect1 the cell is no longer present to reproduce and perform its primary function4 ,changes in cellular function can occur at lower radiation doses than those that cause cell death4 ,changes can include delays in phases of the mitotic cycle1 disrupted cell growth1 permeability changes1 and changes in motility4 ,in general1 actively dividing cells are most sensitive to radiation4 ,additionally1 radiosensitivity tends to vary inversely with the degree of differentiation of the cell4 g4 ,predicting radiation effects is difficult because often it is unknown which organs were exposed4 ,thus1 most predictions are based on whole body irradiation4 ,partial body and specific organ irradiation will occur due to shielding by equipment1 from fallout particles1 or from internal deposition4 ,depending upon the organ system1 the irradiation can be severe4 ,the severe radiation sickness resulting from external1 whole body irradiation and its consequent organ effects is a primary medical concern4 ,the median lethal dose 7,,ld7 of radiation that will kill #ej percent of the exposed persons within a period of #fj days 7designated as ,,ld#ej_/fj7 is estimated to be approximately #d4e gray 7,gy7 if appropriate medical care is not provided to the casualties4 ,medical intervention should raise this figure to approximately #aj ,gy4 ,this larger figure includes most of the casualties who would be actually capable of reaching medical care following a nuclear detonation1 and nearly all those who could be exposed to a ,,rdd4 ,for acute effects of single high dose rate exposures of whole-body irradiation to healthy adults see ,table ,a-#i4 h4 ,recovery of a particular cell system will occur if a sufficient fraction of a given stem cell population remains after radiation injury and appropriate stimulation and protection are received4 ,complete recovery may appear to occur2 however1 the immune system may repair incompletely with consequent greater susceptibility to future insult from a variety of agents4 ,it is possible for late somatic effects to have a higher probability of occurring because of the radiation damage4 ,efficacy of both prior and future immunization in this group is not adequately understood4 i4 ,interactions between radiological injury and chemical or biological agents appear to be synergistic4 ,insult by these agents in radiologically injured personnel1 even in individually subclinical dosages1 may result in significant clinical illness4 ,a-#f4 ,handling and ,managing ,radiologically ,contaminated ,patients a4 ,radiologically ,contaminated ,patients4 ,personnel from contaminated areas may have fallout on their skin and clothing4 ,although the individual will not be radioactive1 he may suffer radiation injury from the contamination4 ,removal of the contamination should be accomplished as soon as possible2 definitely before admission into a clean treatment area4 ,the distinction must be made between a radiation-injured soldier and one who is radiologically contaminated4 ,although personnel may have received substantial radiation exposure1 this exposure alone does not result in the individual being contaminated4 ,contaminated personnel do not pose a short-term hazard to the medical staff1 rather the contamination is a hazard to the individuals' health4 ,however1 without patient decontamination1 medical personnel may receive sufficient exposure to create beta burns1 especially with extended exposure4 b4 ,handling ,radiologically ,contaminated ,patients4 ,to properly handle radiologically contaminated personnel1 medical personnel must first detect the contamination4 ,detectors that may be used are the ,,an_/,,pdr#bg and ,,an_/,,vdr#b to monitor patients for contamination4 ,generally1 a reading on the meter twice the current background reading indicates that the patient is contaminated4 ,monitoring is conducted when potentially contaminated personnel arrive at the ,,mtf4 ,this monitoring is conducted at the ,,mtf's receiving point before admitting the patient4 ,contaminated patients must be decontaminated before admission4 ,removal of radiological contamination is less important than immediate lifesaving treatment and providing the best possible medical care4 ,lifesaving care before decontamination is provided outside the ,,mtf4 c4 ,decontamination4 ,removing all outer clothing and a brief washing or brushing of exposed skin will reduce #ie percent of contamination2 vigorous bathing or showering is unnecessary4 ,see ,appendix ,g for patient decontamination procedures4 d4 ,internal ,contamination4 ,internalization of radioactive isotopes will primarily occur via inhalation1 ingestion1 and contaminated wounds4 ,extensive internal decontamination should only be undertaken when individual dose estimates indicate that the individual will benefit from the procedures4 ,soldiers who wear their protective mask will be adequately protected from inhalation and ingestion of radioactive particulate matter4 ,internal contamination is considered a delayed problem and does not influence triage categories1 as does irradiation injury4 e4 ,treatment4 ,treatment procedures for radiation injuries are described in ,,fm #d-jb4bhc1 ,,fm #h-i1 and the ,,nato ,handbook1 ,emergency ,war ,surgery4 ,appropriate medical intervention and bone marrow resuscitation will prevent most deaths secondary to irradiation and infection4 ,table ,a-#i4 ,acute ,clinical ,effects of ,single ,high ,dose ,rate ,exposures of ,whole-body ,irradiation of ,healthy ,adults ,part #a ---------------------------------------- ------ #j-ajj c,gy #ajj-ajjj c,gy ,,dose 7,,range7 7,,sub- 7,,sublethal ,,clinical ,,range7 ,,range7 ------------ #ajj-bjj c,gy ---------------------------------------- ----- ,,incidence ,,of ,,nausea ,,none #e-ej ,,vomiting ----------------------------------- ,,time ,,of ---- ,,approx ,,initial ,,onset #c-f ,,hrs ,,phase ----------------------------------- ,,duration ---- ,,less ,,than #bd ,,hrs ----------------------------------- ,,combat ,,effect- #ajj #ajj ,,iveness ---------------------------------------- ----- ,,latent ,,duration ---- ,,more ,,than ,,phase #b ,,weeks ---------------------------------------- ----- ,,signs ,,moderate ,,symptoms ,,none ,,leukopenia ----------------------------------- ,,time ,,of ,,onset ,,post ---- #b ,,weeks ,,or ,,secondary ,,exposure ,,more ,,phase ----------------------------------- ,,critical ,,period ,,post ---- ,,none ,,exposure ----------------------------------- ,,organ ,,system ,,none ,,responsible ---------------------------------------- ----- ,,hospital- ,,percentage ,,none ,,less ,,than #e ,,ization ----------------------------------- ,,duration ---- #de-fj ,,days ---------------------------------------- ------ ,,incidence ,,of ,,death ,,none ,,none ---------------------------------------- ------ ,,average ,,time ,,of ,,death ---- ---- ---------------------------------------- ------ ,,reassurance ,,therapy ,,none ,,hematologic ,,surveillance ---------------------------------------- ------ ,part #b ---------------------------------------- ----------------------------- #ajj-ajjj c,gy 7,,sublethal ,,range7 ,,dose 7,,range7 ---------------------------------------- ------ #bjj-fjj c,gy #fjj-ajjj c,gy ---------------------------------------- ---------------------------- ,,incidence ,,of ,,nausea #ej-ajj #ge-ajj ,,vomiting ---------------------------------------- ------------------ ,,time ,,of ,,approx #b-d ,,hrs ,,approx #a-b ,,hrs ,,initial ,,onset ,,phase ---------------------------------------- ------------------ ,,duration ,,less ,,than #bd ,,hrs ,,less ,,than #dh ,,hrs ---------------------------------------- ------------------ ,,can ,,perform ,,routine ,,can ,,perform ,,only ,,simple ,,combat ,,tasks4 ,,sustained ,,routine ,,tasks4 ,,significant ,,effect- ,,combat ,,or ,,comparabl ,,incapacitation ,,in ,,upper ,,iveness ,,activities ,,hampered ,,part ,,of ,,range4 ,,lasts ,,more ,,for #f-bj ,,hrs4 ,,than #bd ,,hrs4 ---------------------------------------- ---------------------------- ,,latent ,,duration ,,approx #g-ae ,,days ,,none ,,to ,,approx #g ,,days ,,phase ---------------------------------------- ---------------------------- ,,signs ,,severe ,,leukopenia2 ,,purpura1 ,,hemorrhage2 ,,symptoms ,,infection2 ,,epilation ,,about #cjj c,gy4 ---------------------------------------- ------------------ ,,time ,,of ,,onset ,,post ,,several ,,days ,,to #b ,,weeks ,,secondary ,,exposure ,,phase ---------------------------------------- ------------------- ,,critical ,,period ,,post #d-f ,,weeks ,,exposure ---------------------------------------- ------------------- ,,organ ,,system ,,hematopoietic ,,tissue ,,responsible ---------------------------------------- ---------------------------- ,,hospital- ,,percentage #ij #ajj ,,ization ---------------------------------------- ------------------ ,,duration #fj-ij ,,days #ij-abj ,,days ---------------------------------------- ---------------------------- ,,incidence ,,of ,,death #j-hj #ij-ajj ---------------------------------------- ----------------------------- ,,average ,,time ,,of ,,death #c ,,weeks ,,to #b ,,months ---------------------------------------- ------------------------------ ,,therapy ,,blood ,,transfusion1 ,,antibiotics ---------------------------------------- ------------------------------ ,part #c ---------------------------------------- ----------------------------- ,,over #ajjj c,gy 7,,lethal ,,range7 ,,dose 7,,range7 ---------------------------------------- ------ #ajjj-cjjj c,gy ,,over #cjjj c,gy ---------------------------------------- ---------------------------- ,,incidence ,,of ,,nausea #ajj ,,vomiting ---------------------------------------- ------------------- ,,time ,,of ,,less ,,than #a ,,hr ,,initial ,,onset ,,phase ---------------------------------------- ------------------ ,,duration ,,less ,,than #dh ,,hrs ,,approx #dh ,,hrs ---------------------------------------- ------------------- ,,progressive ,,incapaci- ,,progressive ,,incapaci- ,,combat ,,tation ,,following ,,an ,,tation ,,following ,,an ,,effect- ,,early ,,capability ,,for ,,early ,,capability ,,for ,,iveness ,,intermittent ,,heroic ,,intermittent ,,heroic ,,response4 ,,response4 ---------------------------------------- ---------------------------- ,,latent ,,duration ,,none ,,to ,,approx #b ,,days ,,none ,,phase ---------------------------------------- ---------------------------- ,,signs ,,diarrhea2 ,,fever2 ,,distur-,,convulsions2 ,,tremor ,,symptoms ,,bance ,,of ,,electrolyte ,,ataxia2 ,,lethargy4 ,,balance4 ---------------------------------------- ------------------ ,,time ,,of ,,onset ,,post #b-c ,,days ,,secondary ,,exposure ,,phase ---------------------------------------- ------------------ ,,critical ,,period ,,post #e-ad ,,days #a-dh ,,hr ,,exposure ---------------------------------------- ------------------ ,,organ ,,system ,,gastrointestinal ,,tract ,,central ,,nervous ,,system ,,responsible ---------------------------------------- ---------------------------- ,,hospital- ,,percentage #ajj #ajj ,,ization ---------------------------------------- ------------------ ,,duration #b ,,weeks #b ,,days ---------------------------------------- ---------------------------- ,,incidence ,,of ,,death #ij-ajj ---------------------------------------- ----------------------------- ,,average ,,time ,,of ,,death #a-b ,,weeks #b ,,days ---------------------------------------- ----------------------------- ,,maintenance ,,of ,,therapy ,,electrolyte ,,balance ,,sedatives ---------------------------------------- ----------------------------- ,a-#g4 ,radiological ,patients in ,stability ,operations and ,support ,operations ,in stability operations and support operations1 high levels of environmental contamination and the use of ,,rdd can cause radiological injury to personnel at levels below that necessary to produce performance decrement and traditional casualty status4 ,treatment and evacuation guidelines will be in accordance with command guidance4 ,individual physical dosimetry is the most expedient measurement technique for this exposure 7see ,table ,a-#aj74 ,these radiation injuries and effects may also be seen in war2 especially1 from hostile forces employment of ,r,d,ds4 ,table ,a-#aj4 ,stability ,operations and ,support ,operations3 ,radiation ,injuries and ,effects of ,radiation ,exposure of ,personnel ,,radiation ,,total ,,stochastic ,,risk ,,exposure ,,cumulative ,,long-,,term ,,medical ,,note ,,medical ,,actions ,,status ,,dose ,,health ,,effects ---------------------------------------- -------------------------------- #j #j4je c,gy ,,normal ,,risk4 ,,us ,,baseline #bj ,,record ,,in ,,exposure ,,lifetime ,,risk ,,of ,,record ,,if ,,normally ,,fatal ,,cancer4 ,,monitored ,,personnel4 ---------------------------------------- -------------------------------- #a;,a #j4je ,,to ,,up ,,to #j4jd ,,none 7#j4jja ,sv ,,us ,,record ,,as ,,history ,,in #j4e c,gy ,,increased ,,annual ,,gen4 ,,pop4 ,,medical ,,record-- ,,risk ,,lifetime ,,exposure ,,limit47 ,,tactical ,,operation ,,fatal ,,cancer4 ,,exposure4 ---------------------------------------- -------------------------------- #a;,b #j4e ,,to #e c,gy ,,us ,,radiation ,,reassurance ,,record ,,in ,,medical ,,occupational 7#j4je ,sv ,,us ,,record-- ,,risk4 ,,annual ,,tactical ,,operation #j4jd-j4d ,,occupational ,,exposure4 ,,increased ,,risk ,,limit47 ,,lifetime ,,cancer4 ---------------------------------------- -------------------------------- #a;,c #e ,,to #aj c,gy #j4d-j4h ,,counsel ,,regarding ,,record ,,in ,,medical ,,increased ,,risk ,,increased ,,long- ,,record-- ,,lifetime ,,fatal ,,term ,,risk4 ,,tactical ,,operation ,,cancer4 ,,no ,,live ,,virus ,,exposure4 ,,vaccines ,x #c ,,months4 ---------------------------------------- -------------------------------- #a;,d #aj ,,to #be c,gy #j4h-b ,,potential ,,for ,,inc- ,,record ,,in ,,medical ,,increased ,,risk ,,reased ,,morbidity ,,record-- ,,lifetime ,,fatal ,,of ,,other ,,injuries ,,tactical ,,operation ,,cancer4 ,,or ,,incidental ,,exposure4 ,,consider ,,disease4 #b ,,routine ,,evacuation ,,increased ,,lifetime ,,from ,,theater ,,iaw ,,risk ,,of ,,fatal ,,commander',s ,,oper- ,,cancer4 ,,ational ,,guidance4 ---------------------------------------- -------------------------------- #a;,e #be ,,to #ge c,gy #b-e4f ,,increased ,,morbidity ,,record ,,in ,,medical ,,increased ,,risk ,,of ,,other ,,injuries ,,record-- ,,lifetime ,,fatal ,,or ,,incidental ,,tactical ,,operation ,,cancer4 ,,disease4 #f ,,exposure4 ,,consider ,,increased ,,lifetime ,,expedited ,,evacu- ,,risk ,,of ,,fatal ,,ation ,,from ,,theater ,,cancer4 ,,iaw ,,commander',s ,,operational ,,guidance4 ,a-#h4 ,effects of ,biological ,weapons ,biological warfare is the intentional use1 by an enemy1 of live agents or toxins to cause death and disease among personnel1 animals1 and plants1 or to deteriorate materiel4 a4 ,live ,agents4 7#a7 ,live agents are living organisms like viruses1 bacteria1 and fungi4 ,they can be delivered directly 7artillery or aircraft spray71 or through a vector such as a flea or tick4 ,advances in modern weaponizing of biological agents have become easier4 7#b7 ,for some agents1 only a few organisms are needed to cause infection4 ,live agents are small and light2 they can be spread great distances by the wind and contaminate unfiltered or nonairtight places4 7#c7 ,aerosolized particles of #a to #e micron 77 size carrying live agents are small and light4 ,they require time after they are ingested to multiply enough to overcome the body's defenses4 ,this incubation period may vary from hours to days or weeks depending on the type of organism4 ,thus1 to be effective1 a live agent attack would need to be launched well in advance of a tactical assault4 7#d7 ,these agents are sensitive to environmental conditions 7for example humidity and sunlight74 ,many bacterial agents will not survive outside the host organism 7human and animals74 7#e7 ,live agents are not detectable by any of the five physical senses2 usually the first indication of a biological attack is the ill personnel4 ,the diseases caused by live agents may be difficult to control when the aerosol attack is directed against a large population4 ,some diseases may be transmitted from person-to-person after the initial attack2 examples include plague1 smallpox1 and some viral hemorrhagic fevers4 7#f7 ,because of their incubation period and life cycle1 likely areas for live agent use are in the combat service support 7,,css7 area2 but attacks in forward areas cannot be ruled out4 b4 ,spore ,forming ,biological ,agents4 ,spore formers such as anthrax can survive for an extended time1 even under very adverse environmental conditions 7dry1 extremes of temperatures1 and flooding74 ,once inhaled1 ingested1 or injected into the human body1 the spores germinate and produce the illness4 c4 ,toxins4 7#a7 ,toxins are by-products 7poisons7 produced by plants1 animals1 or microorganisms4 ,it is the poisons that harm man1 not the organisms that make the toxins4 ,in the past1 the only way to deliver toxins on a large scale was by using the organism4 ,with today's technology large quantities of many toxins can be produced2 thus1 they can be delivered without the accompanying organism4 7#b7 ,toxins have several desirable traits4 ,they are poisonous compounds that do not grow1 reproduce1 or die after they have been dispersed2 they are more easily controlled than live organisms4 ,field monitors capable of providing prompt warning of a toxin attack are not available2 therefore1 personnel must learn to quickly recognize signs of attack1 such as observing unexplained symptoms of victims4 ,toxins produce effects similar to those caused by chemical agents2 however1 the victims will not respond to the first-aid measures that work against chemical agents4 ,unlike live agents1 mycotoxins 7,t#b7 can penetrate intact skin2 other toxins cannot4 ,because the effects on the body are direct1 the symptoms of an attack may appear very rapidly4 ,the potency of most toxins is such that very small doses will cause injuries and_/or death4 ,thus1 their use by an enemy may be an alternative to chemical agents because it allows the use of fewer resources to cover the same or a larger area4 ,slight exposure at the edges of an attack area may produce severe symptoms or death from exposure to toxins because of their extreme toxicity4 ,lethal or injury downwind hazard zones for toxins may be far greater than those of ,,cw agents4 ,a-#i4 ,behavior of ,biological ,weapons ,biological agents can be disseminated in a spectrum of physical states4 ,they may be living microorganisms or spore forms of the organism4 ,see ,table ,a-#aa for stability of various biological agents4 ,they may be spread by-- ,arthropods4 ,contact with infected animals4 ,contamination of food and water4 ,aerosol1 liquid1 or solid dispersion4 ,the only requirement is that they must be stable enough to survive transport and dissemination4 ,the toxicity of biological agents is not the same for everyone2 each individual does not react exactly the same way to the same amount of an agent4 ,some are more resistive than others because of race1 sex1 age1 or other factors4 ,the dose is the quantity of a biological agent received by the subject4 ,the penetration of agents by various routes need not be accompanied by irritation or damage to the absorbent surface4 ,there are often unique signs and identifying symptoms depending on entry route 7inhalation1 ingestion1 or dermal74 a4 ,biological agents dispersed by spray often enter the body through the respiratory tract 7inhalation injury74 ,the agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs4 b4 ,liquid droplets and 7less commonly7 solids may be absorbed from the surface of the skin1 digestive tract1 and mucous membranes4 ,agents penetrating the skin may form temporary reservoirs under the skin4 c4 ,contaminated food and water can produce casualties when ingested4 ,table ,a-#aa4 ,types and ,characteristics of ,some ,biological ,agents ,,entrance ,,type ,,of ,,agent ,,stability ,,incubation ,,time ,,aerosol ,,nonaerosol ---------------------------------------- --------------------------------- ,,anthrax ,,high ,,hours ,,to #g ,,days ,,inhalation ,,skin1 ,,mouth ---------------------------------------- --------------------------------- ,,botulinum ,,toxin ,,high #bd ,,to #cf ,,hours ,,inhalation ,,mouth1 ,,wound ---------------------------------------- --------------------------------- ,,brucellosis ,,high ,,in #a ,,to #d ,,weeks ,,inhalation ,,mouth1 ,,skin1 ,,wet ,,env- ,,eyes ,,ironment ---------------------------------------- --------------------------------- ,,cholera ,,moderate ,,hours ,,to #e ,,days ,,mouth ---------------------------------------- --------------------------------- ,,plague7,,pneumonic7 ,,low #b ,,to #d ,,days ,,inhalation ---------------------------------------- --------------------------------- ,,plague 7,,bubonic7 ,,moderate #b ,,to #aj ,,days ,,bite ,,of ,,vector ---------------------------------------- --------------------------------- ,,ricin ,,high #cf ,,hours ,,inhalation ,,mouth ---------------------------------------- --------------------------------- ,,smallpox ,,high #g ,,to #ag ,,days ,,inhalation ,,lesion ,,contact ---------------------------------------- --------------------------------- ,,staphylococcal ,,high #a ,,to #f ,,hours ,,inhalation ,,mouth ,,enterotoxin ,b ---------------------------------------- --------------------------------- ,,trichothecene ,,high ,,minutes ,,to ,,hours ,,inhalation ,,mouth1 ,,skin ,,mycotoxin ---------------------------------------- --------------------------------- ,,tularemia ,,low #b ,,to #aj ,,days ,,inhalation ,,mouth1 ,,skin1 ,,bite ,,of ,,vector ---------------------------------------- --------------------------------- ,,venezuelan ,,equine ,,moderate #a ,,to #f ,,days ,,inhalation ,,bite ,,of ,,vectors ,,encephalitis ---------------------------------------- --------------------------------- ,,viral ,,hemorrhagic ,,low ,,days ,,to ,,months ,,inhalation ,,bite ,,of ,,vectors ,,fevers ,a-#aj4 ,management of ,biological ,warfare ,patients a4 ,management4 ,management of patients suffering from the effects of ,,bw agents may include the need for isolation4 ,barrier nursing for patients suspected of suffering from exposure to ,,bw agents will reduce the possibility of spreading the disease to health care providers and other patients4 ,specimens must be collected and submitted to the designated supporting laboratory for identification4 ,for details on hospital infection control aspects of managing ,,bw casualties1 see ,,fm #h-bhd4 b4 ,mass ,casualty4 ,a ,,bw agent attack can produce a mass casualty situation at all levels of ,,hss4 ,a major problem with a ,,bw mass casualty situation is that ,,hss personnel are more susceptible to becoming a casualty to ,,bw agents4 ,also1 the ill patient may be the first indicator that a ,,bw agent has been dispersed4 c4 ,decontamination4 ,decontamination is an individual and unit responsibility4 ,however1 some individuals may arrive at the ,,mtf that have not been decontaminated or that become contaminated en route to the ,,mtf4 ,these individuals must be decontaminated at the ,,mtf before they are admitted to prevent contamination of the ,,mtf and exposure of medical personnel to the biological agent4 ,see ,appendix ,g for details on patient decontamination4 d4 ,treatment4 ,specific treatment is dependent upon the ,,bw agent used4 ,patients are treated for symptomatic presentation unless the ,,bw agent identity is known4 ,field ,manuals #h-i and #h-bhd provide detailed information on medical management and treatment4 ,a-#aa4 ,effects of ,chemical ,weapons a4 ,a chemical agent is a chemical that is used to kill1 seriously injure1 or incapacitate man because of its physiological effects4 ,they can be disseminated by artillery1 aircraft1 rocket1 or by nonconventional means used by terrorists4 ,when first employed in combat during ,world ,war ,i1 the chemical weapon 7chlorine7 was so effective that the attacking ,germans were not prepared to exploit the success4 b4 ,chemical agents are very effective weapons against poorly trained and equipped forces2 however1 they are less effective against well-trained forces4 ,a-#ab4 ,behavior of ,chemical ,weapons ,chemical agents can be disseminated as a gas1 vapor1 or aerosol under ambient conditions4 ,they have a range of odors varying from none to highly pungent characteristics4 ,their stability is dependent upon the environmental conditions in the area of employment4 ,see ,table ,a-#aa for persistency of various chemical agents4 a4 ,the toxicity of a chemical agent is not the same for everyone2 each individual does not react exactly the same way to the same amount of an agent4 ,some are more resistant than others because of physiological factors4 ,the dose is the quantity of a chemical received by the individual for percutaneous or oral doses and as a time-weighted concentration1 milligrams-minute 7m#c71 for inhalation4 ,it is usually expressed as milligrams of agent per kilogram of subject body weight 7mg_/kg74 ,the ,,ld#ej is the dose that kills #ej percent of the exposed population4 ,the incapacitation dose #ej 7,,id#ej7 is the incapacitation dose for #ej percent of the exposed subjects4 ,the penetration of agents by various routes need not be accompanied by irritation or delayed superficial damage to the absorbent surface1 but there are often unique signs and symptoms identifiable by the route of entry4 7#a7 ,gaseous1 vapor1 and aerosol chemical agents often enter the body through the respiratory tract 7inhalation injury74 ,the agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs4 ,aerosol particles larger than #e tend to be retained in the upper respiratory tract2 particles in the #a to #e range are retained in the deep volume of the lungs2 while those below #a tend to be breathed in and out again2 although a few are retained in the deep volume of the lungs4 7#b7 ,vapors and droplets of liquids can be absorbed from the surface of the skin and mucous membranes4 ,toxic compounds that are harmful to the skin can produce their effects in liquid or solid state4 ,agents penetrating the skin may form temporary reservoirs under the skin2 the vapors of some volatile liquids can penetrate the skin and cause intoxication4 ,additionally1 wounds and abrasions may present areas that are more permeable than intact skin4 b4 ,chemical agents may be divided into two main categories 7persistent and nonpersistent7 that describe how long they are capable of producing casualties4 ,table ,a-#ab lists the common chemical agents1 their effects and time of effectiveness4 ,table ,a-#ac lists the types and characteristics of common chemical agents4 7#a7 ,persistent agents continue to present a hazard for considerable periods 7days7 after delivery by remaining as a contact hazard1 or by slowly vaporizing to produce a hazard by inhalation4 7#b7 ,nonpersistent agents disperse rapidly after release and present an immediate1 short duration 7hours7 hazard4 ,they are released as airborne particles1 aerosols1 and gases4 ,table ,a-#ab4 ,common ,chemical ,warfare ,agents ,,common ,,name ,,effect ,,time ,,to ,,effect ---------------------------------------- --------------------------------- ,,tabun 7,,ga7 ,,inhalation3 ,,seconds ,,to ,,minutes ,,sarin 7,,gb7 ,,lethal ,,nerve ,,agents ,,topical3 ,,minutes ,,soman 7,,gd7 ,,ingestion3 ,,minutes ,,to ,,hours ,v-,,agents ---------------------------------------- --------------------------------- ,,hydrogen ,,cyanide ,,lethal ,,blood ,,agent ,,minutes ---------------------------------------- --------------------------------- ,,mustard ,,blister ,,agents #a ,,to #ab ,,minutes ,,lewisite ,,minutes ---------------------------------------- --------------------------------- ,,lsd ,,and ,,bz ,,incapacitating ,,agents #ae ,,to #fj ,,minutes ---------------------------------------- --------------------------------- ,,phosgene ,,lung-,,damaging 7,,choking7 ,,minutes ,,chlorine ,,seconds ,,to ,,minutes ,table ,a-#ac4 ,types and ,characteristics of ,chemical ,agents ,part #a ,,type ,,of ,,persistence ,,rate ,,of ,,agent ,,symbol ,,summer ,,winter ,,action ---------------------------------------- ------------------------ ,,ga1 ,,gb1 ,,gd #aj ,,min-#bd ,,hr #b ,,hr-#c ,,days ,,very ,,quick ,,nerve ---------------------------------------- --------------- ,,vx #b ,,days-#a ,,wk #b ,,days-,,weeks ,,quick ---------------------------------------- ------------------------ ,,choking ,,cg1 ,,dp #a-aj ,,min #aj ,,min-#a ,,hr ,,immediate ---------------------------------------- ------------------------ ,,hd1 ,,hn #c ,,days-#a ,,wk ,,weeks ,,slow ---------------------------------------- -------------- ,,blister ,l1 ,,hl #a-c ,,days ,,weeks ,,quick ---------------------------------------- -------------- ,,cx ,,days ,,days ,,very ,,quick ---------------------------------------- ------------------------ ,,blood ,,ac1 ,,ck #a-aj ,,min #aj ,,min-#a ,,hr ,,very ,,quick ,part #b ,,type ,,of ,,entrance ,,agent ,,symbol ,,vapor_/,,aerosol ,,liquid ---------------------------------------- ------------------------ ,,ga1 ,,gb1 ,,gd ,,eyes1 ,,lungs ,,eyes1 ,,skin1 ,,mouth ,,nerve ---------------------------------------- --------------- ,,vx ,,eyes1 ,,lungs ,,eyes1 ,,skin1 ,,mouth ---------------------------------------- ------------------------ ,,choking ,,cg1 ,,dp ,,lungs ,,eyes ---------------------------------------- ------------------------ ,,hd1 ,,hn ,,eyes1 ,,skin1 ,,lungs ,,eyes1 ,,skin ---------------------------------------- -------------- ,,blister ,l1 ,,hl ,,eyes1 ,,skin1 ,,lungs ,,eyes1 ,,skin1 ,,mouth ---------------------------------------- -------------- ,,cx ,,eyes1 ,,lungs1 ,,skin ,,eyes1 ,,skin1 ,,mouth ---------------------------------------- ------------------------ ,,blood ,,ac1 ,,ck ,,eyes1 ,,lungs ,,eyes1 ,,mouth1 ,,injured ,,skin ,a-#ac4 ,characteristics of ,chemical ,agents ,the effectiveness of a chemical agent is a measure of how much agent is required to produce the desired effect4 ,thus1 an agent that is toxic at a lower dose than another similar agent is more effective4 ,besides dose required for a given effect1 persistency may be used to measure effectiveness4 ,persistency depends on the agent's physical characteristics1 the amount of agent delivered1 its physical state1 weapons system used1 the terrain1 and weather in the target area4 ,the desired effects will determine the physical1 chemical1 and toxicological properties of the chemical agent employed4 a4 ,nerve agents are primarily organophosphorus esters similar to insecticides4 ,those of military importance are combined under this term4 ,although some have been given names1 they are usually known by their code letters3 ,,ga2 ,,gb2 ,,gd2 and ,,vx4 ,they are all liquids1 varying in volatility that is in a range between gasoline and heavy lubricating oil4 ,their freezing points are -#dj degrees ,celsius or lower4 7#a7 ,liquid nerve agents are pale yellow to colorless and are almost odorless4 ,they are moderately soluble in water and highly soluble in lipids 7oil74 ,they are rapidly destroyed by strong alkalies and chlorinating compounds4 ,normal clothing is readily penetrated by liquid or vapor agents4 ,butyl rubber and synthetic material are more resistant than natural fibers4 ,agents can penetrate into nonabsorbent material such as web belts and can continue to present a hazard by desorption 7off-gassing7 of the vapor4 ,although local sweating and twitching may occur1 usually there is no local irritant change after cutaneous exposure4 ,toxicity depends upon the route of entry and physical characteristics4 7#b7 ,nerve agents strongly inhibit the cholinesterase enzymes4 ,when acetylcholine is released by the nerve junction1 it is hydrolyzed by the enzyme4 ,acetylcholine is the chemical mediator for transmission of the nerve impulses in numerous synapses of the central nervous system 7,,cns7 and the autonomic nervous system and at the endings of the cholinergic nerves 7for example3 affecting the smooth muscles of the iris1 ciliary1 bronchial tree1 and gastrointestinal tract74 ,the inhibition of cholinesterase by nerve agents is almost irreversible1 so the effects are prolonged4 ,until the cholinesterase level is restored to normal1 there is an increased susceptibility to nerve agent exposure4 ,during this time1 the effects of repeated exposure are cumulative and the patient may feel subpar 7for example3 tired1 fatigue easily1 poor appetite1 impaired concentration7 until recovery is complete4 7#c7 ,nerve agent poisoning is easily identified by the characteristic signs and symptoms as follows3 7a7 ,,mild symptoms 7self-aid74 ,casualties with ,,mild symptoms may experience most or all of the following3 ,unexplained runny nose4 ,unexplained sudden headache4 ,sudden drooling4 ,difficulty in seeing 7dimness of vision7 7miosis74 ,tightness in the chest or difficulty in breathing4 ,localized sweating and muscular twitching in the contaminated area4 ,stomach cramps4 ,nausea4 7b7 ,casualties with ,,moderate symptoms 7buddy aid7 will experience an increase in the severity of most or all of the ,,mild symptoms4 ,especially prominent will be an increase in fatigue1 weakness1 and muscle fasciculations4 ,the progress of symptoms from ,,mild to ,,moderate indicates either inadequate atropine treatment or continuing exposure to agent4 7c7 ,,severe symptoms 7buddy aid74 ,casualties with ,,severe symptoms may experience most or all of the ,,mild symptoms1 plus most or all of the following3 ,strange or confused behavior4 ,wheezing1 dyspnea 7severe difficulty in breathing71 and coughing4 ,severely pinpointed pupils4 ,red eyes with tearing4 ,vomiting4 ,severe muscular twitching and general weakness4 ,involuntary urination and defecation4 ,convulsions4 ,unconsciousness4 ,respiratory failure4 b4 ,there are three major families of blister agents 7vesicants72 ,,hd and ,,hn1 ,l1 and ,,cx4 ,most vesicants 7except ,,cx7 are relatively persistent4 ,mustards can modify the structure of nucleic acids1 cellular membranes1 and proteins by combining with certain functional groups 7particularly the sulfhydryl-containing enzymes7 for which they have an affinity4 7#a7 ,the cutaneous syndrome is divided into four phases3 latent1 erythema1 vesication1 and necrosis4 ,vesicants can penetrate the skin by contact with either liquid or vapor4 ,the latent period is characteristic of the agent4 ,for mustards it is usually several hours1 for ,l it is short1 and for ,,cx it is negligible4 ,the latent period is also affected by the dose1 temperature1 and humidity4 ,the symptoms of the erythema phase are red1 painful itching followed by painful necrosis that heals slowly4 7#b7 ,in the eyes1 vesicants produce intense pain and photophobia4 ,blistering of the eyelids and mucous membranes can result in temporary blindness4 ,even after recovery1 scars on the cornea can reduce visual acuity4 7#c7 ,in the respiratory tract1 these agents attack the mucous membranes irritating them4 ,they can paralyze vocal chords and can lead to chemical pneumonitis1 or possibly death4 7#d7 ,although blister agents can affect other organs and produce deleterious effects1 the skin1 eyes1 and respiratory tract are the principle organs effected4 c4 ,chemical agents that attack lung tissue 7choking agents7 and cause pulmonary edema are classed as lung damaging agents4 ,choking agents consist of ,,cg and ,,dp1 ,,cl1 and ,,ps4 ,phosgene is typical of the lung-damaging agents2 it is used as the example here4 7#a7 ,phosgene is a colorless gas that has an odor resembling new mown hay4 ,although effects are primarily confined to the lungs1 phosgene may also cause mild irritation of the eyes and upper respiratory tract4 ,phosgene causes a shift in the membrane potential of the alveoli allowing the passage of fluid into the alveoli1 resulting in massive pulmonary edema and severely impairing the exchange of oxygen 7,o#b7 and carbon dioxide 7,,co#b7 between the capillary blood and the alveolar air4 7#b7 ,initially hypoxemia occurs and is followed shortly by hyperventilation when the frothy edema fluid fills the bronchioli and ,,co#b expiration stops4 7#c7 ,signs and symptoms during and immediately following exposure are coughing1 tightness of chest1 nausea1 occasionally vomiting1 headache1 and lacrimation 7tearing74 d4 ,blood agents consist of ,,ac and ,,ck2 both are readily absorbed by the mucous membranes and the intact skin4 ,the odor of ,,ac resembles bitter almonds1 but many people cannot detect it4 ,detecting the odor of ,,ck is difficult because of its irritating and lacrimatory effects4 ,it is also poorly absorbed by the metallic salt-impregnated charcoal filters in the protective mask4 ,these agents inhibit certain enzymes 7particularly cytochrome oxidase7 that are important for oxidation-reduction in the cells2 therefore1 cell respiration is inhibited and oxygen carried by the hemoglobin is not consumed causing the venous blood to remain bright red4 ,initial symptoms are characterized by violent convulsions1 increased deep respiratory movements1 followed by cessation of respiration within one minute1 slowing of heart rate to death4 ,high concentrations exert their effects rapidly2 however1 if the patient is still alive after the cloud has passed1 he will probably recover spontaneously4 e4 ,incapacitating agents are chemicals that produce a temporary disabling condition that persists for hours to days after exposure to the agent has ceased 7unlike that produced by riot control agents74 ,while not required1 medical treatment produces a more rapid recovery4 ,characteristics of these agents are that they-- ,are highly potent and logistically feasible4 ,produce their effects mainly by altering or disrupting the higher regulatory activity of the ,,cns4 ,produce effects that last for hours or days rather than momentary or fleeting4 ,do not seriously endanger life1 except in exceedingly high doses4 ,produce no permanent injury4 ,the two types likely to be encountered are ,,cns depressants and ,,cns stimulants4 7#a7 ,central nervous system depressants are compounds that have a predominant effect of depressing or blocking the activity of the ,,cns2 often by interfering with the transmission of information across synapses4 ,an example of this type of agent is ,,bz4 ,the action of acetylcholine1 both peripherally and centrally1 appears to be blocked by ,,bz4 ,low doses disrupt higher integrative functions of memory1 problem solving1 attention1 and comprehension4 ,high doses produce toxic delirium that destroys the ability to perform any military task4 ,within the ,,cns1 ,,bz seems to produce its effects in the same way as atropine4 ,small doses cause sleepiness and decreased alertness with elevated heart rate1 dry skin and eyelids1 drowsiness1 increased pupil size1 and elevated skin temperatures4 ,progressive intoxication is marked by an inability to respond effectively to the environment 7#d to #ab hours71 followed by increasing activity and random_/unpredictable behavior 7#ab to #if hours74 ,because the patient cannot sweat1 heat stress becomes a problem4 7#b7 ,central nervous system stimulants are agents that cause excessive nervous activity1 often by boosting or facilitating transmission of impulses across synapses4 ,the effect is to flood the cortex and other higher regulatory centers with too much information1 making concentration difficult and causing indecisiveness and an inability to act4 ,these include ,,lsd1 psilocybin1 and mescaline4 ,intoxication shows sympathetic stimulation 7rapid heart rate1 sweaty palms1 pupillar enlargement1 and cold extremities7 and mental excitation 7nervousness1 trembling1 anxiety1 and inability to relax or sleep72 feelings of tension1 exhilaration1 heightened awareness1 paranoid ideas1 and profound states of terror may also occur4 ,a-#ad4 ,management of ,chemical ,agent ,patients a4 ,management4 ,movement of chemical agent casualties can spread the contamination to clean areas4 ,all casualties are decontaminated as far forward as the situation permits4 ,all patients must be decontaminated before they are admitted into a clean ,,mtf4 ,the admission of one contaminated patient into an ,,mtf will contaminate the facility2 thereby reducing its treatment capabilities4 b4 ,mass ,casualty4 ,a mass casualty situation is presented when chemical agents are employed4 ,additional ,,hss personnel and equipment must be provided in a short period of time if the level of care is to be maintained4 ,treatment at far forward ,m,t,fs is limited to life- or limb-saving care4 ,patients that can survive evacuation to the next level of care are not treated at the forward facility4 ,this provides time for treating those patients that cannot survive the evacuation time4 c4 ,decontamination4 ,decontamination is an individual and unit responsibility4 ,however1 some individuals may arrive at the ,,mtf that have not been decontaminated or that become contaminated en route to the ,,mtf4 ,these individuals must be decontaminated at the ,,mtf before they are admitted to prevent contamination of the ,,mtf and exposure of medical personnel to the chemical4 ,see ,appendix ,g for detailed information on patient decontamination procedures4 d4 ,treatment4 ,field ,manuals #h-i and #h-bhe provide treatment procedures for chemical agent patients4 ,a-#ae4 ,management of ,toxic ,industrial ,material ,patients a4 ,management4 ,movement of ,,tim casualties can spread the contamination to clean areas4 ,all casualties are decontaminated as close to the incident site as possible4 ,all patients must be decontaminated before they are admitted into a clean ,,mtf4 ,the admission of one contaminated patient into an ,,mtf may contaminate the facility2 thereby reducing its treatment capabilities4 b4 ,mass ,casualty4 ,a mass casualty situation is presented when the number of casualties exceeds the capabilities of medical personnel at the location to provide needed care at the incident site4 ,treatment at the incident site is limited to life- or limb-saving care4 ,patients that can survive are evacuated to the nearest ,,mtf with a patient decontamination capability4 c4 ,decontamination4 ,decontamination is an individual and first responder responsibility4 ,however1 some individuals that self evacuated or were evacuated due to the mass casualty situation arrive at the ,,mtf that have not been decontaminated4 ,these individuals must be decontaminated at the ,,mtf before they are admitted to prevent contamination of the ,,mtf and exposure of unprotected medical personnel and other patients to the ,,tim4 ,see ,,fm #h-ejj for detailed information on decontamination procedures for ,,tim contaminated casualties4 d4 ,treatment4 ,field ,manual #h-ejj provides treatment procedures for some ,,tim casualties4 ,treatment for many ,,tim casualties is agent specific and receiving ,m,t,fs must be prepared for these events4 ,,example3 ,treatment for a casualty exposed to toxic levels of an inorganic phosphate pesticide would be treated in the same manner as a nerve agent casualty except the amount of antidote for the pesticide poisoned casualty will be many times greater than for the nerve agent casualty4 ,,appendix ,b ,,sample_/,,specimen ,,collection ,,and ,,management ,section ,i4 ,,introduction ,b-#a4 ,general a4 ,critical elements for accuracy in analysis of ,,nbc samples and physiological specimens are correct collecting1 packaging1 handling1 and transporting techniques4 ,the quality of any analytical evaluation is directly related to the quality of the sample_/specimen and the degree of postcollection degradation that occurs prior to testing4 ,health service support personnel collect and submit specimens for suspect ,,nbc hazards_/agents involving humans and animals4 ,chemical corps and other nonmedical units collect and submit environmental 7air1 plant1 and soil7 samples for suspect ,,nbc hazards_/agents4 ,preventive medicine personnel collect and submit water and ice samples for suspect ,,nbc hazards_/agents4 ,veterinary personnel collect and submit food samples1 such as fruits and vegetables1 and specimens from animals for suspect ,,nbc hazards_/agents4 ,specimens collected from patients that are suspect of being exposed to a biological agent are forwarded to the supporting medical laboratory 7such as the ,,taml1 ,,aml or ,,us ,navy ,forward ,deployed ,,pvntmed ,unit7 for analysis4 b4 ,essentially all military operations from war to stability operations and support operations may generate medical laboratory testing requirements4 ,each scenario1 geographical region1 population base1 and suspect agent will impact on the type and amount of samples_/specimens required and the collection process4 ,during all operations1 express permission is required before collecting specimens from civilians because of religious or sociological beliefs in many cultures4 ,to obtain such specimens without permission could result in unnecessary mission complications4 ,,notes #a4 ,the term sample refers to nonhuman and nonanimal origin4 ,the term specimen refers to human and animal origin4 #b4 ,always consider that chemical agents may have been employed4 ,check for chemical agents before collecting a biological sample_/specimen4 ,chemical agents can damage or destroy biological agents4 ,also1 chemical agents not identified in the sample_/specimen can pose a hazard to receiving laboratory personnel4 ,mark all samples that are potentially contaminated with chemical agents as such4 #c4 ,precautions should be taken to protect the sample_/specimen collector from potential ,,bw agents2 at a minimum1 respiratory protection and rubber gloves must be worn4 ,additional care must be taken when collecting samples_/specimens to prevent cross-contamination4 ,gloves must be changed or decontaminated between sample_/specimen collections4 #d4 ,samples will not be delivered to the clinical laboratory of an ,,mtf for analysis4 ,they must be delivered to the designated supporting medical laboratory for processing4 ,this will prevent accidentally spreading a biological agent in the ,,mtf4 c4 ,coordination for follow-on testing is absolutely critical to the sample_/specimen collection process4 d4 ,coordination with the receiving laboratory should be made to establish sample requirements1 preferred collection techniques1 methods of preservation1 and transportation conditions1 when the tactical situation and_/or mission permits4 e4 ,the number of medical specimens that need to be collected varies with the type of analysis performed and the impact of the values determined4 ,the number and types of control samples_/specimens required to validate test information is determined by the supporting medical laboratory personnel4 ,random sampling1 matched with control populations1 or other techniques will be employed as the requirements are identified4 ,b-#b4 ,sample_/,specimen ,background ,information a4 ,a complete history of the circumstances about each sample's_/specimen's acquisition must be provided to the agency conducting the analysis4 b4 ,critical information includes1 but is not limited to-- ,meteorological conditions4 ,describe what the meteorological conditions were at the time of the alleged attack and at the time of the sampling4 ,attack to collection time4 ,state the length of time after alleged attack when sample_/specimen was taken4 ,circumstances of acquisition4 ,describe how the sample_/specimen was obtained and the source of the sample_/specimen4 ,physical description4 ,describe the physical state of the sample_/specimen 7solid1 liquid1 powder1 apparent viscosity71 color1 approximate size1 identity of the sample_/specimen 7that is1 dirt1 leaves1 blood1 tissue71 and dose rate 7if radiologically contaminated74 ,circumstances of the agent deposition4 ,describe the type of delivery system1 a description of how the weapon functioned1 how the agent acted on release1 sounds heard during dissemination1 a description of any craters or shrapnel found associated with the burst1 and colors of smoke1 flames1 or mists that may be associated with the attack4 ,agent effects on vegetation4 ,describe the general area 7jungle1 mountain1 grassland7 and changes in the vegetation after the agent deposition 7that is1 color change1 wilting1 drying1 dead7 in the main attack and fringe areas4 ,agent effects on humans4 ,how the agent affected personnel in the main attack area versus fringe areas2 the duration of agent effects2 peculiar odors that may have been noticed in the area before1 during1 or after an attack2 measures taken that alleviated or worsened the effects2 and the approximate number of victims and survivors 7include age and gender74 ,agent effects on animals4 ,describe how they are affected4 ,grid coordinates or other descriptive information on sample collection location4 ,b-#c4 ,sample_/,specimen ,collection and ,preservation a4 ,ante mortem ,specimens4 ,physiological specimens from living human or animal patients can include just about any conceivable body source or excreted by-product4 ,it must be noted that specimen types are seldom interchangeable2 the exact type and amount of specimen required for a specific assay must be known before a collection procedure is initiated 7see ,table ,b-#a74 ,patients seen in an ,,mtf may be the first and in some cases the only source for sampling for suspect biological agent release4 ,the primary medical care provider will determine the level of treatment for these patients and the specimens required for laboratory diagnosis4 ,the ,,mtf laboratory is not equipped to handle biological agents and1 therefore1 specimens generated will be forwarded to the supporting medical laboratory for analysis4 ,patient disposition will be based on evacuation policies1 exposure1 suspect agent1 clinical symptoms1 and required treatment_/isolation4 ,blood specimens represent the most common analytical sample4 ,certain techniques and special care must be exercised to ensure an acceptable specimen is collected and to minimize an adverse affect to the patient or specimen collector4 ,in general1 phlebotomy requires the use of a #bj to #bb-;gauge needle to minimize mechanical hemolysis during aspiration using a syringe or ,vacutainer,,tm tube collection system4 ,blood collected with a syringe and needle should be transferred to an appropriate ,vacutainer,,tm tube immediately after collection4 ,the type of tube1 type of anticoagulant or preservative1 and amount of blood collected will vary with the specific assay requested4 ,unless some special sample preparation step is required1 the blood is best left in the original rubber-stopper tube for transport4 ,urine specimens are best collected using a clean-catch 7midstream1 if possible7 technique in a sterile urine cup4 ,the volume of sample required will vary depending on the specific assay requested2 however1 #be to #ej ml is sufficient for most tests4 ,tissue specimens can originate from any body source accessible by scraping1 swabbing1 or minor excision4 ,tissue specimens are collected only by medical trained personnel4 ,specific techniques for collecting these specimens are not provided in this appendix4 ,sputum specimens are best collected using a sterile cup4 ,the volume of specimen will normally be very small4 ,however1 a sufficient quantity must be collected to provide for in-theater testing and to provide for ,,conus laboratory testing4 ,nasal swabs should be collected using sterile cotton-tipped swabs4 ,the swabs with specimen from each person should be placed in a separate sterile container to prevent cross-contamination4 ,,note ,in cases where the supporting laboratory cannot be contacted1 as a minimum the following specimens should be collected3 ,urine--#be to #ej ml in a sterile container4 ,blood--two #g to #aj ml tubes without anticoagulant 7red-stopper ,vacutainer,,tm72 two #g to #aj ml tubes with potassium or sodium ethylenediaminetetraacetate 7,,edta7 7lavender-stopper ,vacutainer,,tm74 ,all specimens 7regardless of physiological source7 must be labeled to positively identify the individual or animal from whom it was collected2 at a minimum1 the individual's full name1 unique personal identification number 7social security number1 when possible71 military unit and location1 and date and time of collection should be written on the label of the specimen container4 ,all specimens are collected using aseptic techniques4 ,all specimens are packaged1 handled1 and transported in a manner that ensures they arrive at the final destination laboratory in a testable condition4 ,personal protection guidelines must be adhered to when collecting or processing specimens2 at a minimum1 this includes gloves and a mask4 ,in the laboratory1 a gown or other protective items may also need to be used4 ,in the field1 under suspect ,,nbc conditions1 collectors should be in ,,mopp ,level #d or inside ,,nbc-protected vehicles4 ,common sense and the clinical and_/or tactical situation will determine the extent of personal protection necessary4 ,preservation of specimens1 either chemically or mechanically 7cooling71 will be necessary to minimize the amount of analyte degradation that occurs after removing the specimen from its physiological microenvironment4 ,the optimal preservation technique will vary with different laboratory tests and must be confirmed for each requested assay4 ,while freezing may preserve some serum constituents1 freeze-thawing cycles may denature others4 ,freezing may also completely destroy certain microorganisms4 ,this caution also applies to tissue specimens since fixing tissue with a standard #aj percent formalin solution will preserve tissue for special staining techniques2 however1 it renders the specimens completely useless for microbiological culture4 ,always verify specimen preservation requirements for storage and transport with the supporting medical laboratory before processing the specimen4 ,ideally1 confirmation of the correct handling conditions should be coordinated before collection4 ,the importance of coordinating sample_/specimen collection with the supporting laboratory facility cannot be overstated4 ,contact the receiving laboratory for instructions when doubt exists about the appropriate source1 collection technique1 storage and preservation conditions 7such as1 aerobic or anaerobic environment71 and transportation requirements for samples_/specimens4 ,extremely small volumes of samples_/specimens1 properly collected and handled1 can yield a tremendous amount of information to assist in making medical1 tactical1 and strategic decisions4 ,conversely1 very large quantities of poorly collected and insufficiently preserved samples_/specimens are essentially worthless for most analytical techniques4 ,analysis beyond intratheater capabilities will be coordinated by the supporting laboratory1 when deployed1 or through medical channels in the absence of an in-theater supporting laboratory4 b4 ,post mortem and ,forensic ,specimens4 ,the analysis of specimens from deceased humans and animals can provide valuable information about the disease1 organisms1 injuries1 or environmental conditions at the time of death4 ,this information can greatly enhance the treatment of others affected by the same1 or physiologically similar1 process4 ,specimen collection for post mortem or forensic examination is very important2 the techniques involved reflect a significant degree of training1 experience1 and skill4 ,most specimens will be of the same type and size as for ante mortem specimens1 but types and amounts of specimens will be determined by the collector4 7#a7 ,the collection of specimens from remains should be conducted exclusively by a pathologist1 or other personnel specifically trained in forensic collection techniques4 ,an exception is when ,special ,operations ,forces 7,,sof7 personnel are operating under radio silence conditions2 the most qualified medical person with the operation collects1 preserves1 and transports or coordinates transport of specimens for evaluation4 ,the same chain of custody requirements applies to specimens collected by ,,sof personnel1 as with all other specimens4 7#b7 ,a large amount of support information can be gained by analyzing the site of injury and subsequent death4 ,this site scene investigation requires a tremendous attention to detail and a trained observer4 ,if forensic personnel cannot be contacted1 or will be unduly delayed in arriving at the scene1 then photographs of the victim and the immediate surroundings should be made4 ,the scope and extent of the photographs should be composed to reflect as much detail as possible to assist forensic personnel in reviewing the scene retrospectively4 ,in the event that photography is not feasible1 detailed sketches of the scene should be made to assist the forensic investigation4 7#c7 ,techniques such as cardiac or bladder puncture1 needle biopsy of organs1 spinal tap1 or exploratory laparotomy will not be performed by untrained personnel unless specifically requested and directed by forensic investigators4 ,table ,b-#a4 ,specimen ,collection for ,suspect ,biological ,warfare ,agents ,,early ,,postexposure ,,clinical ,,convalescent_/,,terminal_/,,postmortem ---------------------------------------- -------------------------------- ,,anthrax #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,and ,,throat ,,swabs1 ,,and ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,assays4 ,,induced ,,respiratory ,,secretions ,,blood 7,e1 ,c1 ,h7 ,,for ,,pcr4 ,,for ,,culture1 ,,fa1 ,,and ,,pcr4 ,,blood 7,,bc ,,or ,c7 ,,for ,,cultures4 #c ,,to #aj ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,assays4 ,,blood 7,,bc ,,or ,c7 ,,for ,,culture4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,plague #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,swabs1 ,,sputum1 ,,and ,,blood 7,,bc ,,and ,c7 ,,for ,,culture ,,and ,,induced ,,respiratory ,,secretions ,,bloody ,,sputum 7,c7 ,,for ,,fa4 ,,serum ,,for ,,culture1 ,,fa1 7,,tt ,,or ,,rt7 ,,for ,f-#a ,,antigen ,,assays4 ,,and ,,pcr4 ,,blood 7,e1 ,c1 ,,or ,h7 ,,for ,,pcr4 #f ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,ig,m1 ,,later ,,for ,ig,g4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,tularemia #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,swabs1 ,,sputum1 ,,and ,,blood 7,,bc ,,or ,c7 ,,for ,,culture4 ,,induced ,,respiratory ,,blood 7,e1 ,c1 ,,or ,h7 ,,for ,,pcr4 ,,secretions ,,for ,,culture1 ,,fa1 ,,sputum ,,for ,,fa ,,and ,,pcr4 ,,and ,,pcr4 #f ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,ig,m ,,and ,,later ,ig,g1 ,,agglutination ,,titers4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,melioidosis_/,,glanders #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,swabs1 ,,sputum1 ,,and ,,blood 7,,bc ,,or ,c7 ,,for ,,culture4 ,,induced ,,respiratory ,,blood 7,e1 ,c1 ,,or ,h7 ,,for ,,pcr4 ,,secretions ,,for ,,culture ,,and ,,sputum ,,and ,,drainage ,,from ,,skin ,,pcr4 ,,lesions ,,for ,,pcr ,,and ,,culture4 #f ,,days4 ,,blood 7,,bc ,,or ,c7 ,,and ,,tissue ,,for ,,culture4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,immunoassays4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,brucellosis #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,swabs1 ,,sputum1 ,,and ,,blood 7,,bc ,,or ,c7 ,,for ,,culture4 ,,induced ,,respiratory ,,blood 7,e1 ,c1 ,,and ,h7 ,,for ,,pcr4 ,,secretions ,,for ,,culture ,,and #f ,,days4 ,,pcr4 ,,blood 7,,bc ,,or ,c7 ,,and ,,tissue ,,for ,,culture4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,immunoassays4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,q ,,fever #j ,,to #bd ,,hours4 #b ,,to #e ,,days4 ,,nasal ,,swabs1 ,,sputum1 ,,and ,,blood 7,,bc ,,or ,c7 ,,for ,,culture ,,in ,,eggs ,,induced ,,respiratory ,,or ,,mouse ,,inoculation4 ,,secretions ,,for ,,culture ,,and ,,blood 7,e1 ,c1 ,,and ,h7 ,,for ,,pcr4 ,,pcr4 #f ,,days4 ,,blood 7,,bc ,,or ,c7 ,,for ,,culture ,,in ,,eggs ,,or ,,mouse ,,inoculation4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,botulism #j ,,to #bd ,,hours4 #bd ,,to #gb ,,hours4 ,,nasal ,,swabs ,,and ,,induced ,,nasal ,,swabs ,,and ,,respiratory ,,respiratory ,,secretions ,,for ,,secretions ,,for ,,pcr 7,,contaminating ,,pcr 7,,contaminating ,,bacterial ,,dna7 ,,and ,,toxin ,,assays4 ,,bacterial ,,dna7 ,,and ,,toxin #f ,,days4 ,,assays4 ,,usually ,,no ,ig,m ,,or ,ig,g4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,pathology ,,specimens 7,,liver ,,and ,,assays4 ,,spleen ,,for ,,toxin ,,detection74 ---------------------------------------- -------------------------------- ,,ricin ,,intoxication #j ,,to #bd ,,hours4 #cf ,,to #dh ,,hours4 ,,nasal ,,swabs ,,and ,,induced ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,respiratory ,,secretions ,,for ,,assay4 ,,pcr 7,,contaminating ,,castor ,,tissue ,,for ,,immunohistological ,,bean ,,dna7 ,,and ,,toxin ,,assays4 ,,staining4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,pathology ,,specimens4 ,,assays4 #f ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,ig,m ,,and ,ig,g ,,in ,,survivors4 ---------------------------------------- -------------------------------- ,,staph ,,enterotoxicosis #j ,,to #c ,,hours4 #b ,,to #f ,,hours4 ,,nasal ,,swabs ,,and ,,induced ,,urine ,,for ,,immunoassays4 ,,respiratory ,,secretions ,,for ,,nasal ,,swabs ,,and ,,induced ,,pcr 7,,contaminating ,,bacterial ,,respiratory ,,secretions ,,for ,,dna7 ,,and ,,toxin ,,assays4 ,,pcr 7,,contaminating ,,bacterial ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,dna7 ,,and ,,toxin ,,assays4 ,,assays4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,toxin ,,assays4 #f ,,days4 ,,serum ,,for ,ig,m ,,and ,ig,g4 ---------------------------------------- -------------------------------- ,t-#b ,,toxicosis #j ,,to #bd ,,hours ,,postexposure #a ,,to #e ,,days4 ,,nasal ,,and ,,throat ,,swabs ,,and ,,serum 7,,tt ,,or ,,rt7 ,,and ,,tissue ,,for ,,induced ,,respiratory ,,toxin ,,detection4 ,,secretions ,,for ,,immunoassays1 #f ,,days ,,postexposure4 ,,hplc_/,,mass ,,spectrometry4 ,,urine ,,for ,,detection ,,of ,,toxin ,,metabolites4 ---------------------------------------- -------------------------------- ,,equine ,,encephalomyelitis 7,,vee1 ,,eee1 ,,and ,,wee ,,viruses7 #bd ,,to #gb ,,hours4 #j ,,to #bd ,,hours4 ,,serum 7,,tt ,,or ,,rt7 ,,and ,,throat ,,for ,,nasal ,,swabs ,,and ,,induced ,,culture4 ,,respiratory ,,secretions ,,for ,,serum 7,e1 ,c1 ,h1 ,,tt1 ,,or ,,rt7 ,,for ,,rt-,,pcr ,,and ,,viral ,,culture4 ,,rt-,,pcr4 ,,throat ,,swabs ,,up ,,to #e ,,days ,,for ,,culture ,,then ,,csf4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,antigen ,,elisa4 #f ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,ig,m4 ,,pathology ,,specimens ,,plus ,,brain4 ---------------------------------------- -------------------------------- ,,pox 7,,smallpox ,,and ,,monkeypox7 #b ,,to #e ,,days4 #j ,,to #bd ,,hours4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,viral ,,nasal ,,swabs ,,and ,,induced ,,culture ,,respiratory ,,secretions ,,for #f ,,days4 ,,pcr ,,and ,,viral ,,culture4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,viral ,,culture ,,drainage ,,from ,,skin ,,lesions_/ ,,scrapings ,,for ,,microscopy1 ,,em1 ,,viral ,,culture1 ,,and ,,pcr4 ,,pathology ,,specimens4 ---------------------------------------- -------------------------------- ,,ebola #j ,,to #bd ,,hours4 #b ,,to #e ,,days4 ,,nasal ,,swabs ,,and ,,induced ,,serum 7,,tt ,,or ,,rt7 ,,for ,,viral ,,respiratory ,,secretions ,,for ,,culture4 ,,rt-,,pcr ,,and ,,viral ,,culture4 #f ,,days4 ,,serum 7,,tt ,,or ,,rt7 ,,for ,,viral ,,culture ,,pathology ,,specimens ,,plus ,,adrenal ,,gland4 ---------------------------------------- -------------------------------- ,,legend3 ,,bc ,blood culture ,c ,citrated blood ,,csf cerebrospinal fluid ,,dna deoxyribonucleic acid ,e ,,edta ,,eee eastern equine encephalitis ,,elisa enzyme-linked immunosorbent assay ,,em electron microscopy ,f-#a fraction-#a ,,fa fluorescent antibody ,h ,heparin ,,hplc high-pressure liquid chromatography ,ig,g immunoglobulin class ,g ,ig,m immunoglobulin class ,m ,,pcr polymerase chain reaction ,,rt ,red ,top1 if ,,tt is not available ,,rt-,,pcr reverse transcriptase_/polymerase chain reaction ,,tt ,tiger top ,,vee ,venezuelan equine encephalitis ,,wee western equine encephalitis c4 ,water ,sample ,collection4 7#a7 ,water samples for identification or verification of biological agent contamination are collected by ,,pvntmed personnel4 ,the supporting laboratory should provide guidance on sampling procedures and collecting kits for use in collecting the samples4 ,in the absence of guidance1 a technique for use of the ,sep-,pak,,tm is described in ,,fm #c-ai4 7#b7 ,when sampling kits are not available1 samples may be collected in other available sterile containers4 ,the best containers for use are the #ajj-ml glass bottles used for collecting routine water samples4 ,all water samples must be collected and placed in a cooler or refrigerator until the sample is transported to its destination4 ,during transportation the samples must be maintained at a temperature between #a;,c and #d;,c4 d4 ,food ,samples4 ,veterinary personnel must collect suspect biologically contaminated food samples for submission to the supporting laboratory for in-theater verification of contamination4 ,all food samples must be collected and placed in sterile containers4 ,place the samples in a cooler or refrigerator until the sample is transported to its destination4 ,during transportation the samples must be maintained at a temperature between #a;,c and #d;,c4 e4 ,animal ,specimens4 ,veterinary personnel collect specimens from suspect biologically contaminated_/diseased animals4 ,the same types and amounts of specimens are prepared and shipped in the same manner as are human specimens4 f4 ,environmental ,samples4 ,environmental samples are collected as directed in the operators' manual or other publications for operating collection systems4 ,example3 ,the ,biological ,integrated ,detection ,system 7,,bids7 collects an environmental sample using a single liquid sample collector4 ,the collector is a high-volume aerosol sampling and collection device4 ,on demand it samples ambient air through a two-stage virtual impactor that concentrates aerosol particles in the #b to #aj micrometer diameter-size range4 ,the concentrate particle stream is directed through a wet collector containing a buffer solution and1 over a #de-minute period1 a #dj to #ej ml sample is collected4 ,on order or when test results indicate a suspected agent1 the sample and associated documentation are packaged and transported ,,iaw ,,fm #c-aja-d4 ,b-#d4 ,chain of ,custody a4 ,a strict chain of custody must be maintained for every sample_/specimen collected4 ,use ,,dd ,form #aiaa 7,material ,courier ,receipt71 or other document 7such as ,,da ,form #dacg ,evidence_/,property ,custody ,document7 as directed for each sample_/specimen collected4 ,the chain of custody document must accompany the sample_/specimen during transport from the point of collection to the final receiving laboratory4 ,each time the sample_/specimen is transferred to another individual1 the receiving person must sign the document to show that they received the sample_/specimen and state what happened to the sample_/specimen while in their custody4 ,the document will provide the answer to the following questions3 ,when was the sample_/specimen collected8 ,who has maintained custody of the sample_/specimen8 ,what has been done with the sample_/specimen at each change of custody8 b4 ,the samples_/specimens must be appropriately packaged1 labeled1 and evacuated to the designated medical laboratory for confirmation of a biological attack4 ,the standard chain of custody for the evacuation would be as follows3 ,sampling unit4 ,unit ,s#b_/security office or medical operations officer4 ,technical escort unit or other command-designated escort personnel4 ,in-theater supporting medical laboratory4 ,designated ,,conus laboratory4 ,section ,,ii4 ,,sampling ,,techniques ,,and ,,procedures ,b-#e4 ,general ,the collection of environmental1 and background 7control7 samples_/medical specimens is an integral part of investigating allegations pertaining to the first use of chemical or biological agents4 ,the types of samples_/specimens taken and the collection methods primarily depend upon the circumstances encountered by the collector4 ,during all chemical and biological sampling operations1 the commander establishes the required protective equipment to fit the situation4 ,this appendix includes a recommended list of equipment for use during chemical and biological sampling operations 7,table ,b-#b74 ,table ,b-#b4 ,example ,,nbc ,collection and ,shipping ,equipment ,list ,,amount ,,description ,,stock ,,number ---------------------------------------- ------------------------------ #bj ,,labels1 ,,paper1 ,,pressure ,,sensitive #gecj-jj-egg-dcgf #b ,,gloves1 #h-h1 ,,edmont ,,wilson,,tm #hdae-jj-;,,jo#b-bijb #b ,,gloves1 #i-i1 ,,edmont ,,wilson,,tm #hdae-jj-fcd-dfci #a ,,tape1 ,,adhesive1 ,,pressure ,,sensitive1 #b ,,inch #geaj-jj-aei-ddej #a ,,pliers1 #dg1 #e ,,inches #febj-jj-edc-eccj #a ,,screwdriver1 ,,flat ,,tip1 ,,inch #eabj-jj-eif-hfe #a ,,tongs1 ,,teflon,,tm ,,tips ,,af #ae-bjb-e #b ,,microspatula1 ,,with ,,teflon,,tm ,,ends ,,af #ba-dja-ej;,a #a ,,scissors1 ,,universal ,,type ,,af #jh-iea-cj #a ,,scoop1 ,,polypropylene1 #e,x#b,x#b ,,asp ,s#ajba-e #b ,,spoon_/,,spatula ,,with ,,teflon,,tm ,,af #ad-cef-aj #a ,,knife1 ,,pocket #eaaj-jj-ebf-hgdj #e ,,bottles1 ,,sample1 ,,polyethylene1 #f ,,ounce ,,cp ,j-#fajc-ej #a ,,pipet1 ,,jumbo1 ,,transfer ,,type 7#ejj_/,,pkg7 ,,af #ac-gaa-g #aj ,,pipet1 ,,gradual1 ,,transfer ,,type 7#ejj_/,,pkg7 ,,af #ac-gaa-i;,a #aj ,,bag1 ,,insulated1 ,,type ,i ,,af #ja-had-h #aj ,,bag1 ,,insulated1 ,,type #b99 ,,af #ja-had-aj #a ,,bag1 ,,whirl_/,,pak1 #f ,,ounce 7#ejj_/,,pkg7 ,,af #ja-hab-f;,b #a ,,strip1 p,h ,,testing1 ,,nonbleeding1 ,,plastic ,,sw ,s-#febga #a ,,sep-,,pak,,tm ,c#ah ,w#eaiaj 7#ej_/;,,box7 #b ,,syringe1 ,,hypodermic1 #ej ,,or #fj ml #feae-jj-afh-fiac #b ,,stopcock1 ,,three-,,way ,,asp ,s#hife-b #a ,,tubing1 ,,laboratory1 ,r#cfjb ,,clear ,,af #ad-afi-c;,b #a ,,pen1 ,,marking1 ,,waterproof ,,af#ac-cha 7#ab_/,,pkg7 #b ,,tubes1 ,,tenax,,tm ,,ec ,,st-#jbc #a ,,blade1 ,,surgical1 ,,cs#b,l #aej,s #feae-ja-jji-ebig #b ,,pack1 ,,ice ,,cp ,,tr-#fcde-bj #f ,,pad1 ,,nonadhesive1 #c,x#d1 #ajjs #feaj-jj-aaa-jgjh #d ,,pad1 ,,cooling1 ,,chemical1 #d,s #fecj-jj-acc-dbii #b ,,piglettes ,,special ,,order #a ,,tape1 ,,antiseize #hjcj-jj-hhi-cece #a ,,air ,,sampler1 ,,personal ,,lss ,g#dihj #a ,,kit1 ,,metric1 ,,pocket ,,bubble ,,gl#diha #b ,,methanol #a ,,water1 ,,distilled 7#e ,,bottle_/,,pkg7 #a ,,matches1 ,,waterproof #bj ,,razor1 ,,surgical ,,prep #feae-jj-ibf-bjhi #aj ,,watch1 ,,wrist #ffde-jj-jff-dbgi #b ,,parafilm ,,with ,,dispenser #ffdj-ja-ahe-cbhi #b ,,floor ,,sweep 7,,vermiculite7 #hgbj-ja-jbf-idai #ajj ,,seals1 ,,tamper-,,resistant #a ,a ,,gas ,,meter ,,capable ,,of ,,providing ,,on-,,station ,,analysis_/,,detection ,,capability ,,for ,,multiple ,,gases ,,to ,,include ,,industrial ,,gases4 #a ,a ,,combustible ,,gas ,,indicator ,,that ,,indicates ,,percentage ,,of ,,oxygen ,,and ,,explosivity4 #a ,a ,,gas ,,meter ,,that ,,detects ,,vapor ,,in ,,parts ,,per ,,million 7,,ppm7 ,,and ,,indicates ,,presence ,,of ,,vapor ,,and ,,its ,,strength4 #a ,,swabs1 ,,throat #b ,,can1 #f ,,pound1 ,,metal #aj ,,bag1 ,,mylar #a ,,container1 ,,lead ,,shielding 7,,for ,,radiation ,,samples7 #a ,,container1 ,,shipping1 ,,iata #a ,,chest1 ,,ice #aj ,,bag1 ,,plastic1 ,,reclosable 99 ,,will ,,be ,,replaced ,,by ,,mylar ,,bags ,b-#f4 ,expended ,material ,the ,,nbc recon units collect samples under various circumstances4 ,for example1 a recon unit may collect samples in an area free of hostile forces4 ,the ,special ,forces ,,nbc ,reconnaissance team may collect samples within the enemy area of operations or deep into the enemy's rear area4 ,samples include toxic agent munitions1 chemical products1 air1 water1 soil1 and vegetation4 ,in addition1 all expended material used to collect the samples should be turned in to the laboratory with the samples4 ,this material includes items such as expended ,m#bef;,a#a kits1 ,m#h and ,m#i paper4 ,these items should be recovered1 packaged1 and shipped with the suspected samples for analysis4 ,different information may be derived from each type of sample2 ,table ,b-#c compares different types of samples4 ,b-#g4 ,environmental ,samples ,control or background samples that are collected from clean samples must be identical to the samples collected from the areas near the attack areas as baseline data4 ,the contaminated samples must be compared to the baseline data 7control samples74 ,this is especially true if unknown or nonstandard chemical and_/or suspected biological agents were employed4 ,the analysis center uses the control samples to compare with a contaminated one4 ,the recon unit collects control samples of soil1 water1 and vegetation from areas about #ejj meters upwind of an alleged attack area4 ,control samples generically are the same as those collected in an alleged attack area4 ,for example1 if leaves from an apple tree in an attack area were collected as a suspected contaminated sample1 the recon team should collect leaves 7as a control sample7 from an apple tree outside of the contaminated area4 ,if water from a pond in the attack area is collected1 the recon unit should collect control samples of water from a pond 7not a moving stream7 in a nearby clean area4 ,the size of an environmental control sample should be about the same as the suspected contaminated sample collected from the attack area 7see ,table ,b-#d1 page ,b-#bj74 ,table ,b-#c4 ,comparison of ,sample ,types ,,sample ,,stability ,,analysis ,,sample ,,type ,,info ,,value ,,to ,,collect ,,time ,,required ,,reliability ---------------------------------------- ------------------------------ ,,air ,,good ,,good #bj ,,min ,,high ,,water ,,good ,,good #e ,,min ,,high ,,soil ,,fair ,,fair #e ,,min ,,moderate ,,vegetation ,,fair ,,poor #aj ,,min ,,low ,,tissue ,,excellent ,,fair #cj ,,min ,,high ,,blood ,,good ,,fair #aj ,,min ,,high ,,urine ,,good ,,fair #aj ,,min ,,high ,,munition ,,fragments ,,fair ,,fair #aj ,,min ,,fair ,,packing ,,materials ,,fair ,,fair #aj ,,min ,,fair ,b-#h4 ,collection of ,air and ,vapor ,samples a4 ,air is a good sample matrix since it is a well-mixed medium4 ,air from a sample site contains a static concentration of contaminants4 ,the concentration of contaminants depends upon the flow rate of the contaminant into the environment1 the wind speed1 and the physical state of the contaminant1 the terrain contours1 and temperature as a variable4 ,the sample should be taken within #ajb meters of a contaminated surface and at the downwind edge of a contaminated area4 ,the method should consist of pumping a given volume of air1 by hand or electric pump1 through sample tubes4 b4 ,to avoid contamination1 persons conducting air sampling should not use cologne1 perfume1 insect repellent1 medical creams1 or strong soaps before taking a sample4 ,the fragrances from these products are volatile organic compounds that may be absorbed on the filter and skew analytical results4 ,smoke also severely interferes with air sampling1 therefore1 avoid tobacco and vehicle exhaust smoke4 c4 ,the primary method for collecting air samples is with the ,,pas #ajjj automatic air sampler in conjunction with a ,tenax,,tm tube for a total of three to four minutes when possible4 ,upon completion of sampling1 place the ,tenax,,tm tube in a #b-;inch piglette4 ,seal the piglette around the cap with either pressure-sensitive or ,teflon,,tm tape4 ,once sealed1 place the piglette into a ,mylar or reclosable bag4 ,fold the bag around the piglette in a circular motion1 then apply another bag and fold again4 ,once the bag is folded around the piglette1 use any type tape to secure the bag around the piglette4 ,place the piglette into a refrigerator or cooler until the sample is transported to its destination4 d4 ,when chemicals are permitted into the atmosphere from a facility1 the best places to obtain samples are close to the emission source where the concentration of the chemical is not diluted4 ,the further from the original point of release1 the more diluted the sample becomes from mixing with air1 water1 or environmental pollutants4 e4 ,natural and man-made terrain features such as hills1 valleys1 and rows of buildings1 sometimes aid the collector by channeling emissions4 ,when these features are associated with a particular facility1 their downwind side is a suitable place to collect a sample because the emission remains more concentrated further from the release point4 f4 ,for collection in a possibly contaminated location1 and if the situation permits1 initially use a detection kit such as the ,m#ah;,a#b_/,m#bef;,,ai to determine if a possible vapor hazard exists from known chemical agents4 ,also1 use the kit when personnel are required to examine possible toxic agent munitions4 ,in any case1 collect air samples with the white-band tubes and save for identification and analysis4 g4 ,small air samplers also enable the collector to obtain vapor samples from alleged toxic agent munitions at a safe distance while explosive ordnance disposal 7,,eod7 operations are performed4 ,if ,,eod personnel are not on the scene1 the air sampler can be activated1 and the collector can stand at a safe distance while the sampler is operating4 h4 ,perform sampling operations as soon as possible when directed by a higher headquarters or after suspected chemical or biological contamination is encountered4 ,b-#i4 ,collection of ,water ,samples a4 ,water sampling is a matter of collecting enough water to get acceptable information about the contaminants4 ,the collector should provide the analysis center with one ,c#ah and one silica cartridge when using the ,sep-,pak,,tm technique or #ajj ml in a sterile bottle when ,sep-,pak,,tm is not available4 b4 ,general guidelines3 ,if it is believed that the threat has used standard chemical agents during an attack1 use the ,m#bgb chemical agent water test kit for initial screening and sampling4 c4 ,when collecting water samples using the ,sep-,pak,,tm ,c#ah cartridge1 the following items are required3 ,one #fj cc syringe without needle4 ,one #c-way sterile1 plastic1 stopcock with protective covers4 ,one piece of plastic tubing 7#c_/af inner diameter #f long minimum74 ,sterile water or methanol4 ,one clean container1 such as a ,teflon,,tm cup or glass jar4 d4 ,prior to collecting each sample1 prime the ,sep-,pak,,tm system in the following manner3 ,step #a4 ,attach ,sep-,pak,,tm directly to #fj cc syringe4 ,step #b4 ,pour small amount of sterile water or methanol into container4 ,step #c4 ,insert tip of ,sep-,pak,,tm into container4 ,step #d4 ,withdraw at least #dj cc of solution4 ,step #e4 ,detach ,sep-,pak,,tm from syringe and discard solution from syringe4 ,step #f4 ,repeat steps #c through #e using the same syringe4 e4 ,after priming the ,sep-,pak,,tm1 assemble the components in the following configuration3 ,attach the #c-way stopcock to a #fj cc syringe4 ,attach the ,sep-,pak,,tm to the opposite end of stopcock4 ,attach the plastic tubing to the open end of the ,sep-,pak,,tm4 f4 ,use the following procedures to collect samples with ,sep-,pak,,tm3 ,step #a4 ,ensure that the lever on the stopcock is turned sideways with the off arrow pointed toward the large outlet port4 ,step #b4 ,place the open end of the plastic tubing into the water near the bottom1 without touching the bottom or sides of the body of water4 ,step #c4 ,draw #fj cc of water into the syringe4 ,step #d4 ,turn the stopcock lever to the off position by positioning the lever to point toward the stopcock4 ,step #e4 ,push the plunger all the way in1 discharging the water from the syringe through the outlet port4 ,step #f4 ,repeat steps #a through #e4 ,step #g4 ,detach a plastic tubing from the ,sep-,pak,,tm1 and discard it as contaminated waste4 ,step #h4 ,detach ,sep-,pak,,tm from #c-way stopcock2 place into sample container2 seal with pressure-sensitive tape2 and mark for ,identification4 ,,note ,you should take a minimum of four samples3 three samples of the suspected contamination and one control sample from a nearby unaffected 7none contaminated7 area for reference4 ,step #i4 ,dispose of the syringe and stopcock as contaminated waste4 ,step #aj4 ,insert the sample container in a cooler or refrigerator until the sample is transported to its destination4 g4 ,for samples to be representative of the overall contaminated area1 the collection point should be carefully selected4 ,collect samples from-- ,drains and slow-moving streams1 since contamination and dilution from other sources are minimized4 ,stagnant pools of water if the pools of water are part of chemical waste areas1 such as a landfill or chemical disposal area4 ,chemicals may percolate into stagnant pools or sumps close to the site4 ,,note ,if an oil film1 globules of organic materials1 or an unnatural appearing powder-like material is visible on the water's surface1 collect a surface sample of the material4 ,if not1 collect the sample from near the bottom of the water source 7stream1 lake1 pond1 water container74 ,the upper layers of water may have lesser amounts of contaminants1 due to higher temperatures that promote decomposition4 ,since most chemicals of interest are more dense than water1 contaminants usually sink to the bottom of the water source4 h4 ,collect the sample without the ,sep-,pak,,tm by immersing a capped or stoppered container to the desired depth1 removing the cap or stopper1 letting the container fill1 and then capping the container4 ,an alternate method for deeper water is to use a plastic1 pump-operated siphon to pump water from a specific depth4 i4 ,the best time to collect a sample of water from a location is when intelligence or local reports indicate that a process of possible interest is ongoing4 ,in the absence of reliable reporting1 this may be indicated by increased activity1 higher than normal amounts of security1 or increased flow from facility chimneys or water discharge pipes4 ,in field areas where a toxic agent has been sprayed or disseminated over a land area1 the best time to collect water samples is just after the start of a rainstorm when runoff is beginning4 ,natural surface drainage will concentrate any remnants of toxic compounds in depressions1 streams1 or ditches4 ,b-#aj4 ,collection of ,soil ,samples ,soil is a suitable medium to collect as samples for toxic organic compounds4 ,a critical point1 however1 is that the precise site of the agent deposition must be sampled for best results4 ,contamination may be recognized by discoloration or apparent deposition of material on the soil's surface4 ,if discoloration or deposits of material are evident1 only collect the discolored soil or deposited materials1 if possible4 ,dead1 malformed1 and wilted foliage is an indicator of contamination4 ,soil samples should be collected from open areas1 along the drip line tents1 stationary equipment1 bottom of ditches and terrain depressions4 a4 ,collect the soil samples by using a knife1 spoon1 spatula1 or similar item to scrape a square of topsoil 7#bea centimeters7 from areas that appear to have been contaminated in to a collection container4 ,if chunks or clods of earth are collected1 select those that are no larger than #ajea centimeters 7see ,table ,b-#d74 ,also1 collect a control sample of soil of the same type and texture from a nearby uncontaminated area4 b4 ,use a glass bottle1 jar1 or ,teflon,,tm jar as the container when available4 ,when these containers are not available1 ,mylar bags may be used4 ,when using a glass bottle1 jar1 or ,teflon,,tm jar1 seal the cap with either pressure-sensitive or ,teflon,,tm tape1 and mark for identification4 ,when using ,mylar bags1 place each sample in a separate bag1 push excess air out1 and seal by folding the open end over two to three times and wrapping the bag with tape4 ,insert the first bag into a second bag1 seal1 tape1 and mark for identification4 ,if possible1 place the samples in a piglette4 ---------------------------------------- ------------------- ,,caution ,avoid direct contact with the sample to prevent exposing yourself to the suspect agent 7,,mopp #d is required74 ---------------------------------------- ------------------- c4 ,collect samples as soon as possible when directed1 upon detection of a suspect substance1 or after the alleged incident4 ,b-#aa4 ,collection of ,contaminated ,vegetation ,as with soil samples1 vegetation is also a suitable medium to collect as samples for toxic organic compounds4 a4 ,collect samples of vegetation that appear to be different from normal4 ,select leaves that have wilted or appear to have been chemically burned4 ,collect samples of vegetation that appear to have liquid or solid substances deposited on their surfaces 7this may be noticed as a shiny or moist area74 b4 ,collect samples of vegetation at several locations within the suspected contaminated area4 ,using a cutting tool or any sharp object1 cut several affected leaves and_/or a handful of grass whenever possible4 ,do not crush the sample4 ,place the sample into a ,mylar or reclosable bag4 ,squeeze excess air out of the bag and seal it4 ,fold the open end of the ,mylar bag over two to three times1 and wrap it with tape4 ,the minimum size for a sample is three leaves or three handsful of grass4 ,one leaf is of little value1 but is better than nothing4 ,bark is acceptable but not preferred4 ,mark the bag for identification4 ,take a control sample of similar material from an unaffected 7uncontaminated7 area4 ,fold1 seal1 tape1 and mark the control sample in the same manner as the actual sample4 c4 ,when it is possible to determine a probable center of attack in an area1 collect vegetation samples near the center of the area1 about #ajj meters upwind of the area1 and in several #ajj-meter increments downwind of the area4 ,if the collector can discern a contamination pattern in the area1 this should be reported4 ,b-#ab4 ,medical ,specimens a4 ,just as blood and urine specimens are taken from humans who were allegedly exposed in an attack1 also collect specimens from individuals who claim not to be affected by a toxic agent and are from the same group as exposed personnel4 ,the purpose is the same as collecting environmental control specimens2 that is1 to determine if a toxic substance is present in the individuals' natural environment or if it has been artificially introduced4 b4 ,selection of humans for control sampling is somewhat more complicated than selection of environmental control samples4 ,this is because ethnic diets1 racial differences1 physiological makeup1 and actual living conditions of persons who are outwardly similar may introduce potentially large deviations4 ,each of these factors must be accurately considered before selecting subjects as controls4 c4 ,consideration of ethnic diets is important because of unique foods or methods of food preparation that may exist4 ,as an example1 individuals in settled areas may purchase beer that has been carefully filtered and sterilized1 while individuals in a nearby unsettled area may ferment their own beer by burying home crafted jugs in the ground and extracting the product little by little over several months4 d4 ,racial differences can account for differences in mortality and morbidity rates in specific populations4 ,one example of this could be the high rate of hemophilia in a population versus the rarity of the disease in another4 e4 ,physiological makeup is critical because of the differences in hormone balance and tissue composition in males1 females1 adults1 and juveniles4 ,for this reason1 medical control specimens should be drawn from individuals of the same gender and approximate age as specimens from exposed personnel1 if possible4 f4 ,differences in the actual living conditions of people also require a close look4 ,the point here is that conditions in remote1 semicivilized camps are seldom the same as those in a well-established camp that has access to modern amenities4 g4 ,the bottom line in selecting subjects for medical control sampling is that they be as similar in all aspects as possible4 ,b-#ac4 ,collection of ,medical ,specimens a4 ,trained medical technicians or physicians should collect medical specimens 7human or animal72 however1 ,special ,forces ,,nbc ,reconnaissance team personnel are trained to do this procedure4 ,remember1 the collector must have express permission 7authority7 to collect medical specimens from the dead1 because of religious beliefs in many cultures4 ,to obtain such specimens without permission may result in unnecessary mission complications4 ,ensure all personnel handling or collecting medical specimens have received proper immunizations for their own protection4 ,they must be inoculated ,,iaw ,the ,surgeon ,general's guidance4 b4 ,medical specimens collected during an investigation include blood1 urine1 sputum1 nasal swabs1 and tissue specimens from living victims and blood and urine specimens from unexposed persons 7background control specimens74 c4 ,collect blood specimens using either a standard #aj cc disposable syringe with a #a- to #a-;inch needle 7#bj to #bb gauge71 or by using a ,vacutainer,,tm system4 ,when using a ,vacutainer,,tm system1 ensure that multiple specimen needles and red top vacuum tubes are used4 ,ten cc of blood is sufficient for analytical testing4 ,do not take more than #e cc from small1 malnourished children4 ,after blood is collected1 it should be transferred to a polypropylene-type container and sealed with parafilm before transporting4 ,all body fluids should be collected without violating antiseptic techniques4 ,also1 prior to transporting specimens1 collectors need to check specimen containers for paper labels ,,iaw guidelines for labeling medical specimens4 ,collect blood specimens using the following materials equipment3 ,gloves4 #aj cc sterile1 disposable syringe4 #a- to #a4e-;inch sterile needle 7#bj to #bb gauge74 ,vacutainer,,tm device 7adapter with needle74 ,constricting band4 ,disinfectant pads1 ,betadine1 or alcohol4 ,sterile #bb-;inch gauze pads4 ,labels4 ,,note ,gloves should be worn whenever handling medical specimens4 ,do not freeze liquid blood and urine specimens 7ideal cooling temperature is between #ce and #dj;,f #b to #d;,c47 d4 ,collect urine specimens using either a standard urine cup or by a urine catheter and urine cup4 ,when collecting the specimen directly into a urine cup1 the person must urinate into the cup until sufficient fluid is collected 7#dj cc of urine is preferable1 although #aj cc can support analytical testing74 ,when the person is unable to urinate1 the catheterization technique is preferable4 ,the catheterization technique is best performed in a clinical environment4 ,as with other body fluids collected1 urine must be kept cold4 ,do not freeze4 ,,note ,for correct procedures on catheterization refer to ,,stp #h-ia,w#ae-,,sm-,,tg4 e4 ,collect tissue specimens using sterile scissors and forceps or as directed by the attending physician4 7#a7 ,when casualties have unidentified skin lesions1 photographs of the lesion7s7 and overall photos of the extent of the lesion7s7 should be taken1 using color film before biopsy4 ,a specimen of the lesion should be obtained4 ,this is done by surgically removing a portion of the skin with a sterile pair of scissors and forceps4 7#b7 ,place tissue specimens in a ,teflon,,tm container filled inch from the bottom with a preservative1 7formalin #aj7 for preservation of the specimen until it reaches its proper destination4 ,seal the container and lid with parafilm4 ,as with any other medical specimens1 tissue specimens are refrigerated prior to shipment2 but do not freeze tissue specimens4 f4 ,collect nasal swabs by using a cotton-tipped swab4 ,place the swab with collected specimen in a ,teflon,,tm container filled inch from the bottom with a preservative for preservation of the specimen until it reaches its destination4 ,seal the container and lid with parafilm4 ,refrigerate the specimen for shipment1 but do not freeze4 g4 ,collect sputum by having the patient discharge the sputum into a small1 sterile screw-top jar or urine specimen cup4 ,seal the container and refrigerate the specimen for shipment1 but do not freeze4 ,b-#ad4 ,post mortem ,specimens ,post mortem specimens should be collected by individuals trained in forensics4 ,when forensics-trained individuals are not available1 the most qualified medical person should collect human specimens4 ,specimens from animals should be collected by veterinary personnel4 ,in either case1 the following specimens are collected3 ,blood4 ,use a #ej to #fj cc sterile syringe with an #ah-;gauge1 #e-;inch 7large bore7 needle to collect blood from the heart1 and urine directly from the bladder4 ,use a spinal needle to collect cerebral spinal fluids4 ,three of each type of specimens must be collected4 ,lungs4 ,a biopsy needle is needed to properly collect lung tissue specimens4 ,after collecting specimens from the lungs1 place specimens in a plastic or ,teflon,,tm container filled with #aj formalin 7preservative7 and seal the container for transporting to its destination4 ,liver4 ,if possible collect liver core specimens1 using a large-gauge needle 7#ah-;gauge1 #e-;inch long7 via intercostal or abdominal puncture4 ,or1 if the family consents1 perform a minilaparotomy and obtain one or two #bbb cm sections of liver4 ,store and package the specimen as directed for tissue specimens4 ,for suspect biological agents1 see ,table ,b-#a for specific types of specimens1 amount1 collection medium1 and from whom to collect4 ,,note ,before attempting any of the above procedures1 collector must be certified by a qualified person 7medical doctor7 on the correct procedures to collect specimens from cadavers4 ,table ,b-#d4 ,standard ,sizes of ,,cb ,samples_/,specimens to be ,collected ,,type ,,size ,,notes ---------------------------------------- -------------------------------- ,,chemical ,,warfare ,,samples ,,soil 7#aj ,,cm ,x #e ,,cm ,x #a ,,cm7 ,,cigarette-,,pack ,,size ,,or ,,larger ,,area ,,is ,,more ,,useful ,,than ,,greater ,,depth ,,dilute ,,agent #aj ,,ml ,,water #ejj ,,ml 7,,maximum7 ,c#ah ,,sep-,,pak,,tm #bjj ,,ml ,,vegetation 7,,equivalent ,,to #c ,,leaves ,,depends ,,on ,,amount ,,of ,,contamin- ,,or #c ,,handsful ,,of ,,grass7 ,,ation4 ,,best ,,samples ,,will ,,be ,,found ,,near ,,the ,,release ,,point ---------------------------------------- -------------------------------- ,,biological ,,warfare ,,samples ,,soil 7#aj ,,cm ,x #e ,,cm ,x #a ,,cm7 ,,cigarette-,,pack ,,size ,,or ,,larger ,,area ,,is ,,more ,,useful ,,than ,,greater ,,depth ,,liquid #be ,,to #ej ,,ml ,,do ,,not ,,use ,c#ah ,,sep-,,pak,,tm ,,with ,,medical ,,specimens ,,vegetation ,,size ,,of ,,soft ,,drink ,,can ,,best ,,samples ,,depend ,,on ,,the ,,amount ,,of ,,contamination ,,found ,,near ,,the ,,release ,,point ---------------------------------------- -------------------------------- ,,medical ,,specimens ,,urine #bj ,,to #ej ,,ml ,,must ,,obtain ,,consent ,,to ,,collect ,,specimens ,,from ,,other ,,than ,,us ,,casualties ,,whole ,,blood ,,or #e ,,ml ,,must ,,obtain ,,consent ,,to ,,collect ,,serum ,,specimens ,,from ,,other ,,than ,,us ,,casualties ,,cerebral ,,spinal #b ,,ml ,,must ,,obtain ,,consent ,,to ,,collect ,,fluid ,,specimens ,,from ,,other ,,than ,,us ,,casualties ,,organ ,,tissue #cj ,g 7,,minimum7 ,,mediastinal #b ,,should ,,be ,,removed ,,by ,a ,,surgeon ,,lymph ,,nodes ,,during ,,an ,,autopsy ,b-#ae4 ,reporting1 ,packaging1 and ,shipment ,although a sample_/specimen collected from an alleged attack area can be significant1 it can become useless if proper steps are not taken to record critical information about its collection or if it is improperly packed and breaks during shipment to an analysis center4 ,this section discusses the information needed when acquiring samples_/specimens and the preferred methods for handling and packing samples_/specimens for shipment4 a4 ,a complete background information history of the circumstances about each sample's_/specimen's acquisition must be provided to the agency analyzing the sample_/specimen4 b4 ,critical background information includes-- ,circumstances of acquisition4 ,how the sample_/specimen was obtained1 where it was found1 and how it was collected4 ,physical description4 ,the physical state 7solid1 liquid1 powder1 apparent viscosity71 color1 approximate size1 identity of the specimen 7such as military nomenclature71 dirt1 leaves1 or so forth4 ,circumstances of agent deposition4 ,the type of delivery system1 a description of how the weapon functioned1 how the agent acted on release1 sounds heard during dissemination1 a description of any craters or shrapnel found associated with a burst1 and colors of smoke1 flames1 or mist that may be associated with the attack4 c4 ,provide information on the agent effects on vegetation for soil or environmental samples4 ,a description of the general area 7jungle1 mountain1 grassland7 and changes in the vegetation after agent deposition 7such as color change1 wilting1 drying1 dead7 in the main attack and fringe areas4 d4 ,provide information on the agent effects on humans for medical specimens4 ,describe how the agent affected personnel in the main attack area versus fringe areas2 the duration of agent effects2 peculiar odors that may have been noticed in the area prior to1 during1 and_/or after an attack2 measures taken that alleviated or deteriorated the effects2 and the approximate number of victims and survivors1 to include their ages and genders4 e4 ,describe the agent effects on animals4 ,provide information on the types of animals that were or were not affected by an attack and of how they were affected4 ,b-#af4 ,handling and ,packaging ,materials ,materials used for packaging samples_/specimens primarily consist of ,mylar collection bags1 ,teflon,,tm specimen jars and tubes1 pigs and piglettes1 ice chests1 sealing materials1 and wrapping and cushioning supplies4 a4 ,collection ,bag4 ,use the ,mylar bag as the initial container for such samples as protective masks and filter canisters1 individual antidote and decon kits1 munition fragments1 and other items too large to place in a specimen jar4 ,use it also to package sample_/specimen containers to ensure a vapor barrier in case the container is broken in transit4 ,the bag acts as an initial or secondary vapor barrier to prevent air from leaking inward and toxic material outward4 ,follow the procedures below when using the bag4 ,if packaging a specimen container or nonenvironmental sample_/specimen1 first1 verify it has a sample_/specimen number4 ,carefully place the sample_/specimen in a bottom corner of the ,mylar bag4 ,squeeze all the air out of the bag and seal it by removing the adhesive's protective strip1 and pressing the two sides together4 ,place a piece of #b-;inch-wide fiber or cloth tape across the end of the bag that you just sealed to reseal the ,mylar bag on the outside4 ,this serves as extra insurance in case the internal seal is broken4 ,with the bag lying in front of you and the seal at the top1 fold the bag across its width to as small a size as possible without damaging the sample_/specimen4 ,at this point1 use tape to hold the fold4 ,next1 fold the bag from the top down to the bottom of the bag to as small a size as possible4 ,the sealing of the bag is the most critical step during the packaging process4 ,at this point1 turn the bag over and use a marker or file label to put the sample_/specimen number on the outside of the bag so that analysis center personnel can identify the sample_/specimen4 ,place the folded ,mylar bag in a clear plastic reclosable bag1 if available4 ,following the same steps you used for the ,mylar bag1 fold and seal the plastic bag4 ,when this has been completed1 again mark the sample_/specimen number on the exterior of the bag4 b4 ,glass ,specimen ,jars and ,polypropylene ,tubes4 ,use glass containers to hold small environmental samples1 water samples1 and medical and post mortem specimens4 ,use polypropylene containers to hold medical specimens such as blood or urine4 ,polypropylene containers may be used for post mortem specimens if required2 however1 glass containers are preferred4 ,the use of glass rather than plastic containers is preferred for environmental samples because toxic agents may leach chemicals from plastics into a sample1 introducing contamination and confusing the analysis efforts4 ,if the container has a screw-on lid1 place ,teflon,,tm plumber's tape 7,,nsn #hjcj-jj-hhi-cece2 ,tape1 ,antiseize7 on the threads of the container before putting on the lid4 ,this helps to limit the leakage of liquids and vapor from the container and to assure the lid will not fall off while in transit4 ,if the lid has a cardboard liner1 remove the liner and replace it with one or two layers of parafilm 7a laboratory sealant film74 ,once the lid is on1 stretch parafilm around the outside of the container at the junction of the lid and the glass4 ,two wraps of the film are enough to provide a leakage barrier and more assurance that the lid cannot fall off4 ,at this point1 ensure the sample_/specimen number is on the outside of the container4 ,use a diamond etching pencil or an adhesive label to put the sample_/specimen number on the exterior of the container4 c4 ,six-,pound ,metal ,can4 ,use metal cans as the external container for packaging small items that have been sealed in ,mylar bags1 specimen jars1 and polypropylene tubes containing medical specimens4 ,the metal can helps absorb shock from rough handling during shipment and eliminates the spread of contamination if a specimen container is broken4 ,the six-pound metal can is capable of holding more than one sample_/specimen 7depending upon size of samples_/specimens74 ,before placing samples_/specimens in the can for shipping1 ensure a sample_/specimen number is assigned and is visible on each item4 ,place about #a to #b inches of packing material in the bottom of the can4 ,wrap jars and tubes in plastic bubble wrap or - to -inch-thick foam rubber sheeting1 secure the wrap with tape or a rubber band1 and place the wrapped item in the can4 ,if bubble wrap or foam rubber is not available1 use newspaper4 ,the guiding principle is that the sample_/specimen containers should fit snugly and not be able to move in the can4 d4 ,ice ,chest4 ,standard polyethylene or metal ice chests are the most easily procured items used for transworld shipment of ,,cb samples_/specimens4 ,the most easily used size is about #bd inches long by #ah inches high by #ae inches deep4 ,this size permits the sender to ship two or three #f-pound metal cans in each chest with sufficient dry ice to maintain freezing temperatures for about four days4 ,also1 each chest remains at a weight that one individual can handle4 e4 ,transport ,container4 ,when the samples_/specimens must be transported on commercial aircraft1 an ,,iata-approved sample transport container must be used for shipment_/delivery to the ,,conus laboratory4 f4 ,coolants4 ,samples_/specimens submitted for laboratory analysis must be properly packaged1 labeled1 and shipped to ensure they arrive in an analytically acceptable condition4 ,all samples should be maintained at a temperature of #a to #d;,c during transport4 ,ideally1 samples_/specimens should arrive at the in-theater laboratory within #f hours of collection4 ,the samples_/specimens should be delivered to the ,,conus laboratory within #bd to #dh hours4 ,if the samples_/specimens cannot be delivered to the ,,conus laboratory within this time1 then they should be flash frozen to -#afe;,c1 if capabilities are available4 ,if available1 dry ice should be used when flash freezing cannot be accomplished4 ,if the samples_/specimens cannot be delivered to the ,,conus laboratory within #bd hours1 the supporting laboratory should subculture the samples_/specimens and send the subculture with the samples_/specimens to the ,,conus laboratory4 ,the subculturing date should also be provided4 g4 ,internal ,insulation4 ,while a commercial ice chest provides good insulation of both the samples_/specimens and the coolant1 it is best to place extra insulation and cushioning around the metal cans inside the chest4 ,newspapers1 plastic bubble wrap1 and foam rubber may all be used with almost equally good results except newspapers and standard ice do not mix well4 ,b-#ag4 ,collection ,reporting a4 ,the collector must provide a formatted message for transmission as soon as possible to report acquisition and shipment of samples_/specimens4 ,during special operations in a theater in which a ,special ,forces ,group 7,,sfg7 is deployed1 the message is transmitted by the fastest means through the fewest channels to the ,,nbc control 7,,nbcc7 center4 ,if a ,,nbcc center has not been deployed to the area of operations1 as in low-sample_/specimen volume peacetime ,,nbc sampling operation1 the message is transmitted by the fastest means through the fewest channels to the message addressees below4 ,in addition1 a written report accompanies each sample_/specimen or batch of samples_/specimens4 ,the collector ensures that the acquisition message has been properly classified4 b4 ,the collection report includes at least the following addressees3 ,,secstate ,,washdc ,,secdef ,,washdchosd-,,isa_/,,ous-,,dreh ,,jcs ,,washdc_/_/,j-#c_/;,j-#e;,h ,,cia ,,washdchoswr-,,std-,,lsbnic-,,nio7,,stp 7,h ,,dia ,,washdc_/_/,,dt-#c;,b_/,,dt-#e;,a_/_/ ,,dir ,,afmic ,,ft ,,detrick ,,md_/_/,,afmic-,,cr_/,,afmic-,,sa_/_/ ,,da ,,washdc_/_/,,dami-,,fit_/,,damo-,,swc_/ _/ ,,cmdt ,,usacmls ,,ft ,,leonard ,,wood ,,mo_/_/,,atsn-,,cm-,,co_/_/ ,,cdr ,,sbccom ,,apg ,,mdhsmccr-,,opf_/,,smcte-,,ope-,,ra-,,i d#b;,h ,,cdr ,,fstc ,,charlottesville ,,va_/_/,,aiast-,,ra-,,id#b;,h ,,cdr ,,usamriid ,,ft ,,detrick ,,md 7,for suspect biological samples_/specimens only47 c4 ,a collection message contains the following information3 ,the sample_/specimen identification number is part of the subject line if only a single sample_/specimen is referred to in the text4 ,otherwise1 refer to the sample_/specimen number within the message body with its background information4 ,the shipment date1 mode of transportation1 courier identification1 air bill of lading number1 flight number destination1 and estimated time of arrival are included if the sample_/specimen is to be shipped immediately4 ,also1 the material courier receipt form 7,,dd ,form #aiaa7 should be used to maintain chain of custody4 ,background information on the sample_/specimen4 ,questionable circumstances surrounding acquisition of a sample_/specimen4 ,the name of another country or agency that acquired a sample_/specimen from the same event or area and is not shown on the message address4 ,a recommended priority and rationale for analysis to guide the analysis center on the assessment of the potential value of the sample_/specimen4 ,all details relating to the collection of the sample_/specimen1 regardless of how insignificant they may seem to the collector4 d4 ,ship all samples_/specimens by the fastest1 safest means1 preferably by a technical escort unit 7,,teu7 to the theater ,chemical-,biological ,sampling ,control ,element 7,,cbsce7 or to a location the ,,cbsce designates4 ,if there is no ,,cbsce in the theater1 send the samples_/specimens ,,iaw preplanned instructions from the ,chemical-,biological ,sampling ,control ,center 7,,cbscc7 at ,,cbda1 ,aberdeen1 ,maryland4 ,the ,,cbscc uses the following criteria to determine the final destination of each sample3 ,is the sample_/specimen chemical or biological in content8 ,is the sample_/specimen content completely unknown8 ,is the sample_/specimen a possible biological material8 7#a7 ,in any case1 the ,,nbcc center must be notified in advance of shipment of the sample so additional instructions or deviations from standard instructions can be given4 ,figure ,b-l shows an example of a shipping notification message4 ,the ,,nbcc center will direct1 in advance1 that samples be sent to one or more of the following locations1 depending on the category of the samples4 ,prior to shipment of samples_/specimens1 contact must be made with-- ,commander ,technical ,escort ,unit ,,attn3 ,,smcte-,,ope ,aberdeen ,proving ,ground1 ,,md #bajaj ,,dsn3 #ehd-dcha 7,duty hours7 ,,dsn3 #ehd-bggc 7,after duty hours7 7#b7 ,this unit controls the transport of samples_/specimens to their final destination7s74 ,do not ship suspected toxic samples_/specimens or munition systems to ,,conus technical centers or intelligence agencies without coordination and prior approval by the recipient4 ,,note ,suspect ,,cb samples_/specimens are first delivered to the supporting medical laboratory in the ,,ao for in-theater analysis before they are transported out of the ,,ao4 ,the supporting laboratory will withdraw an aliquot of selected samples_/specimens for analysis4 ,the supporting medical laboratory is responsible for providing the ,,ao commander confirmatory identification within the ,,ao4 ,the ,,conus-based reference laboratory is responsible for providing confirmatory identification for ,president and ,secretary of ,defense purposes4 ,,fm ,,amembassy ,,ddttttz ,,jan #jb ,,to ,,cdr ,,teu ,,apg ,,md_/_/,,smcte-,,ope_/_/ ,,secstate ,,washdc ,,secdef ,,washdc_/_/,,osd-,,isa_/,,ous-,,dre_/_/ ,,info ,,cia ,,washdc_/_/,,oswr-,,std-,,lsb_/,,nic-,, nio7,,stp7_/_/ ,,jcs ,,washdc_/_/,j-#c_/;,j-#e_/_/ ,,dia ,,washdc_/_/,,dt-#c;,b_/,,dt-#e;,a_/_/ ,,dir ,,nsa ,,ft ,,meade ,,md ,,dir ,,afmic ,,ft ,,detrick ,,md_/_/,,afmic-,,cr_/,,afmic-,,sa_/_/ ,,da ,,washdc_/,,dami-,,fit_/,,damo-,,swc_/_/ ,,cdr ,,fstc ,,charlottesville ,,va_/_/,,aiast-,,ra-,,id#b_/_/ ,,cdr ,,cbda ,,apg ,,md_/_/,,smccr-,,opf_/_/ ,,cdr ,,usacmls ,,ft ,,mcclellan_/_/,,atzn-,,cm-,,cu_/_/ ,,classification ,,secstate ,,for444 ,,secdef ,,for444 ,,cia ,,for444 ,,jcs ,,for ,j-#c_/;,j-#e ,,for444 ,,da ,,for ,,damo-,,swc ,,for444 ,,afmic ,,for444 ,,cbda ,,for ,,fio444 ,,fstc ,,for ,,amxst-,,fw444 ,,usacmls ,,for ,,threat ,,mgr444 ,e4#j4abcef3 ,,decl3 ,,oadr 7,note3 ,this is included if the message is classified47 ,,tags3 444 ,subject3 ,shipment of ,,cb ,samples_/,specimens ,,ref7,s73 ,,teu ,,msg 1 7,,dtg ,,ddtttt time zone ,,jan #jb7 #a4 7,w7 ,,shipping ,,information3 ,a4 ,,date ,,shipped3 ,,january #aa1 #bjjb4 ,b4 ,,mode ,,of ,,transportation3 ,,air ,,express1 ,,air ,,bill ,,number ,,rpt ,c4 ,,flight ,,schedule3 ,,to ,,tyo ,,by ,,jal ,,xxx1 ,,january #aa1 #bjjb4 ,,to ,,jfk ,,by ,,jal ,,yyy1 ,,january #ab1 #bjjb4 ,,to ,,iad ,,by ,,dec ,,zzz1 ,,january #ab1 #bjjb4 ,d4 ,,destination3 ,,dulles ,,international ,,airport4 ,e4 ,,estimated ,,time ,,of ,,arrival3 #bjaj ,,hours1 ,,january #ab1 #bjjb4 #b4 ,,special ,,handling ,,requirements3 ,,dry ,,ice ,,enclosed ,,as ,,coolant4 #c4 ,,shipment ,,consists ,,of ,,two ,,ice ,,chests 7#a ,,for ,,crdec ,,and #a ,,for ,,afmic7 ,,containing ,,six ,,samples_/,,specimens4 ,,all ,,liquid ,,samples_/,,specimens ,,are ,,in ,,polypropylene ,,tubes ,,and ,,have ,,been ,,carefully ,,packed ,,to ,,avoid ,,breakage4 ,,the ,,following ,,samples ,,are ,,included ,,in ,,the ,,shipment3 ,,sample_/,,specimen ,,number ,,message ,,reference ,,th-#hejajb-jja;,,ag ,,thru ,,th-#hejajb-jje;,,ag ,,bangkok ,,ddttttz ,,jan #jb #d4 ,,usdao ,,has ,,stated ,,that ,,this ,,shipment ,,is ,,partial ,,fulfillment ,,of ,,cir4 ,figure ,b-l4 ,sample shipping notification message4 ,b-#ah4 ,sample_/,specimen ,background ,documents ,the sample_/specimen background document allows a collector to note the most relevant details associated with pre- and post-sample_/specimen collection conditions4 ,do not consider the report to be all-inclusive4 ,the information collected should include at least the items listed in ,figure ,b-#b4 ,interviews should be conducted with individuals exposed to the ,,cb agent as well as individuals not exposed 7see ,figure ,b-#c74 #a4 ,,id ,,number #b4 ,,collection 7,,date_/,,time73 #c4 ,,collector_/,,unit3 #d4 ,,type3 ,,environmental ,,biomedical ,,single ,,multiple #e4 ,,purpose3 ,,attack ,,chem_/,,bio ,,alarm ,,chem ,,detect ,,recon ,,illness_/,,death ,,other #f4 ,,postexposure3 ,,hours ,,days ,,weeks ,,unknown #g4 ,,location3 ,,town ,,coordinates ,a4 ,,terrain3 ,,flat ,,hills ,,mountain ,,desert ,,jungle ,,sparse ,,trees ,,grass ,,body ,,of ,,water_/,,type ,b4 ,,weather3 ,,clear ,,cloudy ,,rain ,,fog ,,snow ,,dust ,c4 ,,wind3 ,,light ,,heavy ,,gusty ,,none ,d4 ,,odor3 ,,sweet ,,fruity ,,pepper ,,flower ,,irritating ,,changing ,,none ,,other ,e4 ,,temperature ,,at ,,time ,,of ,,attack3 ,,temperature ,,at ,,time ,,of ,,sample ,,collection3 #h4 ,,comments3 #i4 ,,attack3 ,,date_/,,time ,,method3 ,,artillery ,,rocket ,,aircraft ,,mortar ,,rpg_/,,grenade ,,other1 ,,describe3 ,a4 ,,explosion3 ,,air 7,,height7 ,,ground ,,size ,,distance ,,describe3 ,b4 ,,consistency3 ,,smoke ,,mist ,,dust ,,rain ,,gel ,,invisible1 ,,describe3 #aj4 ,,environmental ,,sample3 ,,soil ,,water ,,vegetation ,,air ,,other #aa4 ,,biomed ,,specimen3 ,,acute ,,convalescent ,,exposed ,,not ,,ill ,,postmortem ,,control1 ,,explain3 ,,blood ,,liver ,,lung ,,spleen ,,brain ,,skin ,,kidney ,,urine ,,other1 ,,describe3 #ab4 ,,comments3 #ac4 ,,casualty3 ,,ssn ,,unit ,,sex #ad4 ,,signs_/,,symptoms3 ,,onset ,,duration ,a4 ,,head3 ,,fever ,,chills ,,headache ,,flushed ,,dizziness ,,unconsciousness ,,coma ,,hallucinations ,b4 ,,eyes3 ,,sunlight ,,sensitive ,,painful ,,burning ,,droopy ,,eyelids ,,double ,,vision ,,blurred ,,vision ,,large ,,pupils ,,pinpoint ,,pupils ,c4 ,,nose3 ,,runny ,,bleeding ,d4 ,,throat3 ,,sore ,,dry ,,salivating ,,bloody ,,sputum ,,hoarseness ,,difficulty ,,speaking ,e4 ,,respiration3 ,,difficulty ,,breathing ,,chest_/,,pain ,,discomfort ,,wheezing 7,,in_/,,out7 ,,coughing ,,labored ,,breathing ,f4 ,,heart ,,pounding ,,or ,,running ,,irregular ,,heartbeat ,g4 ,,gi3 ,,loss ,,of ,,appetite ,,nausea ,,frequent ,,vomiting ,,frequent ,,diarrhea ,,vomiting ,,blood ,,diarrhea ,,with ,,blood ,h4 ,,urinary3 ,,bloody ,,urine ,,unable ,,to ,,urinate ,i4 ,,musculoskeletal3 ,,neck ,,pain ,,muscle ,,tenderness ,,muscle ,,trembling_/,,twitching ,,weakness ,,paralysis1 ,,describe3 ,,convulsions ,,tremors ,,muscle ,,aches ,,back ,,pain ,,joint ,,pain ,j4 ,,skin3 ,,rash ,,reddening ,,itching ,,blisters ,,pain ,,numbness ,,profuse ,,perspiration #ae4 ,,comments3 #af4 ,,animals ,,affected3 ,,yes ,,no ,,describe3 #ag4 ,,related ,,specimens ,,id ,,number ,,description #ah4 ,,collector ,,signature ,,name ,,phone ,,number ,e-,,mail #ai4 ,,reviewer ,,signature ,,name ,,phone ,,number ,e-,,mail ,figure ,b-#b4 ,sample_/specimen background document4 ,,cb ,,incident ,,interview ,,date3 ,,interviewer3 ,,subject',s ,,name3 ,,alias #a #b ,,age3 ,,sex3 ,m ,f ,,year ,,of ,,birth3 ,,nationality3 ,,subject',s ,,address3 ,,identity ,,card 3 ,,delivery ,,methods3 ,,type3 ,,unknown ,,ground ,,air ,,artillery_/,,rocket ,,mine ,,other1 ,,describe3 ,,height3 7,m7 ,,size3 7,,affected ,,area ,,in ,,meters7 ,,distance3 7,m7 ,,agent ,,characteristics ,,odor3 ,,none ,,sweet ,,fruity ,,irritating ,,pepper ,,flower ,,changing ,,other1 ,,describe3 ,,comments3 ,,consistency3 ,,smoke ,,mist ,,dust ,,rain ,,gel ,,dry ,,visible ,,invisible ,,other1 ,,describe3 ,,color3 ,,describe ,,development ,,of ,,color3 ,,area ,,coverage3 ,,physical ,,dissemination_/,,coverage 7i4e41 ,,droplet ,,size ,,and ,,distribution73 ,,write ,,or ,,draw ,,symptoms3 ,,individual',s ,,actions3 ,,during ,,attack3 ,,after ,,attack3 ,,protective ,,measures3 ,,treatment ,,received3 ,,environmental ,,effects3 ,,vegetation ,,change8 ,,yes ,,no ,,describe3 ,,animals ,,affected8 ,,yes ,,no ,,describe3 ,,others ,,affected3 ,,name ,,age ,,symptoms ,,resolution ,figure ,b-#c4 ,chemical_/biological incident interview4 ,,fm ,,amembassy ,,ddttttz ,,jan #jb #a4jj ,,shipping ,,to ,,cdr ,,teu ,,apg ,,md_/,,smcte-,,opei_/ ,,secstate ,,washdc ,,secdef ,,washdc_/_/,,osd-,,isa_/,,ous-,,dre_/_/ ,,info ,,cia ,,washdc_/_/,,oswr-,,std-,,lsb_/,,nic-,, nio7,,stp7_/_/ ,,jcs ,,washdc_/_/,j-#c_/;,j-#e_/_/ ,,dia ,,washdc_/_/,,dt-#c;,b_/,,dt-#e;,a_/_/ ,,dir ,,nsa ,,ft ,,meade ,,md ,,dir ,,afmic ,,ft ,,detrick ,,md_/_/,,afmic- ,,cr_/,,afmic-,,sa_/_/,,da ,,washdc_/_/ ,,dami-,,fit_/,,damo-,,swc_/_/ ,,cdr ,,fstc ,,charlottesville ,,va_/_/,,aiast-,,ra-,,id#b_/_/ ,,cdr ,,crdec ,,apg ,,md_/_/,,smccr-,,ope_/_/ ,,cdr ,,usacmls ,,ft ,,leonard ,,wood ,,mo_/_/,,atsn-,,cm-,,co_/_/ ,,cdr ,,usamriid ,,ft ,,detrick ,,md_/_/ 7,,for ,,suspect ,,biological ,,samples_/,,specimens ,,only7 ,,classification ,,secstate ,,for444 ,,secdef ,,for ,,cia ,,for ,,jcs ,,for ,j-#c_/;,j-#e ,,for ,,da ,,for ,,damo-,,swc ,,for ,,afmic ,,for ,,crdec ,,for ,,fio ,,fstc ,,for ,,amxst-,,fm ,,usacmls ,,for ,,threat ,,mgr ,e4,o4 #abcef3 ,,decl3 ,,oadr 7,,note3 ,this is included if the message is classified47 ,,tags3 ,,subject3 ,,shipment ,,of ,,cb ,,samples ,,ref7,s73 ,,teu ,,msg1 4 7,,dtg ,,ddtttt time zone ,jan #jb7 #a4 ,,information3 ,a4 ,,date ,,shipped3 ,,january #aa4bjjb4 ,b4 ,,mode ,,of ,,transportation3 ,,air ,,express4 ,,air ,,bill ,,number ,,rpt ,c4 ,,flight ,,schedule3 ,,to ,,tyo ,,by ,,jal ,,xxx ,,january #aa1 #bjjb4 ,,to ,,jfk ,,by ,,jal ,,yyy1 ,,january #ac1 #bjjb4 ,,to ,,iad ,,by ,,dec ,,zzz1 ,,january #ab1 #bjjb4 ,d4 ,,destination3 ,,dulles ,,international ,,airport ,e4 ,,estimated ,,time ,,of ,,arrival2 #bjaj ,,hours4 ,,january #ab1 #bjjb4 #b4 ,,special ,,handling ,,requirements3 ,,dry ,,ice ,,enclosed ,,as ,,coolant4 #c4 ,,shipment ,,consists ,,of ,,two ,,ice ,,chests 7#a ,,for ,,crdec ,,and #a ,,for ,,afmico7 ,,containing ,,six ,,samples_/,,specimens4 ,,all ,,liquid ,,samples_/,,specimens ,,are ,,in ,,polypropylene ,,tubes ,,and ,,have ,,been ,,carefully ,,packed ,,to ,,avoid ,,breakage4 ,,the ,,following ,,samples_/,,specimens ,,are ,,included ,,in ,,the ,,shipment3 ,,sample_/,,specimen ,,number ,,message ,,reference ,,th-#heja #a;,,ag ,,thru ,,th-#hejajb-jje;,,ag ,,bangkok ,,ddttttz ,,jan #jbjb-jj #d4 ,,usdao ,,has ,,stated ,,that ,,this ,,shipment ,,is ,,partial ,,fulfillment ,,of ,,cir4 ,figure ,b-#d4 ,sample_/specimen shipping report4 ,,appendix ,c ,,guidelines ,,for ,,operational ,,planning ,,for ,,health ,,service ,,support ,,in ,a ,,nuclear1 ,,biological1 ,,and ,,chemical ,,environment ,c-#a4 ,general ,as the ,,hss unit prepares for its support role1 ,,nbc1 ,,tim1 and ,,cbrne considerations must be included4 ,this appendix provides guidelines for ,,hss planning1 preparing for1 and conducting operations in an ,,nbc environment and responding to a homeland defense ,,cbrne event4 ,c-#b4 ,predeployment ,when preparing the unit's mobilization plan and ,,tsop1 include the supplies and equipment that will be required for the unit to operate in an ,,nbc environment4 ,,do ,,not wait until ordered to mobilize to begin preparation for the mission4 ,a well-prepared and trained unit stands a much better chance of surviving and accomplishing their assigned mission4 ,at a minimum include the following3 ,nerve agent pretreatment and antidotes 7see ,,fm #h-bhe74 ,blister agent antidote_/treatment 7see ,,fm #h-bhe74 ,incapacitating agent treatment 7see ,,fm #h-bhe74 ,lung-damaging agents 7choking agents7 treatment 7see ,,fm #h-bhe74 ,blood agent 7cyanogen7 treatment 7see ,,fm #h-bhe74 ,biological agent immunizations and chemoprophylaxis 7see ,,fm #h-bhd74 ,biological agent treatment 7see ,,fm #h-bhd74 ,nuclear and radiological treatment 7see ,,fm #d-jb4bhc74 ,protective mask with hood for each individual 7see ,,fm #c-d74 ,replacement filters for protective mask 7see ,,fm #c-d74 ,two sets of ,,mopp per individual assigned to unit 7see ,,fm #c-d74 ,all authorized radiation detection equipment4 ,all authorized chemical agent detection equipment4 ,all authorized ,,nbc alarm systems4 ,biological agent detection equipment1 if available4 ,sample_/specimen collection1 packaging1 and shipping supplies for suspect ,,nbc agents4 ,decontamination equipment and supplies 7,,ds#b1 ,,stb1 pails1 sponges1 mops1 decontaminant application apparatus1 individual skin decontamination kits1 and individual equipment decontamination kits see ,,fm #c-e74 ,material for covering supplies and equipment 7such as plastic sheeting1 tape1 and tarpaulins74 ,material for preparing improvised protection in shelters 7such as plastic sheeting1 tarpaulins1 tape1 and sandbags74 ,collective protection shelter systems with repair parts1 if available4 ,chemical agent patient decontamination ,medical ,equipment ,set 7,,mes74 ,the ,,mes can also be used to decontaminate nuclear and biological patients1 if authorized4 ,chemical agent patient treatment ,,mes4 ,some components may also be used to treat nuclear and biological patients1 if authorized4 ,water supply for patient decontamination1 if required4 ,shovels1 picks1 and axes4 ,lightweight decontamination system ,m#ag and other decontamination apparatuses4 ,applicable references 7,army ,regulations ,a,rs1 ,joint publications1 ,f,ms1 technical manuals ,t,ms1 training circulars ,t,cs1 and ,t,s,o,ps74 ,c-#c4 ,mobilization ,during mobilization the unit must ensure that all supplies and equipment are on hand and are serviceable4 ,commanders and leaders must also ensure that-- ,movement plans are prepared4 ,transportation support requirements are identified and requested4 ,load plans include provisions for the transportation of ,,nbc supplies and equipment 7medical and nonmedical74 ,a ,,mopp level has been established for the movement1 if applicable4 ,a checklist of training shortfalls is prepared and a training plan is in place4 ,c-#d4 ,establish a ,medical ,treatment ,facility ,plans for establishing a ,,bas1 ,,dcs1 or ,,fst for operating in a ,,nbc environment must include employment of ,,cbps systems4 ,when establishing a hospital using ,deployable ,medical ,systems 7,,depmeds71 the chemically protected 7,,cp7 ,,depmeds must be set up as the conventional shelters are being set up4 ,once the conventional shelter has been set up and is operational1 ,,cp ,,depmeds cannot be established without first taking down the existing shelter4 ,follow the technical manual provided with the ,,cp ,,depmeds system issued to your unit4 ,plans for operating a ,,depmeds equipped hospital in the ,,nbc environment should include1 but not be limited to-- ,coordinating with the supported unit to ensure unit casualty collecting points and patient decontamination points are on the ,,hss template4 ,if possible1 integrate ,,hss units_/elements into local units ,,nbc detection systems and communications systems4 ,surveying the ,,ao4 ,survey the area to ensure contamination is not present before establishing the ,,mtf4 ,establishing detection stations on the unit's perimeter4 ,determining direction of prevailing wind4 ,all contaminated patients1 ambulances1 and helicopters must arrive on the downwind side of the ,,mtf2 this must be done with or without ,,cps4 ,setting up the contaminated triage1 patient decontamination1 and contaminated treatment areas 7including overhead cover74 ,establishing the contaminated ambulance point4 ,establishing the contaminated helicopter landing area4 ,preparing the contaminated waste dump4 ,establishing the clean ambulance point4 ,establishing the clean helicopter landing area4 ,marking the hot line and preparing the shuffle pit4 ,employing ,,cp ,,depmeds system 7close shelter1 turn on ,,cb filtration units1 close air locks1 and maintain overpressure71 if available4 ,establishing the clean treatment area #cj to #ej yards 7meters7 upwind of hot line1 when ,,cps is not available4 ,ensuring provisions for overhead cover at the patient decontamination area4 ,requesting patient decontamination personnel from supported units for the ,,bas and ,,dcs1 or from units located within the geographic area for hospitals4 ,requesting issue of chemical patient treatment and chemical patient decontamination ,m,e,ss1 if not on-hand4 ,establishing contamination monitoring procedures in ,,cps4 ,establishing control procedures for personnel crossing the hot line 7through the shuffle pit74 ,establishing ,,cps entry and exit control procedures 7see ,appendix ,f74 ,making improvisations2 if the ,,mtf must operate in a nuclear_/radiological environment4 ,for optional improvisations1 see ,appendix ,h4 ,c-#e4 ,operate a ,medical ,treatment ,facility ,receiving ,contaminated ,patients ,individuals should have decontaminated themselves or have been decontaminated by unit personnel2 however1 an ,,mtf must plan for and be prepared to receive contaminated patients4 ,the patients may not have been decontaminated at the unit1 or they may have become contaminated en route to the ,,mtf4 ,selected ,c,s,hs may be designated as the primary ,,nbc ,,mtf and be augmented with additional supplies and medical staff4 ,when designated as such1 plans must be prepared designating the location of the ,,csh that can best support the forward deployed ,m,t,fs4 ,all actions listed in paragraph ,c-#d must be taken4 ,during operations1 actions that must be taken are-- ,establishing a ,,mopp level commensurate with the operation4 ,requiring all ambulances and helicopters with contaminated 7or suspected7 patients to stay downwind of the ,,mtf4 ,conducting initial triage1 decontamination1 and contaminated treatment downwind of the clean treatment area 7,appendixes ,f and ,h74 ,ensuring all personnel crossing the hot line are decontaminated4 ,monitoring personnel entering clean area to ensure that they are contamination free4 ,monitoring for contamination in the clean treatment area 7with or without ,,cps74 ,establishing an internal monitoring program to periodically verify that the ,,mtf is contamination free4 ,monitoring ,,cps for entry of contamination4 ,providing protection for patients if contamination enters the ,,mtf4 ,ensuring personnel drink sufficient quantities of water to prevent heat injury 7see ,,fm #ba-aj74 ,providing protection for personnel and patients in a cold environment4 ,use sheltered_/heated area for patient decontamination4 ,providing protection of personnel and patients in a hot environment4 ,controlling contaminated waste4 ,isolating biological agent patients1 if necessary1 to control spread of agent_/disease 7see ,,fm #h-bhd74 ,protecting supplies and equipment from contamination4 ,providing medical resupply to clean areas4 ,providing food service for personnel and patients in ,,cps4 ,providing latrine facilities in ,,cps4 ,providing drinking water in ,,cps4 ,providing waste disposal support4 ,remove waste from the ,,cps at least two times dally4 ,more frequently if large amounts are collected or if odors become a problem4 ,collecting suspect ,,bw agent specimens from patients4 ,packaging1 preparing chain of custody document1 and shipping specimens to supporting medical laboratory4 ,c-#f4 ,preventive ,medicine ,services ,plans for providing preventive medicine services must include monitoring water supplies for contamination4 ,to perform this mission1 equipment and supplies must be available and operational4 ,essential equipment and supplies include-- ,radiation detection equipment such as ,,an_/,,pdr#gg1 ,,an_/,,pdr#bg1 ,,an_/,,vdr#b4 ,preventive ,medicine ,water ,quality ,control ,set4 ,m#bgb ,chemical ,agent ,detection ,set4 ,biological sample collection kit1 shipping containers1 refrigerant1 and chain of custody forms4 ,c-#g4 ,veterinary ,services ,plans for veterinary services must include provisioning for treatment to government-owned animals and quality control of food supplies4 ,to perform their mission1 essential supplies and equipment include-- ,treatment for ,,nbc injured animals4 ,especially1 antidotes and treatment for ,,cb agents4 ,radiation detection equipment4 ,m#bgb ,chemical ,agent ,detection ,set4 ,biological sample_/specimen collection kit1 shipping containers1 refrigerant1 and chain of custody forms4 ,c-#h4 ,dental ,services ,most dental services at the dental treatment facilities will have to be suspended in ,,nbc contaminated areas due to a lack of ,,cps4 ,plans must include for emergency dental services to be provided in a clean area or in an ,,mtf with a ,,cps4 ,essential supplies and equipment include-- ,dental treatment set for maxillofacial injuries4 ,material for covering and protecting supplies and equipment4 ,c-#i4 ,combat ,operational ,stress ,control ,although specific supplies and equipment are not required for ,,cosc1 plans must be prepared to provide these services under ,,nbc conditions4 ,the ,,cosc staff must locate clean areas to conduct ,,cosc activities or manage the ,,cosc patients in a ,,mopp level commensurate with the command ,,mopp guidance4 ,c-#aj4 ,medical ,laboratory ,services ,planning for medical laboratory support must include plans for conducting analysis on suspect ,,nbc samples_/specimens4 ,designated supporting medical laboratories must be prepared to analyze and provide confirmation_/identification on specimens_/samples of suspect ,,nbc agents from humans1 water sources1 food supplies1 and the environment 7air and soil74 ,the samples_/specimens may be collected by ,,mtf personnel1 chemical corps personnel1 ,,pvntmed personnel1 veterinary personnel1 or other services personnel4 ,to perform this mission1 supplies and equipment should include-- ,general supplies and equipment4 ,biological sample_/specimen collection kits and supplies4 ,to provide capabilities for others to collect samples_/specimens 7in the event that they do not have these items otherwise available74 ,biological test kits or apparatus4 ,microbiology services4 ,immunology_/serology ,,mes4 ,microbiology ,,mes4 ,laboratory1 general ,,mes4 ,veterinary services4 ,laboratory1 veterinary ,,mes4 ,veterinary postmortem field ,,mes4 ,preventive medicine services4 ,water1 biological sampling and analysis supplies and equipment4 ,radiation protection ,,mes4 ,entomology ,,mes4 ,alpha_/beta detectors4 ,microscope1 phase4 ,ambient air analyzer4 ,epidemiology ,,mes4 ,c-#aa4 ,health ,service ,logistics ,plans must include health service logistics support to continue under ,,nbc conditions4 ,to continue this role1 all supplies must be protected from contamination4 ,materials required include-- ,detection equipment4 ,plastic sheeting4 ,tape4 ,tarpaulins4 ,,nbc detection equipment such as1 ,m#h chemical agent detection paper1 ,m#i chemical agent detection tape1 radiation detection equipment1 and biological agent sample_/specimen collection supplies4 ,,note ,this guideline contains items that are required specifically for ,,hss operations in an ,,nbc environment4 ,the items are in addition to supplies and equipment required for conventional operations4 ,this guideline is not all inclusive1 but is a starting point for ,,hss units to develop their specific guidelines4 ,c-#ab4 ,homeland ,security ,health service support units and installation medical activities_/centers must be prepared to provide support in the event that ,,cbrne are used on the ,united ,states4 ,medical commanders and leaders should develop plans on how the provision of medical support will be provided to a ,,cbrne event4 ,the plan should include1 but not be limited to-- ,number and type of units required to respond4 ,medical equipment and supplies required4 ,personal protective equipment required for medical response personnel4 ,time required to prepare unit_/personnel to respond4 ,length of time response support is required4 ,sources for food1 shelter1 local transportation1 and resupply of expended or lost equipment and supplies4 ,,appendix ,d ,,medical ,,planning ,,guide ,,for ,,the ,,estimation ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,battle ,,casualties ,section ,i4 ,,introduction ,d-#a4 ,general ,the primary purpose of the ,medical ,planning ,guide for the ,estimation of ,nuclear1 ,biological1 and ,chemical ,battle ,casualties--,a,med,p-#h7;,a71 a three-volume publication for ,,nbc1 is to assist medical planners1 medical logisticians1 and medical staff officers in predicting ,,nbc warfare contingency requirements for ,,hss personnel1 medical materiel stockpiles1 patient transport or evacuation capabilities1 and facilities needed for patient decontamination1 triage1 treatment1 and supportive care4 ,the optional use of these guides is for projecting medical ,,nbc operational estimates at brigade1 division1 corps1 and ,,eac4 ,,note ,the use of the guide in this appendix refers to ,a,med,p-#h7;,a71 ,volume ,i1 ,,ii1 or ,,iii4 ,the ,a,med,p-#h7;,a71 ,volume ,i1 ,,ii1 or ,,iii1 is the text for each of the ,s,t,a,n,a,gs4 ,the contents of this appendix are extracts from ,sections #a1 #b1 and #c of the guide4 ,d-#b4 ,medical ,planners' ,tool ,medical planners' estimates 7such as casualty1 logistics1 evacuation1 and personnel cross leveling7 must be modified for the ,,nbc environment4 ,estimates of ,,nbc medical workload can be found in ,a,med,p-#h7;,a74 ,a compact disk containing these documents and an automated version of ,a,med,p-#h7;,a71 the ,casualty ,requirements ,estimation ,tool 7,,crest71 can be obtained from ,headquarters1 ,department of the ,army1 ,,attn3 ,,dasg-,,hcz-,,fd1 #eaji ,leesburg ,pike1 ,falls ,church1 ,,va #bbjda-cbeh4 ,the ,,crest is primarily an ,army tool focusing on corps1 brigades1 and battalions1 but also models aerial ports of debarkation1 seaports of debarkation1 and other units4 -------------------------------------- ,this ,section ,implements ,,stanag #bdge4 -------------------------------------- ,section ,,ii4 ,,medical ,,planning ,,guide ,,for ,,the ,,estimation ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,battle ,,casualties 7,,nuclear7--,a,med,p-#h7;,a71 ,,volume ,i ,d-#c4 ,general a4 ,volume ,i of the guide provides estimates of casualties and remaining operational strength after a nuclear detonation in a brigade-sized unit during an out-of-area contingency operation4 ,these estimates include the numbers1 injury type 7initial nuclear radiation1 blast1 and thermal injuries71 and injury severity of nuclear patients based on several brigade scenarios4 ,the scenarios include three different brigade-sized units1 in warned or unwarned posture1 which have single detonation of #e1 #bj1 or #ej ,,kt in the unit area4 b4 ,the guide is organized into #aj sections4 ,section #a introduces the guide and presents background and medical planning considerations4 ,section #b provides information on the methodology used to develop the estimates of fatalities1 casualties1 and effectiveness of individuals remaining in the unit4 ,section #c explores the use of the casualty prediction tables based on combat effectiveness decrements and estimates of the number of casualties categorized by insult level4 ,sections #d through #aj contain tables of casualty estimates4 c4 ,a sample of this information is graphically depicted in ,tables #a-a and #a-b of the guide4 ,the casualty estimates used to prepare these tables are presented in the guide as ,tables #f-d and #aj-d in ,sections #f and #aj respectively4 ,the use of these tables is explained in paragraphs #c4a through #c4f of the guide4 ,paragraphs #c4g and #c4h of the guide discuss how to use the guide for situations not explicitly addressed4 d4 ,the effects of residual radiation on personnel are not included in the guide4 ,a,med,p-#f and ,a,med,p-#g provide information on planning1 operations1 and treatment for a residual radiation situation4 ,also not included is the impact of tumbling2 impact of glass shards from windows of vehicles or buildings2 crushing deaths from building failure2 or ,,cosc casualties2 thus causing underestimations on the number of patients4 ,further1 there will be personnel who get radiation doses or burns and do not seek medical care4 e4 ,a nuclear detonation may introduce new levels of destruction to the battlefield4 ,there is very little experience with nuclear effects and there is certainly no experience with these weapons on a modern1 highly technological battlefield4 ,therefore1 there is little historical data on which to base estimates of personnel injured4 ,computer simulations are generally used to estimate numbers of personnel injured4 ,although these estimates may include significant uncertainty1 they provide the best estimates to date4 ,d-#d4 ,medical ,planning ,considerations a4 ,for effective mass casualty management1 key medical and related considerations must be well planned and practiced4 ,these include on-site triage and emergency care1 communications1 health service logistics1 evacuation by ground and air resources1 and personnel training in self-aid_/buddy aid4 ,plans need to be made for requirements that may differ from the usual combat situation4 ,for example1 in combat situations1 severe burn injuries in large numbers are relatively uncommon4 ,therefore1 no special planning for the care of large numbers of burn patients is required4 ,in a nuclear environment1 this may not be true1 and consideration must be given to the increased need for medical support that would result from a high incidence of burn patients4 b4 ,prior to an attack1 the data may be used by medical planners to augment the requirements for conventional combat as appropriate for the nuclear situation4 ,the tables can be used to prepare estimates of the number of patients at all echelons4 c4 ,after an attack1 the effectiveness and adequacy of the medical support effort during the first #bd hours are critical4 ,commanders should be informed rapidly of the estimated medical load in order to provide rescue and treatment resources or request assistance from higher headquarters1 adjacent units1 or allied units4 ,these estimates should be updated postattack based on aerial or ground reconnaissance and survey4 d4 ,in addition to casualties1 a nuclear weapon detonation can generate an ,,emp that may cause catastrophic failures of electronic equipment components and may adversely affect the capability of all units in the area of the detonation4 ,electromagnetic pulse has no direct effect on personnel and is not further addressed in this publication4 ,d-#e4 ,triage ,since a nuclear detonation may produce mass casualties1 plans for a triage system must be in place4 ,paragraphs #c4d through #c4e of the guide describe patient categories by injury severity and may be used to estimate the number and injury severity of patients for a particular operational scenario4 ,the guide does not1 however1 provide estimates of the number of patients by triage classification4 ,d-#f4 ,evacuation a4 ,an efficient and flexible evacuation plan is absolutely essential for the preservation of life and to retain the mobility of forward medical resources4 ,in a potential mass casualty situation1 the full range of evacuation assets should be considered4 b4 ,the extended hospital time of nuclear casualties will influence levels of evacuation or hospitalization4 ,in addition1 estimates of the different types of casualties can be a consideration in evacuation planning4 ,in planning for evacuation1 estimates provided in the guide can be used as a starting point from which to estimate evacuation resources4 ,d-#g4 ,in-,unit ,care a4 ,some personnel within the military unit may not be classified medically as casualties1 but will require some self-aid and buddy aid4 ,a casualty is defined as anyone entering the medical system4 ,paragraph #b4e of the guide further describes the basis for casualty calculation4 b4 ,nuclear detonations will produce a large number of blast1 burn1 and projectile injuries that initially must be treated by individual soldiers trained in first aid procedures4 ,the physical damage to the surrounding area as a result of a nuclear detonation will increase delays in medical assistance and evacuation4 ,training in self-aid_/buddy aid will improve casualty survival rates and conserve medical resources4 ,the guide can be used to provide a conservative estimate of the numbers of injured that will require first aid4 ,the tables in ,sections #d through #aj of the guide1 showing the status of unit personnel by time period1 can be used to indicate the numbers of personnel who are injured 7but not casualties7 who may require first aid4 ,d-#h4 ,hospital ,bed ,requirements ,the data provided in the guide can be used to determine immediate additional bed requirements resulting from a nuclear detonation4 ,in addition to the numbers of patients who will need beds1 the data provided in the guide can also indicate the increased hospitalization time of nuclear casualties4 ,long-term bed requirements1 greater than #cj days1 are not provided4 ,based on the theater evacuation policy specified for the operation1 the hospital bed days may be in theater or in ,,conus4 ,d-#i4 ,medical ,logistics ,the data provided in the guide can assist in estimating the needed supplies4 ,the supply system must be prepared for increased demands for certain types of medical and general supplies and equipment1 kits1 dressings1 and antibiotics4 ,the treatment of combined injuries will not require any special types of supplies1 although demands for certain types of supplies will increase4 ,d-#aj4 ,medical ,force ,planning ,the assignment of medical support is normally based upon the total military population and the expected conventional casualty rate4 ,the data provided in the guide may be used to assess the requirement for additional medical units4 ,the planning guidance presented in this document can 7and should7 be modified to reflect the needs of the anticipated operation1 including operational tempo1 national_/coalition priorities1 medical resource allotment1 and so forth4 ,when trying to augment personnel1 consider that the use of a nuclear weapon in a tactical situation could be an indication of an increased tempo of warfare4 ,therefore1 even though a unit may be targeted with a nuclear detonation1 that unit may not be the site where the highest numbers of casualties are being produced1 and another unit may have priority of support4 -------------------------------------- ,this ,section ,implements ,,stanag #bdgf4 -------------------------------------- ,section ,,iii4 ,,medical ,,planning ,,guide ,,for ,,the ,,estimation ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,battle ,,casualties 7,,biological7--,a,med,p-#h7;,a71 ,,volume ,,ii ,d-#aa4 ,general ,the guide1 ,a,med,p-#h7;,a71 ,volume ,,ii1 provides estimates of casualties1 and remaining operational strength1 after single ,,bw attacks on tactically deployed1 brigade-sized land force units1 offshore naval and marine forces1 and selected strategic targets in rear areas4 ,these worst-case casualty estimates are for personnel within both the targeted and the downwind hazard areas of the attacked forces4 ,they assume that all affected personnel will be unsheltered and unwarned4 ,to further estimate worst-case outcomes1 the guide assumes that exposed individuals have not been vaccinated against any of the evaluated agents1 nor have they undergone any type of medical prophylactic treatment prior to exposure4 ,the tables included in the guide are designed to show numbers of expected casualties2 expected fatalities2 personnel at different performance levels2 and times after exposure4 ,in selected scenarios1 the guide provides a method for estimating casualties among collocated civilians based on local population density4 a4 ,the guide presents casualty estimates for all possible combinations of the following conditions3 ,eleven operational scenarios4 ,seven biological agents4 ,four types of delivery systems4 ,three attack intensities4 b4 ,the guide is subject to limitations of extent and content4 ,since there are many more possible attack variables than those considered1 the guide presents a limited number of estimates and provisional guidance for estimating cases not modeled4 ,these estimates are based upon the best available medical data1 but such data result in qualified estimates4 ,therefore1 for more authoritative medical descriptions1 medical planners and staff personnel should use ,,fm #h-i1 ,,nato ,handbook on the ,medical ,aspects of ,,nbc ,defensive ,operations1 ,a,med,p-#f7;,b71 ,part ,,ii--,biological4 ,users of the guide must amplify or modify these estimates to meet emergent requirements such as injuries resulting from combined biological and conventional attacks4 c4 ,computer models that integrate available information have been used to predict the effects of future biological attacks4 ,these resultant estimates may include substantial uncertainties when applied to specific situations4 ,however1 they provide the best estimates available to date4 d4 ,the guide is also organized into #aj sections4 ,section #a introduces features of the guide1 and then presents background and medical planning considerations4 ,section #b provides information on the methodology used to develop the estimates4 ,section #c describes how to use the tables presented in the guide4 ,sections #d through #aj of the guide contain tables of casualty estimates1 with one section for each of the seven biological agents4 e4 ,biological attacks are likely to have a significant impact on the medical system4 ,as detailed elsewhere in the guide1 victims may number in the hundreds or even thousands4 ,demand for medical care may quickly overwhelm available resources2 this problem will be exacerbated if medical personnel themselves become victims of the attack4 ,local civilian populations will be victimized as well1 limiting host-nation support and potentially adding to the demands on the military medical system4 f4 ,a variety of medical responses to ,,bw attacks are available1 depending on the agent used and whether medical countermeasures are employed prior to attack or after exposure has already occurred4 ,for many agents1 immunization or pre-exposure prophylaxis with antibiotics may prevent illness in those subsequently exposed4 ,after exposure1 disease can often be prevented or ameliorated via immunization and therapeutic use of antibiotics1 antiviral drugs1 and hyperimmune gammaglobulins4 ,d-#ab4 ,medical ,planning ,considerations a4 ,effective mass casualty management requires careful planning4 ,the guide is designed to support such planning by providing medical planners and staff personnel with a systematic means for estimating the number of biological casualties4 ,however1 casualty management also involves practice of self-aid and buddy aid1 on-site triage and emergency care1 decontamination1 transport to medical facilities1 infection control measures1 communications1 health services1 logistics1 and evacuation by ground or air transportation4 b4 ,medical requirements resulting from attacks with biological agents may be substantially different from those resulting from conventional1 nuclear1 or chemical combat4 ,there would be no indication of the presence of biological agents in most tactical situations4 ,units downwind from an attack area may be unexpectedly exposed to biological agents4 ,in some cases1 there will also be a risk of secondary infection and subsequent epidemics amongst troops and_/or the local population4 ,additionally1 use of biological agents may generate reservoirs within the local animal population that may serve as a further source of infection4 c4 ,often the first indication of an attack with a biological agent will be the development of symptoms in exposed personnel4 ,diagnosis and treatment are complicated by the fact that many of the agent-induced diseases described in the guide begin with symptoms associated with common illnesses1 such as influenza4 ,in such cases1 biological agent attacks may generally be distinguished from naturally occurring epidemics by the sudden onset of disease1 the large number of personnel presenting with similar symptoms1 and the concentration of those personnel in geographically contaminated areas4 ,d-#ac4 ,triage a4 ,since a biological attack may produce mass casualties1 preparations for a triage system should be in place before the attack4 ,paragraph #c4c4h of the guide describes patient categories by illness severity4 ,for a particular described operational scenario1 this information may be used to estimate the number of patients with specified levels of illness4 ,the guide does not provide estimates of the number of patients by triage classification or usual medical descriptions4 b4 ,decontamination of patients must be considered before further evacuation4 ,d-#ad4 ,evacuation a4 ,an efficient and flexible evacuation plan is essential for adequate casualty treatment and to retain mobility of forward medical resources4 ,for an assessment of a potential mass casualty situation1 the medical planner should consider the full range of evacuation assets1 limitations1 and obstacles4 ,after an attack1 the medical staff may need to estimate the number of casualties that could require evacuation at given postexposure times4 b4 ,evacuation requirements will vary with the type of biological agent used4 ,casualties resulting from some agents may not be evacuated because the time course of effects is relatively short4 ,for others1 like botulinum toxin1 casualties may require evacuation to a facility where they can receive care for weeks or even months4 ,estimates provided in the guide can be used as a starting point from which to plan for evacuation resources1 including those required for decontamination of personnel and transportation assets4 ,d-#ae4 ,in-,unit ,care ,the casualty estimates in the guide are presented without allowance for in-unit care4 ,however1 there may be need for rapid intervention4 ,delays in obtaining medical care may occur because of physical damage or contamination of the surrounding area4 ,soldiers trained in first aid procedures may be the first to provide aid to biological agent casualties4 ,the guide provides a conservative estimate of the numbers of exposed personnel who will require first aid4 ,the tables described in paragraphs #c4c4b through #c4c4d of the guide give the time courses of effects that may apply to estimation of in-unit care and delayed medical requirements4 ,d-#af4 ,patient ,bed ,requirements ,bed requirements can be estimated using the tables described in paragraphs #c4c4b through #c4c4d of the guide4 ,the latter type of table is useful after an attack since it shows gains and losses of casualties over time4 ,the type of table described in paragraph #c4c4e of the guide may be more useful for long-range planning4 ,it shows maximum numbers of personnel by illness severity category4 ,the tables in the guide only provide estimates for the first #ce days after attack4 ,based on the theater evacuation policy specified for the operation1 hospital days may be in theater or in the national area4 ,d-#ag4 ,medical ,logistics a4 ,the estimates provided in the guide are intended to support projections of medical materiel and logistical requirements4 ,increased demands may occur for certain types of medical and general supplies1 including equipment1 kits1 antibiotics1 disinfectants1 and other critical medical materiel4 ,demands may also increase for items unique to the prevention and treatment of biological agent casualties1 such as vaccines1 antibiotics1 and antisera1 as well as items adapted to contaminated environments4 ,tables showing maximum numbers of personnel by illness severity category can provide useful input for logistical planning4 b4 ,often the first indication of an attack with a biological agent will be the development of symptoms in exposed personnel4 ,diagnosis and treatment are complicated by the fact that many of the agent-induced diseases described in the guide begin with symptoms associated with common illnesses1 such as influenza4 ,in such cases1 biological agent attacks may generally be distinguished from naturally occurring diseases4 ,d-#ah4 ,medical ,force ,planning a4 ,the assignment of medical support is normally based upon the total military population and the expected conventional casually rate4 ,the guide may be used to assess requirements for additional medical units4 b4 ,although a specific unit may be the target of a biological attack1 more casualties could be suffered by other units downwind4 ,accordingly1 a unit other than the targeted one may have priority for support4 ,the tables presented in the guide can be used in planning for either situation4 ,some tables show estimated maximum numbers of personnel by illness severity category4 ,such estimates should be combined with a comprehensive array of other available information to increase the effectiveness of medical force planning4 -------------------------------------- ,this ,section ,implements ,,stanag #bdgg4 -------------------------------------- ,section ,,iv4 ,,medical ,,planning ,,guide ,,for ,,the ,,estimation ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,battle ,,casualties 7,,chemical7--,a,med,p-#h7;,a71 ,,volume ,,iii ,d-#ai4 ,general a4 ,the primary purpose of ,volume ,,iii is to assist medical planners1 logisticians1 and staff officers in predicting ,,cw contingency requirements4 ,requirements include medical personnel1 medical materiel stockpiles1 patient transport or evacuation capabilities1 and facilities needed for patient decontamination1 triage1 treatment1 and supportive care4 ,an optional purpose is to support medical operational estimates4 b4 ,the guide provides medical worst-case estimates of casualties and remaining operational strength after a single ,,cw attack on a tactically deployed1 brigade-sized land force units1 with protection available and protection unavailable4 ,these worst-case casually estimates are for personnel located within both the targeted and the downwind hazard areas of the brigade4 ,it is assumed that all targeted personnel will be unsheltered and without medical pre-exposure prophylactic treatment4 ,tables in the guide are designed to show total numbers of-- ,casualties with different types and severities of injury at various times after exposure4 ,personnel at different performance levels and times after exposure4 ,fatalities at specified times after exposure4 c4 ,the guide presents estimates of personnel status at specific time points4 ,these range from #a to #c hours to #g to #cj days after an attack1 depending on the type of agent considered4 ,such estimates are projected from all possible combinations of the following conditions3 ,seven operational scenarios involving three types of units3 heavy brigade1 support brigade1 and light infantry brigade4 ,three chemical agents3 the nerve agents ,,gb and ,,vx1 and the blister agent ,,hd4 ,three types of munitions delivering the agents3 aerial bombs1 tactical ballistic missiles1 and rounds from multiple launch rocket systems_/artillery batteries-- ,three attack intensities for each type of munition3 light1 moderate1 and heavy4 ,two postures of individual physical protection against the attacks3 unavailable and available4 d4 ,an index to essential information and four sample problems to illustrate use of this information are at the end of the guide 7see ,section #aa74 ,section #aa provides a planning guide overview1 describes applications1 and presents a brief explanation of modeling methods used to prepare estimates4 e4 ,the guide is subject to limitations of extent and content4 ,since there are many more possible attack variables than those considered1 the guide presents a limited number of estimates4 ,these estimates are based upon the best available toxicological values1 but such values are qualified estimates4 ,therefore1 medical planners and staff personnel should use ,,fm #h-i1 ,,nato ,handbook on the ,medical ,aspects of ,,nbc ,defensive ,operations1 ,a,med,p-#f 7,b71 ,part ,,iii--,chemical1 for more authoritative medical descriptions and information on effects of longer duration4 f4 ,the guide is most value to the user who needs to know what kinds of casualties to expect1 relative numbers of each1 and the time frames in which they are likely to appear4 ,to assist the user1 who lacks experience in actual ,,cw1 the guide describes types of injury1 relevant factors1 general magnitudes of effects1 and effects of time courses on chemical casualty numbers4 ,the casualty estimates are appropriate for training exercises4 ,however1 this initial attempt to provide complex estimates has limitations for battlefield use4 ,the limitations are described as follows3 ,the guide provides estimates for a few of many possible chemical attacks4 ,each estimate is based upon computer modeling of the consequences of specified conditions4 ,this is like saying that the numbers of men who sneeze1 after inhaling an allergic flower pollen1 might be predicted if specific information 7,,example3 ,the wind speed and direction1 the current weather1 altitude1 time of day1 and sites of concentrated flower growth7 is known for the specific geographic location of a particular brigade on a given mountain4 ,if such estimates are made for a few widely different mountains1 a user of the estimates may be able to guess the numbers of sneezing men in his own brigade1 located on a separate mountain4 ,however1 if the conditions on both mountains are not nearly identical1 the user will need to estimate a scaling factor and apply it to adjust the number predicted for a different environment4 ,it is unlikely that exactly identical conditions will exist for any two mountains or chemical attacks4 ,the user of the guide must decide which scenario best represents his conditions 7or interpolate from two scenarios71 then use or adjust the estimates4 ,therefore1 each user must recognize any differences from modeled conditions that might require him to increase1 or decrease1 an estimate4 ,the user may need to apply a commander's guidance on acceptable risk levels1 or consider restrictions of available resources1 before accepting1 interpreting1 or modifying the relevant planning guide numbers4 ,the most difficult problem for the user will be to determine how much to increase1 or decrease1 planning guide numbers to fit the user's situation4 ,this problem is discussed in paragraph #c4d of the guide4 ,the user should be aware that medical worst-case targeting selects for maximal numbers of survivors entering the medical system1 not for maximal operational losses4 ,the tabulated estimates are very highly sensitive to the degree of clustering of personnel and their assumed location within a standardized brigade area4 ,accordingly1 use of this targeting method leads to large variations that are based upon the probabilities of hitting clustered personnel1 not evenly or widely distributed personnel4 ,therefore1 these estimates do not provide a good basis for estimating the most likely outcomes for a series of average attacks1 or for comparing a scenario with an actual attack4 ,although the tabular format of the guide suggests that the listed numbers are exact1 the user should understand that different targeting could readily produce other numbers4 ,selection of a scaling factor ,is discussed in paragraph #c4d of the guide4 ,d-#bj4 ,medical ,planning ,considerations a4 ,the guide provides medical planners and staff personnel with a systematic means for estimating chemical casualties in various-sized units1 without regard to composition4 ,this document provides more accurate and detailed estimates and is based upon detailed operational scenarios for brigade-sized units4 ,both chemical planning guides support estimates of combat performance from individuals remaining in the unit4 b4 ,effective mass casualty management requires careful planning4 ,the guide is designed to support such planning by providing medical planners and staff personnel with a systematic means for estimating the number1 type1 and time-related status of chemical casualties4 ,,note ,each user is advised to consult any available national military ,,nbc defense doctrinal publications of similar nature4 c4 ,medical requirements during ,,cw may be substantially different from those for the usual combat situation4 ,there may be no indication of the presence of chemical agents in some tactical situations4 ,unprotected units downwind from an attack area1 or those entering contaminated areas in an unprotected posture1 may be unexpectedly exposed to chemical agents4 ,however1 casualty management also involves practice of self-aid and buddy aid1 on-site medical triage and emergency care1 transport to medical facilities1 communications1 health services1 logistics1 and evacuation by ground or air transportation4 d4 ,the signs and symptoms of chemical agent exposure may be sudden and intense1 or delayed and subtle1 depending on the agent used and the level of exposure4 ,individuals may not reach the first level of care for #ae to #fj minutes after the onset of effects4 ,decontamination may delay medical treatment4 ,stabilization should occur before casualties leave emergency care areas1 but contamination of these areas may delay the stabilization process4 ,however1 effects of decontamination or secondary contamination on estimated doses and effects are not considered in the guide4 ,for medical planning1 users of the guide need to consider the various qualifications of its casualty estimates1 as discussed in paragraphs #c4d and #c4d4b of the guide4 e4 ,a chemical burn caused by ,,hd can require more care than a same-sized burn induced by conventional munitions4 ,therefore1 the initial prognosis may require revision after treatment is underway1 and estimates of percent capable by performance band may require adjustment4 ,d-#ba4 ,triage ,since a chemical attack may produce mass casualties1 preparations for a triage system should be in place before the attack4 ,paragraph #b4e4a of the guide describes patient categories by injury severity4 ,for a particular described operational scenario1 this information may be used to estimate the number of patients with specified levels of injury4 ,the guide does not provide estimates of the number of patients by triage classification or usual medical and toxicological descriptions4 ,d-#bb4 ,evacuation a4 ,an efficient and flexible evacuation plan is essential for adequate casualty treatment and to retain mobility of forward medical resources4 ,for assessment of a potential mass casualty situation1 the full range of evacuation assets1 limitations1 and obstacles should be considered by the medical planner4 ,after an attack1 the medical staff may need to estimate the number of casualties that require evacuation resources at given postexposure times4 b4 ,evacuation requirements will vary with the type of chemical agent used4 ,nerve agent casualties may not be evacuated because the time course of severe effects is relatively short4 ,depending upon exposure conditions1 ,,hd casualties may or may not require evacuation to a facility where they can receive care for several days1 or possibly #f to #i months4 ,estimates provided in the guide can be used as a starting point from which to plan for evacuation resources4 ,d-#bc4 ,in-,unit ,care ,the casualty estimates in the guide are presented with no allowance for in-unit care such as self-aid or buddy aid4 ,soldiers trained in first aid procedures may be the first to see chemical injuries4 ,the guide can provide an estimate of the numbers of injured personnel who will require first aid4 ,however1 there may be need for rapid augmentation1 support1 or other intervention4 ,delays in obtaining medical care may occur because of physical damage or contamination of the surrounding area4 ,the tables described in paragraphs #c4c4b and #c4c4c of the guide give the time courses of effects that may apply to estimation of in-unit and delayed medical requirements4 ,d-#bd4 ,patient ,bed ,requirements ,requirements for patient beds and hospitalization time may be greater after chemical exposures than after a conventional attack4 ,such increases are particularly important for agents1 such as ,,hd1 that produce injuries followed by a long recovery period4 ,bed requirements can be estimated using the tables described in paragraphs #c4c4b and #c4c4c of the guide4 ,casualties ,occurring by ,time ,period tables 7see paragraph #c4c4c7 in the guide are useful after an attack since they show gains and losses of casualties over time4 ,personnel by ,injury ,category tables 7as described in paragraph #c4c4d7 in the guide may be more useful in long-range planning4 ,they show maximum numbers of personnel by injury severity category4 ,the tables in the guide only provide estimates for the first #cj days after attack4 ,depending upon the theater evacuation policy specified for the operation1 hospital days may be either in theater or in the national area4 ,d-#be4 ,medical ,logistics ,the estimates provided in the guide are intended to support projections of medical materiel and logistical requirements4 ,increased demands may occur for certain types of medical and general supplies4 ,these may include specific equipment1 kits1 dressings1 antibiotics1 and other critical medical materiel4 ,demands may also increase for items unique to the chemical battlefield 7such as nerve agent antidote autoinjectors71 as well as items adapted to chemical environments 7including ,,iv systems and special self-contained intensive care units74 ,tables showing maximum numbers of personnel by injury severity category 7see paragraph #c4c4d in the guide7 can provide useful input for logistical planning4 ,d-#bf4 ,medical ,force ,planning a4 ,the assignment of medical support is normally based upon the total military population and the expected conventional casualty rate4 ,the guide may be used to assess requirements for additional medical units4 ,the use of chemical weapons in tactical situations could be one indication of an increased tempo of warfare and need for additional personnel4 b4 ,although a unit may be targeted for chemical attack1 that unit might not be located where the highest number of casualties could occur 7as in a downwind hazard area74 ,accordingly1 another unit might have priority for support4 ,the tables presented in the guide can be used in planning for either situation4 ,some tables 7see paragraph #c4c4d in the guide7 show estimated maximum numbers of personnel by injury severity category4 ,such estimates should be combined with a comprehensive array of other available information to increase the effectiveness of medical force planning4 c4 ,the guide is organized into #aa sections4 ,section #a introduces the guide and presents background and medical planning considerations4 ,section #b provides information on the methodology used to develop the estimates of fatalities1 casualties1 and effectiveness of individuals remaining in the unit4 ,section #c explores the use of the casualty prediction tables based on combat effectiveness decrements and estimates of the number of casualties categorized by insult level4 ,sections #d through #aj contain tables of casualty estimates4 ,section #aa is a tutorial on use of the tool4 d4 ,these medical worst-case casualty estimates 7see paragraph #b4a4b through #b4a4g in the guide7 are for personnel in the chemical-targeted and downwind hazard areas of the brigade sector4 ,the actual areas presenting chemical agent hazards to personnel are relatively small and localized when compared to the entire brigade sector4 ,these estimates are not valid for acute effects from repeated exposures1 possible delayed effects of low dosage exposures1 operational worst-case targeting1 targets with different numbers or distributions of exposed personnel1 or attacks involving different conditions 7of meteorology1 terrain1 protective status1 and so forth7 than are modeled4 ,although the guide is primarily designed to support medical force planning for future ,,cw defense1 it may be used to anticipate short-term requirements4 ,for example1 delayed requirements of ,,hd victims for care or evacuation resources may be predicted from tables that give estimates of casually numbers by injury type at given times after a ,,cw attack 7see paragraphs #c4c4b and #c4c4c in the guide74 ,,appendix ,e ,example ,x-1 ,,annex1 ,,to ,,hss ,,plan_/,,operation ,,order1 ,,medical ,,nbc ,,staff ,,officer ,,planning ,,for ,,hss ,,in ,,an ,,nbc ,,environment #a4 ,,purpose4 ,establish standardized procedures for medical ,,nbc staff officers planning1 preparing for1 detecting1 reporting1 and providing preventive_/protective measures for ,,nbc_/,,tim hazards4 ,establish planning procedures for conducting ,,hss in ,,nbc_/,,tim environments4 ,also1 establish procedures for providing technical guidance_/support to leadership before1 during1 and after an ,,nbc_/,,tim event4 #b4 ,,procedures a4 ,medical ,,nbc staff officers prepare list of equipment and procedural guidelines for ,,hss operations under ,,nbc_/,,tim conditions4 7,provide a list of radiological detection devices1 chemical agent detection_/identification kits_/devices1 components of biological sample_/specimen collection1 and shipping containers4 ,provide guidelines_/references for operating detection_/identification devices47 b4 ,planning actions for use before an ,,nbc_/,,tim event4 7,provide preventive_/protective measures that the leadership can employ to reduce the health effects of a ,,nbc_/,,tim event4 ,also1 provide preventive_/protective measures that leadership can employ to reduce the health effects of existing ,,nbc_/,,tim hazards_/contamination in an ,,ao4 ,provide ,,hss leadership with procedures that can be employed to protect their unit and patients47 c4 ,planning action for use during an ,,nbc_/,,tim event4 7,provide preventive_/protective measures that the leadership can employ to reduce the health effects of a ,,nbc_/,,tim event4 ,provide ,,hss leadership with procedures that can be employed to protect their unit and patients47 d4 ,planning actions for use after an ,,nbc_/,,tim event4 7,provide preventive_/protective measures that line leadership can employ to reduce_/mitigate the health effects of an ,,nbc_/,,tim event on the force4 ,provide ,,hss leadership with procedure that can be employed to mitigate the effects on their unit and patients47 e4 ,planning actions for preventive medicine support for ,,nbc_/,,tim events4 7,provide types and numbers of ,,pvntmed units_/personnel required to perform ,,pvntmed missions during such events4 ,describe mission requirements for units_/personnel preparing for and reacting to the event4 ,describe types of samples required and how samples must be collected1 preserved1 packaged1 and shipped to supporting medical laboratory for analysis4 ,describe detection_/monitoring equipment required for the event2 such as ,,an_/,,pdr#gg1 ,,an_/,,vdr#b radiac meter1 chemical agent monitor 7,,cam71 and ,m#bgb water test kit47 f4 ,planning actions for veterinary support for ,,nbc_/,,tim events4 7,provide types and numbers of veterinary units_/personnel required to perform the veterinary service missions during such events4 ,describe mission requirements for units_/personnel preparing for and reacting to the event4 ,describe types of samples_/specimens required and how samples_/specimens must be collected1 preserved1 packaged1 and shipped to supporting medical laboratory for analysis4 ,describe food contamination and decontamination procedures4 ,describe detection_/monitoring equipment required for the event2 such as ,,an_/,,pdr#gg1 ,,an_/ ,,vdr#b radiac meter1 and ,,cam47 g4 ,planning actions for medical laboratory support for ,,nbc_/,,tim events4 7,provide requirements for medical laboratory support for an ,,nbc_/,,tim event4 ,describe types of laboratory test_/ procedures required to provide command verification on the use of an ,,nbc device_/weapon4 ,provide medical laboratory reporting requirements2 example3 provide report to command surgeon2 ,joint ,task ,force_/theater commander2 senior commander in affected operational area47 h4 ,planning actions for combat health logistics support for ,,nbc_/,,tim events4 7,provide requirements for combat health logistics support units and personnel4 ,describe types of ,class ,,viii supplies required to support ,,hss response to an event4 ,examples3 ,numbers of chemical agent patient decontamination ,m,e,ss1 chemical agent patient treatment sets1 number of packets of chemical agent pretreatment tablets required1 and chemoprophylaxis required for personnel exposed to a biological agent47 i4 ,planning actions for combat stress control_/mental health support for ,,nbc_/,,tim events4 7,provide requirements for ,,cosc_/mental health support units_/personnel4 ,describe where and how ,,cosc_/ mental health personnel will provide their support in response to the event47 j4 ,planning for medical treatment of ,,nbc_/,,tim event casualties4 7,provide requirements for medical evacuation and treatment 7including emergency dental care7 support units_/personnel4 ,provide requirements for nonmedical personnel to perform patient decontamination at the ,,mtf4 ,describe where and how evacuation and treatment personnel will provide their support in response to include supervision of patient decontamination procedures47 #c4 ,,coordination ,,requirements4 7,provide requirements for support such as who should transport_/escort samples_/specimens from unit of origin to support medical laboratory and on to the ,,conus gold standard laboratory4 ,example3 ,the ,technical ,escort ,unit normally provides transportation and escort for suspect ,,nbc samples1 in their absence describe who will provide this service4 ,provide requirements for numbers of personnel required to perform patient decontamination at supporting ,m,t,fs4 ,describe decontamination support requirements for medical units2 especially hospitals and major combat health logistics facilities47 #d4 ,,reports4 7,describe types of reports required and frequency of reporting on ,,hss aspects of ,,nbc_/,,tim events4 ,reports should provide1 at a minimum1 aspects of event and recommended preventive_/ protective actions needed to prevent or minimize casualties47 ,,appendix ,f ,,employment ,,of ,,chemical ,,and ,,biological ,,collective ,,protection ,,shelter ,,systems ,,by ,,medical ,,units ,section ,i4 ,,introduction ,f-#a4 ,general ,to continue the ,,hss mission under ,,cb conditions1 ,m,t,fs must search out contamination free areas or employ ,,cps systems4 ,levels ,i and ,,ii ,m,t,fs may be able to locate contamination free areas2 however1 due to the mobility limitations of hospitals1 they must always be prepared to operate under ,,cb conditions if the area is under attack4 ,systems that can be employed as an ,,mtf 7,levels ,i1 ,,ii1 ,,iii1 and ,,iv7 are described in this appendix4 ,f-#b4 ,types of ,collective ,protection ,shelter ,systems a4 ,the ,,cbps system is employed at the ,,bas1 ,,dcs1 and ,,fst4 ,the ,,cbps is attached to the hard-walled box on the rear of a high mobility multi-purpose wheeled vehicle 7,,hmmwv74 ,the ,,bas will have one ,,cbps system per treatment team2 the ,,dcs will have four ,,cbps systems2 the ,,fst will have three ,,cbps systems4 ,also1 systems will be issued to other selected medical treatment teams4 ,when employed at the ,,dcs1 the patient holding team will also require ,,gp tents to hold their required number of patients 7see ,chapter #d74 ,patients held inside the ,,cbps will be those that have been decontaminated and admitted into the system for treatment and are recovering from the treatment procedures and are awaiting evacuation4 ,any patients held in the ,,gp tent must remain in ,,mopp ,level #d 7the ,,gp tent will not have collective protection72 these patients are those that are expected to ,,rtd within #gb hours4 ,,notes #a4 ,normally1 patients will not be held at the ,,dcs under ,,nbc conditions unless evacuation cannot be accomplished4 ,they should be ,,rtd or evacuated to a clean ,,mtf1 as soon as the mission permits4 #b4 ,the ,,cbps can also be employed as the ,,dcs in the conventional mode4 ,employment in either mode still requires ,,gp tentage for patient holding to meet total patient holding requirements4 b4 ,the ,,depmeds-equipped patient care areas of the ,,us ,army ,force ,,xxi hospital and the hospital unit base 7,,hub7 of the ,medical ,force #bjjj 7,,mf#b,k7 will employ the ,,cp ,,depmeds4 ,it will not protect personnel or patients from the thermal1 blast1 and initial radiation effects of nuclear weapons2 however1 it will provide some protection against fallout effects4 ,areas of the hospital that are not included in the chemically protected 7,,cp7 ,,depmeds are ,,mf#b,k general hospital unit medical 7,,hum71 ,,mf#b,k field hospital unit holding 7,,huh71 ,,mf#b,k combat support and general hospital unit surgical 7,,hus71 minimum care wards1 administrative areas1 food service1 supply 7including ,class ,,viii71 and staff quarters4 ,the system includes-- ,chemically_/biologically protected liners for tent1 expandable1 modular1 personnel 7,,temper7 and passageways4 ,,cb-filtered and conditioned 7heated or cooled7 air 7field deployable environmental control unit ,,fdecu or ,h#hj ,army ,standard ,heater74 ,chemically_/biologically protected ambulatory1 litter1 and supply air locks4 ,chemically_/biologically protected latrines4 ,chemically_/biologically protected seals for ,,iso shelters4 ,chemically_/biologically protected water supply system4 c4 ,the ,m#bj simplified collective protection system is another system that is available4 ,it consists of a chemically protected room liner1 a ,,cb filter blower1 and an ambulatory air lock4 ,however1 it does not have a litter air lock making it unsuitable for litter patient care4 ,the ,m#bj may be used to protect medical staffs at the ,,dcs1 ,,fst1 and hospitals1 patients held in the ,,gp tents at the ,,dcs and in the minimum care wards and staff quarters of the hospitals4 ,thus providing additional ,,cb protection for staffs and patients4 ,section ,,ii4 ,,employment ,,of ,,the ,,chemically ,,biologically ,,protected ,,shelter ,,system ,f-#c4 ,establish a ,battalion ,aid ,station in a ,chemically ,biologically ,protected ,shelter ,to establish a ,,bas in a ,,cbps1 use one ,,cbps per treatment team for conventional operations in a split-team mode4 ,when operating in a squad configuration and in the conventional mode1 the two ,,cbps systems may be complexed to provide more workspace4 ,however1 keep in mind that the treatment squad is not staffed to operate the two systems in the ,,cb mode4 ,therefore1 when the two systems are complexed and the treatment squad must convert and operate in the ,,cb mode1 they may want to close the complexing door and only use one system4 ,when initially setting up the ,,cbps for operations in the ,,cb mode1 only one ,,cbps is setup2 see ,note #b below4 ,set up the system as described in ,,tm #aj-edaj-bbh-aj4 ,to be operational as a ,,bas1 set up medical supplies and equipment as required or as designated in the ,,tsop4 ,a ,,pds consisting of a contaminated ambulance point1 contaminated triage point1 a patient decontamination area1 and a contaminated treatment area is established on the downwind 7prevailing wind7 side of the ,,cbps4 ,an overhead cover of plastic sheeting 7approximately #bj feet wide by #ej feet long7 is set up over the ,,pds1 the hot line1 and the clean treatment_/waiting area2 the cover overlaps the air locks4 ,the clean treatment_/waiting area should have an area at least #bj feet wide by #ae feet long to allow space for placing patients into the litter air lock without crossing the hot line4 ,a second area covered with #bj #be feet of plastic sheeting 7the evacuation holding area7 is set up beside the shelter on the opposite side from the generator4 ,the clean treatment area is separated from the decontamination area by a hot line with a shuffle pit4 ,only clean 7decontaminated7 patients or personnel are allowed to cross the hot line into the clean treatment area1 or are admitted into the ,,cbps4 ,figure ,f-#a presents one layout of a ,,bas using the ,,cbps4 ,see ,,tm #aj-edaj-bbh-aj for complete details on setting up1 operating1 and maintaining the ,,cbps4 ,each ,,cbps provides #cjj square feet of work area4 ,,notes #a4 ,the overhead cover is not needed when the wind speed exceeds #aj knots per hour4 ,the plastic will not stay in place4 #b4 ,although each treatment team of the ,,bas has a ,,cbps2 only one system is set up when operating in the ,,cb mode4 ,this is due to the lack of authorized personnel to operate all systems at one time in the ,,cb mode4 ,eight medical personnel are required to operate the ,,bas 7employing one ,,cbps7 in the ,,cb mode4 ,at least eight nonmedical personnel are required to perform patient decontamination under medical supervision4 ,also1 only setting up one system in the ,,cb mode provides the ,,bas the ability to retain its flexibility in order to maintain its support mission of being where it is needed and when it is needed4 ,the ,,cbps can be used as the treatment shelter in the conventional mode as well4 ,when the treatment squad is operating in the split-team mode1 each team will have a ,,cbps for use as its treatment shelter4 ,when operating one system in the ,,cb mode1 the other system provides a replacement in the event the one in use in the ,,cb mode is damaged beyond repair4 ,this ensures continued ,,hss to the command4 ,illustration3 ,figure ,f-#a4 ,battalion aid station using the chemically biologically protected shelter4 ,f-#d4 ,division ,clearing ,station in a ,chemically ,biologically ,protected ,shelter ,to establish a ,,dcs using the ,,cbps1 set up four shelters as described in the ,,tm4 ,to be operational1 medical supplies and equipment are set up as outlined in the unit ,,tsop4 ,the four shelters are complexed as shown in ,figure ,f-#b4 ,with four ,,cbps systems set up and operational1 a total of #a1bjj square feet of work area is available4 ,the contaminated triage1 decontamination1 and contaminated treatment areas are separated from the clean treatment_/waiting area by a hot line with a shuffle pit4 ,overhead covering is provided as described for the ,,bas4 ,patients are admitted through the ,,emt litter or ambulatory air lock4 ,patients are released through the patient holding air locks4 ,this aids in controlling entry and exits2 thus preventing the introduction of contamination into the systems4 ,at least eight nonmedical personnel from supported units are required to perform patient decontamination under medical supervision at the ,,dcs4 ,,note ,in the event that the overpressure system fails on a system that is in use with entry_/exit air locks1 move to the available shelter with an entry_/exit air lock in the same direction for use as the entry_/exit until the failed system can be restored4 ,example #a3 ,at the ,,dcs the ,,emt system fails1 move to the ,,atm shelter to receive patients until the ,,emt system has been restored4 ,example #b3 ,at the ,,dcs the patient hold system fails1 move exits to the dental_/lab_/x-ray shelter until the patient hold system can be restored4 ,example #c3 ,at the ,,fst the postoperative system fails1 use the preoperative shelter until the postoperative system can be restored4 ,these options will allow patient care operations to continue until the failed systems can be restored4 ,illustration3 ,figure ,f-#b4 ,chemically biologically protected shelter configuration as a division clearing station4 ,f-#e4 ,forward ,surgical ,team in a ,chemically ,biologically ,protected ,shelter ,to establish a ,,fst using the ,c,b,p,ss1 follow the procedures for the ,,dcs except set up three ,c,b,p,ss4 ,all equipment is set up inside the ,,cbps as required by your unit ,,tsop4 ,with three ,c,b,p,ss set up and operational1 a total of #ijj square feet of work area is available 7,figure ,f-#c74 ,when the ,,fst is forward in support of a medical company and operating in the ,,cb mode1 the ,,fst systems are connected to the ,,dcs of the supported medical company4 ,figure ,f-#d shows the ,,fst and ,,dcs connected4 ,when operating in the ,,cb mode with the medical company1 all patients are received through the ,,emt air lock of the ,,dcs4 ,the patients are triaged in the ,,dcs and1 based upon their injuries1 they are routed to the ,,dcs treatment area or to the ,,fst for surgical care4 ,patients released from the ,,fst for evacuation are placed in a ,,ppw and processed through the litter air lock in the ,,fst recovery section4 ,patient decontamination is performed at the ,,pds operated by the ,,dcs4 ,the ,,fst cannot operate in a ,,cb environment without being complexed with the ,,dcs4 ,they do not have any patient decontamination capabilities4 ,illustration3 ,figure ,f-#c4 ,forward surgical team configuration for operations in conventional mode4 ,illustration3 ,figure ,f-#d4 ,forward surgical team and division clearing station configuration for operations in a nuclear1 biological1 chemical environment4 ,section ,,iii4 ,,employment ,,of ,,the ,,chemically ,,protected ,,deployable ,,medical ,,systems ,,and ,,simplified ,,collective ,,protection ,,systems ,f-#f4 ,collective ,protection in a ,deployable ,medical ,system-,equipped ,hospital a4 ,when the threat of ,,nbc action is anticipated in the ,,ao1 the ,,cp ,,depmeds components must be set up as the hospital is being established4 ,the system cannot be set up in a hospital that has already been established2 to do so requires the hospital to be closed1 all ,t,e,m,p,e,rs be struck1 and erected with the ,m#bh liners installed during the erection process4 ,to establish ,,cps in a ,,depmeds-equipped hospital1 follow the procedures as described in ,,tm #aj-edaj-bhc-ad,p4 ,training ,circular #h-ac provides instructions on establishing a ,,us ,army ,,depmeds-equipped hospital 7without ,,cps74 ,figure ,f-#e presents one layout of the ,,depmeds-equipped patient care area of a ,,mf#b,k ,,csh ,,hub employing the ,,cp ,,depmeds with an internal water supply system4 ,figure ,f-#f presents a layout of the patient care area of the ,,depmeds-equipped portion of an #hd-;bed ,,mri hospital4 ,figure ,f-#g presents a layout of the patient care area of the ,,depmeds-equipped portion of a #afd-;bed ,,mri hospital4 b4 ,when employing ,,cp ,,depmeds1 provisions for waste disposal and protected water and food supplies within the system are established4 ,additionally1 ,class ,,viii supplies must be protected from contamination4 ,supplies not in use or needed in the protected operational areas are stored in medical chests1 shipping containers1 or wrapped in layers of plastic that are inside covered areas1 such as closed ,m,i,l,v,a,ns or tents4 ,when contamination is present1 only open these storage areas for operational area emergency resupply4 ,use plastic sheeting or other leak-proof material to provide an additional barrier between the supplies and the contamination4 ,wrap supplies in plastic or other barrier material for movement from the storage area to the resupply air lock of the ,,cp ,,depmeds4 ,a water supply system with distribution hoses is established inside the ,,cp ,,depmeds areas 7,figure ,f-#e74 ,pumps continuously circulate the water from the storage tank through the hose system back to the storage tank4 ,the continuous circulation ensures that the chlorine residual is maintained in the water supply4 ,personnel in areas that are not included in the continuous flow system must draw water from the system and carry it to their work areas in #e-;gallon water cans or other containers4 ,water resupply is accomplished by passing a hose through the utility port at the end of the ,,temper and ,m#bh liner for a connection to the water transport vehicle4 ,the ends of both hoses must be decontaminated with a #e percent chlorine solution before connecting them together4 ,the vehicle must have a tank or water supply container that is ,,nbc protected to ensure that the water supplied is free of ,,nbc contamination4 ,rations1 as determined by the hospital commander1 should be available within the protected area for personnel and patients4 ,under emergency conditions the commander can authorize feeding patients ,,mre rations for limited periods of time 7up to #gb hours71 if they are able to chew and swallow4 ,however1 attempts must be made to ensure the required types of rations for patient feeding are available in the ,,cps4 ,the rations can be stored in any available space2 however1 the rations must be protected from exposure to possible contaminants1 especially liquids4 ,ration control measures are established to ensure that the rations are only consumed as provided for in the hospital ,,tsop4 ,two ,,cb protected latrine systems are included in the ,,cp ,,depmeds4 ,the latrines contain bedpan wash areas4 ,the waste from the latrines is collected in an outside receiving container4 ,the waste is removed from the container and disposed of as outlined in the unit ,,tsop4 ,solid waste 7including medical7 must be placed in plastic bags4 ,seal the top of the bags to prevent spillage1 odors1 or spread of infections_/disease4 ,,never overfill the bags2 always leave enough room in the bag to make a good seal4 ,place the sealed bags in the supply air lock4 ,inside personnel close the inner door to the air lock4 ,outside personnel check to ensure that the inner air lock door is closed before opening the outside door4 ,remove the bags and take them to the designated waste collection_/disposal site4 ,disposal may be by burial on site or by transport to a designated disposal facility4 ,transport may be by organic vehicles or contractor support vehicles4 ,the specific technique for disposal will be outlined in the unit ,,tsop4 ,all liquid waste produced within the ,,cp ,,depmeds is collected through a piped liquid waste system to a central collection container4 ,the waste container for the latrines may be used to collect the liquid waste from the operational areas of the ,,cp ,,depmeds4 ,the container is emptied and the waste disposed of as outlined in the unit ,,tsop4 ,illustration3 ,figure ,f-#e4 ,sample layout of a medical force #bjjj combat support hospital unit base employing chemically protected deployable medical system4 ,illustration3 ,figure ,f-#f4 ,sample layout of an #hd-;bed medical reengineering initiative hospital employing chemically protected deployable medical system4 ,illustration3 ,figure ,f-#g4 ,sample layout of a #afd-;bed medical reengineering hospital employing chemically protected deployable medical system4 ,f-#g4 ,chemically_/,biologically ,protecting the ,international ,organization for ,standardization ,shelter ,to chemically_/biologically protect the ,,iso shelters1 seal all seams and openings of the ,,iso to prevent the entry of ,,cb agents4 ,the seals connecting the various sides and floor of the shelter may be a ,,cb protected material2 thus providing a seal to the shelter4 ,when the seals are not of a ,,cb protected material1 the seams must be taped to provide a ,,cb protected barrier over the soft seals4 ,any openings not being used for introduction of support power lines1 water lines or waste water lines must be sealed to prevent entry of ,,cb agents4 ,all access panels must be securely closed to prevent entry of vapors4 ,f-#h4 ,chemically_/,biologically ,protecting the ,vestibules ,the vestibules connect ,t,e,m,p,e,rs to ,t,e,m,p,e,rs1 ,i,s,os to ,i,s,os1 and ,i,s,os and ,t,e,m,p,e,rs4 ,to harden the vestibules1 install the ,,cb liners inside and fasten the ends to the liners of the ,,temper or to the doors of the ,i,s,os4 ,vestibule liner connectors are provided for use at the entry of each ,,iso4 ,f-#i4 ,chemically_/,biologically ,protecting ,air ,handler ,equipment a4 ,the ,,fdecu is chemically_/biologically protected4 ,the system can be operated without the ,,cb filters4 ,when required to operate in the ,,cb mode1 the fresh air intake on the ,,fdecu is closed and the ,,cb filter blower is turned on drawing fresh air through the filters to support the ,,fdecu and to provide clean air for the ,,cps4 ,additionally1 recirculation filters are placed within the shelter system to remove any agent that may have entered through any of the entry_/exit areas or through breaches in the shelter system4 b4 ,when heaters are required1 they must be chemically_/biologically protected to prevent entry of contamination4 ,the ,,cb filter units are connected to the fresh air intake side of the heater and the heated air discharge side of the heater is connected to the air supply of the ,,temper_/,,iso4 ,f-#aj4 ,establish ,collective ,protection ,shelter ,using the ,m#bj ,simplified ,collective ,protection ,system ,the ,m#bj is used to establish a ,,cps within a room of opportunity1 or inside a tent2 however1 the available space will be limited by tent poles and other components of the tent4 ,currently this system only provides ambient temperature air4 ,see the ,,tm and manufacturer's publication provided with the system and system components for details4 ,,note ,the ,m#bj does not have a litter air lock4 ,only staff or ambulatory patients can enter4 ,see the ,,tm provided with the system for setup procedures4 ,f-#aa4 ,casualty ,decontamination ,patients admitted into the ,,mtf must be contamination free4 ,therefore1 a casualty decontamination area must be established near the ,,mtf4 ,the casualty decontamination area should be provided with an overhead cover as described for the ,,cbps system1 except that it does not overlap the entry to the hospital4 ,also1 consideration must be given to the location of other operations at the hospital site when establishing the casualty decontamination area4 ,however1 the area must be close enough to the entry_/exit of the ,,cps to protect the patients from the environment and reduce their exposure to recontamination4 ,keep in mind that under ,,nbc conditions personnel outside of the ,,cps are at ,,mopp ,level #d 7except decontaminated patients2 they have their mask on71 thus increasing the stress load and reducing their overall performance capabilities4 ,the entry_/exit area must have overhead cover to protect patients awaiting access to the ,,cps4 ,see ,appendix ,i for setting up a casualty decontamination area and for decontamination procedures4 ,section ,,iv4 ,,operations1 ,,entry1 ,,and ,,exit ,,guidelines ,f-#ab4 ,operations ,these operations1 entry1 and exit guidelines may be used to prepare a unit ,,sop for the operation of ,,cps systems in your unit4 a4 ,when using these guidelines1 the following should be considered3 ,location of the shelter 7flat1 hilly1 rocky ground74 ,general climate of the ,,ao 7high and low temperature variations during operation74 b4 ,information on setting up1 striking1 and operating the ,,cps is contained in the equipment publications4 ,where applicable1 special procedures are provided in these publications for setting up in both clean and ,,cb vapor hazard areas4 ,however1 the ,,cp ,,depmeds is ,,not set up in a ,,cb vapor hazard area4 ,the commander will determine which procedures to use4 c4 ,during operations1 periodic checks are made of the atmosphere within the shelter4 ,these checks are made by using available chemical agent detection equipment and material to determine if chemical agent penetration has occurred4 ,should chemical agent penetration occur1 all personnel must mask2 then ensure that patients are protected until the agent has been purged from the shelter4 ,f-#ac4 ,decontamination of ,entrance ,area a4 ,normally1 the ,,mtf will not operate in a ,,cb vapor hazard environment4 ,however1 if the ,,mtf must remain in an area on a temporary basis and liquid agent contamination is present1 the immediate area around the entrance must be decontaminated4 b4 ,to decontaminate the area around the entrance1 use one or more of the following methods3 ,turn over about #b inches of soil4 ,remove the top #a-;inch layer of soil containing the liquid agent4 ,use the ,,cam or ,m#h detector paper to check the area after the topsoil is removed to ensure complete agent removal4 ,add several inches of clean soil or sand4 ,mix ,,stb into the top #a_/b to #a inch of soil4 ,use ,,ds#b on contaminated hard-surfaced areas or frozen ground4 ,f-#ad4 ,procedures ,prior to ,entry ,all personnel 7staff and patients7 must be decontaminated before they are permitted entry into the ,,cps4 ,use chemical detection equipment to check for the presence of contamination on individuals and their equipment2 also check for presence of contamination on individual weapons if they are allowed in the ,,cps4 ,normally1 weapons will not be allowed in the patient care areas1 but will be stored outside near the entry_/exit4 ,thorough decontamination is critical in preventing contamination transfer into the ,,cps4 ,when a chemical agent is detected1 follow the procedures in ,appendix ,c for patient decontamination and ,,fm #c-e for other personnel decontamination before entering the ,,cps4 ,all contaminated clothing and equipment are placed in the contaminated dump4 ,weapons should not have been evacuated with patients4 ,however1 if weapons are evacuated with the patient1 they are decontaminated and held by the ,,mtf 7administrative personnel or hospital supply7 for disposition instructions4 ,decontamination must be thorough2 procedures must be strictly followed4 ,failure to do so can contaminate the interior of the ,,mtf and injure medical treatment personnel2 thus reducing their mission support capabilities4 ---------------------------------------- --------- ,,warnings #a4 ,,always ,,purge ,,the ,,air ,,lock ,,before ,,opening ,,the ,,inner ,,door1 ,,if ,,the ,,outer ,,door ,,has ,,been ,,opened4 #b4 ,,when ,,operating ,,in ,a ,,toxic ,,environment1 ,,never ,,open ,,the ,,outer ,,and ,,inner ,,doors ,,of ,,the ,,air ,,locks ,,at ,,the ,,same ,,time4 ---------------------------------------- --------- ,f-#ae4 ,entry_/,exit for the ,collective ,protection ,shelter ,system a4 ,ambulatory ,personnel4 7#a7 ,entry procedures4 7a7 ,ambulatory patients and others remove their ,,mopp 7except their mask71 ,b,d,us1 and boots outside the air lock4 ,this procedure reduces the amount of possible contamination entering the air lock4 7b7 ,a check is made to ensure that the ambulatory air lock is empty and the inner door is closed4 7c7 ,the individual enters the air lock and closes the outer door4 7d7 ,the air lock is purged for #c minutes4 ,at the end of the purge cycle1 the individual checks for contamination4 ,if contaminated1 the individual must return to the outside and decontaminate his skin2 then return to the air lock and repeat the purge cycle and contamination check4 ,if no contamination is detected1 the protective mask is removed and placed in a plastic bag4 ,the plastic bag is sealed and labeled4 ,the individual opens the inner air lock door and enters the ,,cps2 the plastic bag is carried into the shelter with the individual4 7#b7 ,exit procedures4 7a7 ,a check is made to ensure that the ambulatory air lock is empty and the outer door is closed4 7b7 ,the individual enters the air lock and closes the inner door4 7c7 ,the individual puts on his protective mask2 then exits through the outer door4 7d7 ,the individual puts on his ,,bdu and boots then assumes the established ,,mopp level before departing the immediate area of the exit door4 ---------------------------------------- --------- ,,warning ,,do ,,not ,,open ,,the ,,outer ,,door ,,until ,,the ,,protective ,,mask ,,has ,,been ,,put ,,on4 ---------------------------------------- --------- ,,notes #a4 ,ambulatory patients that enter the ,,cbps become litter patients and are placed in ,,ppw when released because the ,,mtf does not have replacement ,,mopp ensembles for patient issue4 #b4 ,exits must be spaced so that at least a #c minute purge of the air lock is accomplished before the inside door is opened4 ,only open the doors long enough to permit passage4 b4 ,litter ,patients4 7#a7 ,entry procedures4 7a7 ,an outside aidman notifies an inside aidman that a litter patient is ready for admission4 7b7 ,the inside aidman ensures that the inner litter air lock door is closed4 ,the outside aidmen open the outer air lock door and place the litter on the litter rails2 they push the patient into the air lock headfirst2 then they close the outer door4 ,after a purge time of #c minutes1 an aidman inside the ,,cps opens the inner door and checks the patient to ensure that he is contamination free4 ,the patient is checked by placing the ,,cam nozzle near absorptive surfaces1 such as the patient's hair4 ,if no contamination is found1 the aidman removes the patient's mask and places it in a plastic bag4 ,the inside aidmen remove the patient from the air lock and position him on treatment litter stands1 or move him to the treatment area as directed by supervisory personnel4 7c7 ,patients received at the treatment facility in the ,,ppw are checked for contamination2 if they are contamination free1 they may be processed through the litter air lock in the ,,ppw4 ,the inside aidmen ensure that the inner litter air lock door is closed4 ,the outside aidmen open the outer air lock door and place the litter on the litter rails and push the patient into the litter air lock headfirst1 then close the outer door4 ,purge the air lock for #c minutes4 ,after the purge time1 an aidman inside of the ,,cps opens the inner air lock door and uses the ,,cam to check the patient to ensure that he is free of contamination4 ,if no contamination is found1 the inside aidmen remove the patient from the air lock4 7,if the patient is wearing a protective mask1 the mask is removed and placed in a plastic bag before the patient is moved from the air lock47 ,as the patient is removed from the air lock1 the ,,ppw is opened and rolled inside out so that any desorbing vapors are adsorbed by the charcoal layer4 ,the inside aidmen remove the patient from the air lock and position him on litter stands4 ,the patient is transferred to a clean litter2 then moved to the treatment area as directed by supervisory personnel4 ,the receiving litter and ,,ppw is returned to the outside2 dispose of the ,,ppw in the contaminated waste dump4 ,decontaminate the litter and return it to the litter pool4 ,,note ,should contamination be found when monitoring the air lock in 7b7 or 7c7 above1 repeat the purge cycle1 then retest for contamination4 ,all vapor hazards must be eliminated before the patient is moved into the ,,cps4 ,repeating the purge cycle may ,,not be possible if the patient is in need of immediate lifesaving care4 ,the patient may have to be returned to the outside treatment area for immediate care4 7#b7 ,exit procedures4 7a7 ,the litter patient is placed in a ,,ppw4 ,a battery operated blower unit with a ,,cb filter may be attached to the ,,ppw to provide fresh air to the patient2 thus reducing the heat load on the patient and the carbon dioxide buildup inside the ,,ppw4 7b7 ,an inside aidman notifies an outside aidman that the patient is ready to exit the shelter4 ,an outside aidman ensures that the outer air lock door is closed4 ,the patient is placed in the litter air lock feet first4 ,the inner air lock door is closed4 ,the outside aidmen open the outer door and remove the patient4 7c7 ,hospital staff1 visitors1 or ambulatory patients exit through the ambulatory air lock4 ,before entering the air lock1 each individual must ensure that the outer air lock door is closed4 ,the individual enters the air lock and closes the inner door2 puts on his protective mask and exits through the outer door4 ,the individual puts on his ,,bdu and boots1 and then assumes the established ,,mopp level before departing the immediate area of the exit door4 ---------------------------------------- --------- ,,warning ,,do ,,not ,,open ,,the ,,outer ,,door ,,until ,,the ,,inner ,,door ,,has ,,been ,,closed4 ---------------------------------------- --------- ,,note ,exits must be spaced at least #c minutes apart to allow for a complete purge cycle of the air lock4 ,f-#af4 ,resupply of ,protected ,areas ,resupply of protected areas is accomplished by placing contamination-free supplies or equipment on a litter and passing it through the litter air lock1 or processing it through the supply air lock4 ,the litter air lock must be purged for #c minutes4 ,the supplies must be checked for contamination before they are removed and placed within the ,,cps4 ,the supply air lock must be purged for the stated time as outlined in the supporting technical manual2 usually #de minutes4 ,again the supplies must be checked for contamination before they are removed and placed within the ,,cps4 ,,appendix ,g ,,patient ,,decontamination ,section ,i4 ,,introduction ,g-#a4 ,general a4 ,patient decontamination presents special problems for units and ,,hss personnel4 ,nuclear1 biological1 and chemical contaminated patients create increased hazards to rescuers and ,,hss personnel2 thus1 causing delays in providing essential first aid and medical treatment for injuries from sources other than the exposure to ,,nbc weapons_/agents4 ,casualty decontamination procedures are performed by each individual1 as buddy aid1 or at a unit decontamination station prior to the arrival of medical personnel4 ,see ,,fm #c-e for procedures on individual1 buddy aid1 and unit decontamination4 ,patient decontamination procedures are normally performed at an ,,mtf under medical supervision4 ,patient decontamination stations may be established 7collocated7 at central unit decontamination faculties1 if medical support is available4 ,however1 augmentation medical support must be requested to provide patient care and supervise the patient decontamination process4 ,because1 when the unit is undergoing decontamination operations1 organic medical personnel must also decontaminate their equipment and personnel4 ,therefore1 they are not available to provide medical support for operating the patient decontamination station that is collocated with the central unit decontamination facility4 b4 ,the term decontamination as used herein means the removal or neutralization of radioactive particles1 ,,bw agents1 and ,,cw agents to levels low enough that patients may be treated without contaminating the ,,mtf and without posing health risks to unprotected medical providers4 ,decontamination does not imply absolute removal of contaminants4 ,,note ,the decontamination procedures described below are for ,,nbc contaminated patients4 ,these procedures may also be used for most ,,tim contaminated patients4 ,however1 soap and water will suffice for most ,t,i,ms2 but some ,t,i,ms react with water4 ,for those ,t,i,ms another material must be used to decontaminate patients4 ,for detailed information on decontamination of ,,tim contaminated patients1 see ,,fm #h-ejj4 c4 ,physical removal of contaminants is the primary method of decontamination4 ,physical removal does not require vigorous scrubbing2 in fact1 vigorous scrubbing can force some agents deeper into the skin2 thus1 increasing the agent effect rather than reducing its effects4 ,the use of a ,m#bia skin decontaminating kit 7,,sdk7 neutralizes_/reduces the effects of an agent1 but physical removal is of utmost importance4 ,when a ,,sdk is not available1 the use of soap and water should be considered as the next best method4 ,however1 the use of soap and water requires large amounts of water that may not be available because the soap must be rinsed from the skin to reduce skin irritation from the soap4 ,an alternate skin decontaminant is a hypochlorite solution2 but it should only be used when ,s,d,ks and_/or sufficient quantities of water are not available4 ,use a #j4e percent hypochlorite solution on the protective mask and skin4 ,a #e percent hypochlorite solution can be used on the mask hood1 gloves1 and other outer garments4 ---------------------------------------- --------------- ,,caution ,do not use the #e percent solution on the skin2 it can cause severe skin irritation4 ---------------------------------------- --------------- ,g-#b4 ,immediate ,decontamination ,decontamination must begin at the platoon and company level with the individual soldier1 prior to the arrival of medical personnel4 ,the soldier himself or members of his team must perform immediate decontamination4 ,when the casualty's condition and the mission permits1 they may go through a ,,mopp gear exchange at their unit before evacuation 7see ,,fm #c-e74 ,performing a ,,mopp gear exchange at the unit before evacuation will reduce the amount of contamination that can be transferred to the ,,medevac vehicle4 ,however1 the ,,mopp gear exchange must not cause further injury to the casualty4 ,first aid for ,,cw agent must be administered2 such as administering nerve agent antidotes 7such as nerve agent antidotes and convulsant antidote for nerve agent ,,cana71 as required4 ,enter the time and type of contamination on a field expedient ,,nbc casualty card 7,figure ,g-#a74 ,use the ,,cam1 ,m#h chemical agent detector paper1 or ,m#i tape to determine the type of chemical contamination4 ,use a radiation detection meter_/device to determine the level of radioactive contamination1 if required4 ,currently1 there are no ,,bw agent detectors that can be used to check patients for ,,bw agent contamination4 ,therefore1 all patients suspected of being contaminated with a ,,bw agent must be decontaminated4 ,when medical personnel arrive1 they should enter the time and type of contamination and number of antidote injections that were administered as first aid on the ,department of ,defense 7,,dd7 ,form #achj 7,field ,medical ,card ,,fmc74 ,illustration3 ,figure ,g-#a4 ,field expedient nuclear1 biological1 and chemical patient card4 ,g-#c4 ,patient ,decontamination and ,thorough ,decontamination ,collocation a4 ,collocating patient and thorough decontamination operations in the ,,bsa may provide several advantages 7,figure ,g-#b74 ,it-- ,preserves the principle of limiting the spread of contamination4 ,reduces confusion on the battlefield4 ,reduces demand on logistics support elements4 ,improves contamination control and reporting3 ,one location and one person in charge4 ,reduces overall security requirements4 ,speeds ,,pds closure by using the thorough decontamination site4 b4 ,an identified disadvantage is the increased size of the site and the requirement for medical support augmentation 7a treatment squad from another organization with required patient decontamination and treatment ,m,e,ss7 to operate the ,,pds4 ,,note ,organic medical personnel must not be used to perform the ,,hss mission at the collocated site4 ,they must go through the decontamination process with their unit4 c4 ,these operations do not require that both patient decontamination and unit thorough decontamination be executed simultaneously4 ,the ,,pds can be running while the thorough decontamination site is being prepared4 ,patient decontamination cannot be delayed since patients may be suffering life-threatening injuries as well as exposure to ,,nbc agents4 ,therefore1 the ,,pds must be established and operational before the first patients arrive4 ,the wind direction must be common to both sites4 d4 ,the decontamination platoon leader is responsible for establishing the combined decontamination site4 ,the medical unit commander_/surgeon coordinates with the decontamination platoon leader for the location of the patient receiving1 ,,pds1 and ,,mtf4 ,the lowest level at which this operation will usually be planned is brigade4 ,this operation requires extensive planning and must involve the brigade chemical officer1 brigade ,s#d1 and the medical company commander_/brigade surgeon4 ,decontamination support for special operation forces1 other unique operational organizations1 or for nonlinear operations may require execution at a lower level4 ,the supporting medical personnel operate the ,,pds4 ,nonmedical personnel perform patient decontamination procedures under medical supervision4 ,patient decontamination procedures are described below4 ,,note ,patient decontamination differs from thorough decontamination in that the patients' medical status must be monitored and medical treatment must be provided during the decontamination process4 e4 ,although a ,,pds may be collocated with thorough decontamination1 a ,,pds must be operational at ,levels ,i1 ,,ii1 ,,iii1 and ,,iv ,m,t,fs4 ,contaminated patients may present directly to the ,,mtf for care1 or patients previously decontaminated may become contaminated en route4 ,therefore1 all patients arriving at an ,,mtf must be checked for contamination4 ,if contaminated1 they must be decontaminated before they are admitted to the ,,mtf4 ,illustration3 ,figure ,g-#b4 ,thorough decontamination site collocated with patient decontamination station1 without collective protection shelter4 ,g-#d4 ,patient ,decontamination at the ,battalion ,aid ,station 7,level ,i7 a4 ,when battle conditions prevent patient decontamination procedures forward or the patient is contaminated en route1 the patient may have to be decontaminated at the ,,bas4 ,contaminated patients arriving at the ,,bas must be decontaminated before admission into the clean treatment area4 b4 ,patient decontamination is performed by eight nonmedical personnel from the supported unit at the ,,bas4 ,the patient decontamination personnel operate as two-man teams to perform the patient decontamination procedures4 ,the patient decontamination teams operate under the supervision of medical personnel to ensure that no further injury is caused to the patient by the decontamination process4 ,each team receives a patient from the triage point and performs both clothing removal and skin decontamination procedures4 ,the team requires assistance from another team to perform litter changes2 see details below4 ,g-#e4 ,patient ,decontamination at the ,medical ,company ,clearing ,station 7,level ,,ii7 ,the medical company clearing station may receive patients from the ,,bas or directly from other areas who have not been decontaminated4 ,the clearing station must also have a patient decontamination area4 ,as with the ,,bas1 the clearing station must have a minimum of eight nonmedical personnel from the supported units to perform patient decontamination4 ,procedures for patient decontamination at the clearing station are the same as for the ,,bas4 ,g-#f4 ,patient ,decontamination at a ,hospital 7,level ,,iii or ,,iv7 ,to the maximum extent possible1 hospitals are located away from tactical or logistical targets4 ,contaminated patients will arrive from forward ,m,t,fs and units located within the geographical area of the hospital4 ,patient decontamination is done by at least #bj nonmedical personnel from units located in the geographical area_/base cluster of the hospital4 ,procedures for patient decontamination at the hospital are the same as for the ,,bas4 ,however1 several patient decontamination stations can be operated simultaneously at the hospital patient decontamination site4 ,further1 all patients arriving at the hospital will be decontaminated and receive full treatment within the capabilities of the hospital4 ,g-#g4 ,prepare ,hypochlorite ,solutions for ,patient ,decontamination ,an alternative patient decontamination agent is a hypochlorite solution2 however1 the hypochlorite solution must be prepared4 ,two concentrations of the hypochlorite solution are required4 ,a #e percent hypochlorite solution to decontaminate gloves1 aprons1 litters1 cutting devices1 the patient's mask hood1 and other nonskin contact areas4 ,the patient's mask1 skin1 splints1 and tourniquets and their wounds are irrigated using a #j4e 77 percent hypochlorite solution4 ,to prepare the solutions1 use calcium hypochlorite 7,,hth7 granules 7supplied in #f-ounce jars in the chemical agent patient treatment and chemical agent patient decontamination ,,mes71 bulk ,,hth1 or sodium hypochlorite 7household bleach74 ,prepare the required solutions as shown in ,table ,g-#a below4 ,table ,g-#a4 ,preparation of ,hypochlorite ,solutions for ,patient ,decontamination ,,hth ,,hth ,,mre ,,household ,,percent ,,in #e ,,ounces ,,spoonfuls ,,bleach ,,gallons ,,of ,,water ---------------------------------------- -------------------------- #f 99#e #b ,,quarts #j4e #dh #dj 9999 #e4j ---------------------------------------- -------------------------- 99 ,,these ,,measurements ,,are ,,used ,,when ,,bulk ,,hth ,,is ,,used4 ,,to ,,measure ,,this ,,preparation1 ,,use ,,the ,,plastic ,,spoon ,,supplied ,,with ,,your ,,meal1 ,,ready-,,to-,,eat 7,,mre74 ,,the ,,amount ,,of ,,hypochlorite ,,to ,,be ,,used ,,is ,a ,,heaping ,,spoonful 7,,that ,,is1 ,,all ,,that ,,the ,,spoon ,,will ,,hold74 ,,do ,,not ,,shake ,,any ,,granules ,,off ,,of ,,the ,,spoon ,,before ,,adding ,,to ,,the ,,water4 9999 ,,do ,,not ,,dilute ,,in ,,water2 ,,household ,,bleach ,,is #e ,,to #f4be ,,percent ,,solution2 ,,it ,,is ,,used ,,full ,,strength ,,for #e ,,percent ,,applications4 ---------------------------------------- -------------- ,,cautions #a4 ,do not use the #e percent hypochlorite solution on the patient's skin4 ,the #e percent solution can burn the skin4 #b4 ,only wipe the skin when applying the #j4e percent hypochlorite solution4 ,vigorous scrubbing may force the agent into the skin4 ---------------------------------------- -------------- ,g-#h4 ,classification of ,patients ,on the ,,nbc battlefield1 two classifications of patients will be encountered--contaminated and uncontaminated4 ,those contaminated may suffer from the effects of an ,,nbc agent1 of a conventional wound1 or both4 ,some may suffer combat stress or heat injuries induced by the stress of ,,nbc conditions and extended time spent in ,,mopp ,level #d4 ,it is important to follow proper decontamination procedures to limit the spread of contamination to others and equipment4 ,the most important decontamination is performed at the site of contamination4 ,decontamination at a later time may be too late to prevent injury to the individual1 especially when exposed to vesicants4 ,all agents should be promptly removed from the skin4 ,g-#i4 ,patient ,treatment ,this appendix only describes patient decontamination procedures4 ,for ,,nbc treatment procedures1 refer to ,,fm #d-jb4bhc1 ,,fm #h-bhd1 and ,,fm #h-bhe4 ,section ,,ii4 ,,patient ,,decontamination ,,procedures ,g-#aj4 ,decontaminate a ,litter ,chemical ,agent ,patient ,before contaminated patients receive medical treatment in the clean treatment area1 they must be decontaminated4 ,place the cutting device in a container of #e percent hypochlorite solution between each use4 ,each decontamination team member decontaminates his gloves and apron with the #e percent hypochlorite solution frequently to prevent spreading any contamination to patient's skin4 ,decontaminate the patient's skin1 bandages1 wounds1 mask1 identification tags with chain1 and splints with a #j4e percent hypochlorite solution4 ,the litter patient is decontaminated and undressed as follows3 ,,note ,litter patients requiring ,,emt or ,,atm in the clean area of the ,,mtf will be completely decontaminated4 ,a patient not requiring clean ,,emt or ,,atm at the ,,mtf1 but requiring further evacuation 7for example3 a stable patient with a partial amputation of a lower extremity7 should only have his wound area and ,,mopp spot decontaminated to remove any gross contamination4 ,the patient should be evacuated in his ,,mopp4 a4 ,step #a4 ,physically remove gross contamination4 ,use any stiff material 7stick1 cardboard1 plastic strip1 metal banding strap7 to physically remove gross contamination from the patient's ,,mopp ensemble4 ,much of the ,,cw agent contamination can be removed through physical means4 b4 ,step #b4 ,decontaminate the patient's mask and hood4 ,the patient has been triaged and stabilized 7if necessary7 by the senior trauma specialist in the patient decontamination area4 ,a two-man decontamination team moves him to the litter stands at the clothing removal station4 7#a7 ,decontaminate the mask and hood4 ,use the ,,sdk1 or use a #e percent hypochlorite solution or household bleach to sponge down the front1 sides1 and top of the mask hood4 ,decontaminate spots with the ,,sdk or the #e percent hypochlorite solution4 7#b7 ,remove hood4 ,remove the hood by cutting the hood4 ,before cutting the hood1 dip the cutting device in a #e percent hypochlorite solution4 ,for the ,m#ag-series mask1 cut the neck cord and the small string under the voicemitter4 ,release or cut the hood shoulder straps and unzip the hood zipper4 ,cut the hood1 close to the filter inlet cover and eye-lens outsert1 upward to the top of the eye-lens outsert1 and across the forehead to the outer edge of the other eye-lens outsert4 ,proceed downward toward the patient's shoulder1 staying close to the eye-lens1 then across the lower part of the voicemitter to the zipper4 ,after dipping the cutting device in the #e percent hypochlorite solution1 cut the hood from the center of the forehead over the top of the head 7see ,figure ,g-#c74 ,fold the left and right sides of the hood to the side of the patient's head1 laying the sides of the hood on the litter4 ,for the ,m#dj-series protective mask cut the hood shoulder straps1 then cut the quick-doff hood from the front bottom center to the chin through the elastic band under the chin4 ,fold the left and right sides of the hood over the shoulders away from the head4 ,illustration3 ,figure ,g-#c4 ,cutting the ,m#ag protective mask hood4 7#c7 ,decontaminate the protective mask and exposed skin4 ,using the ,,sdk1 soap and water1 or a #j4e percent hypochlorite solution1 wipe the external parts of the mask4 ,cover the mask air inlet7s7 with gauze or your hand to keep the mask filter dry4 ,continue by wiping the exposed areas of the patient's face1 including the neck and behind the ears4 7#d7 ,remove the ,field ,medical ,card4 ,cut the patient's ,,fmc tie wire1 allowing the ,,fmc to fall into a plastic bag4 ,seal the plastic bag and rinse the outside of the bag with a #e percent hypochlorite solution4 ,place the plastic bag with the ,,fmc under the back of the protective mask head straps4 ,the ,,fmc will remain with the patient4 c4 ,step #c4 ,remove gross contamination from the patient's overgarment4 ,remove all visible gross contamination by scraping with a stick or other device4 d4 ,step #d4 ,remove the patient's personal effects and protective overgarment4 7#a7 ,remove patient's personal effects4 ,remove the patient's personal effects from his protective overgarment and ,,bdu pockets4 ,place the articles in a plastic bag1 label with the patient's identification1 and seal the bag4 ,if the articles are not contaminated1 return them to the patient4 ,if the articles are contaminated1 place them in the contaminated holding area until they can be decontaminated1 and then return them to the patient4 7#b7 ,cut the patient's overgarment4 ,the overgarment jacket and trousers may be cut simultaneously4 ,two persons may be cutting clothing at the same time4 ,cut around bandages1 tourniquets1 and splints1 leaving them in place4 ,,note ,a cut is a separation of material by use of a cutting device that cuts material into two pieces4 ,,example3 ,cutting the sleeve from the cuff to the jacket collar is one cut4 ---------------------------------------- ------------------- ,,caution ,bandages may have been applied to control severe bleeding and are treated like tourniquets4 ,only medical personnel remove bandages1 tourniquets1 and splints4 ---------------------------------------- ------------------- 7#c7 ,remove overgarment jacket4 ,make two cuts1 one up each sleeve from the wrist up to the shoulder1 and then through the collar 7,figure ,g-#d74 ,do not allow the gloves to touch the patient along the cut line4 ,dip the cutting device in the #e percent hypochlorite solution before making each cut to prevent contamination of the patient's uniform or underclothing4 ,keep the cuts close to the inside of the arms so that most of the sleeve material can be folded outward4 ,unzip the jacket2 roll the chest sections to the respective sides1 with the inner surface outward4 ,continue by tucking the clothing between the arm and chest4 ,roll the cut sleeves away from the arms1 exposing the black liner4 ,illustration3 ,figure ,g-#d4 ,cutting the overgarment jacket4 7#d7 ,remove overgarment trousers4 ,cut both trouser legs starting at the ankle as shown in ,figure ,g-#e4 ,keep the cuts near the inseams to the crotch4 ,with the left leg1 continue cutting to the waist1 avoiding the pockets4 ,with the right leg1 cut across at the crotch to the left leg cut4 ,place the cutting device in the #e percent hypochlorite solution4 ,fold the cut trouser halves away from the patient and allow the halves to drop to the litter with contaminated 7green7 side down4 ,roll the inner leg portion under and between the legs4 ,illustration3 ,figure ,g-#e4 ,cutting the overgarment trousers4 7#e7 ,remove outer gloves4 ,this procedure can be done with one person on each side of the patient working simultaneously4 ,the decontamination team will decontaminate their gloves in #e percent hypochlorite solution4 ,next1 lift the patient's arms up and out of the cutaway sleeves unless detrimental to the patient's condition4 ,grasp the fingers of the glove1 roll the cuff over the fingers1 turning the glove inside out4 ,do not remove the inner cotton glove liners at this time4 ,carefully lower the arms across the chest after the outer gloves have been removed 7,figure ,g-#f74 ,do not allow the patient's arms to come into contact with the exterior of his overgarment4 ,drop his gloves into the contaminated waste bag4 ,dip your gloves in the #e percent hypochlorite solution4 ,illustration3 ,figure ,g-#f4 ,remove outer gloves and position arms after glove removal4 7#f7 ,remove overboots4 ,cut the overboot laces and fold the lacing eyelets flat outwards4 ,if the green vinyl overboot 7,,gvo7 is worn1 first try to remove the overboot without cutting2 if necessary1 cut the boot along the front4 ,while standing at the foot of the litter1 hold the heel with one hand1 pull overboot downwards1 and then pull towards you to remove the overboot over the combat boot heel4 ,remove the two overboots simultaneously4 ,this reduces the likelihood of contaminating one of the combat boots4 ,while holding the heels off the litter1 have a decontamination team member wipe the end of the litter with the #e percent hypochlorite solution to neutralize any liquid contamination that was transferred to the litter from the overboots4 ,lower the patient's heels onto the decontaminated litter4 ,place the overboots in the contaminated waste bag4 ,decontamination personnel dip their gloves in the #e percent hypochlorite solution4 e4 ,step #e4 ,remove patient's battle dress uniform4 7#a7 ,remove battle dress uniform4 ,cut the ,,bdu jacket and trousers as described above for the protective overgarment4 ,roll the jacket and trousers as described for the protective overgarment4 7#b7 ,remove combat boots4 ,cut the bootlaces along the tongue4 ,remove the boots by pulling them towards you4 ,place the boots in the contaminated waste bag4 ,do not touch the patient's skin with contaminated gloves when removing his boots4 7#c7 ,remove undergarments4 ,remove the patient's tee shirt4 ,dip the cutting device in the #e percent hypochlorite solution between each cut4 ,cut both sleeves from the inside1 starting at the elbow1 up to the armpit4 ,continue cutting across the shoulder to the collar4 ,cut around bandages or splints1 leaving them in place4 ,next1 peel the tee shirt away from the body to avoid spreading contamination4 ,if the patient is wearing a brassiere1 cut it between the cups4 ,cut both shoulder straps where they attach to the cups and lay them back off of the shoulders4 ,remove the patient's under shorts_/panties by cutting from the lower side of the hip to the waist on both sides4 ,fold the front flap of the shorts_/panties down between the patient's legs onto the litter4 ,do not allow the outside of the garment to touch the patient's skin4 ,remove the socks and cotton glove liners4 ,do not remove the patient's identification tags4 f4 ,step #f4 ,transfer the patient to a decontamination litter4 ,after the patient's clothing has been cut away1 he is transferred to a decontamination litter or a canvas litter with a plastic sheeting cover4 ,three decontamination team members decontaminate their gloves and aprons with the #e percent hypochlorite solution4 ,one member places his hands under the patient's legs at the thighs and ,achilles tendons1 a second member places his arms under the patient's back and buttocks1 and a third member places his arms under the patient's shoulders and supports the head and neck4 ,they carefully lift the patient using their knees 7not their backs7 to minimize back strain4 ,while the patient is elevated1 another decontamination team member removes the litter from the litter stands and replaces it with a decontaminated 7clean7 litter4 ,the patient is carefully lowered onto the clean litter4 ,the contaminated clothing and overgarments are placed in bags and moved to the contaminated waste dump4 ,the dirty litter is rinsed with the #e percent hypochlorite solution and placed in the litter storage area4 g4 ,step #g4 ,decontaminate skin4 7#a7 ,spot decontamination4 ,with the patient in a supine position1 spot decontaminate the skin using the ,,sdk or a #j4e percent hypochlorite solution4 ,decontaminate areas of potential contamination4 ,include areas around the neck1 wrists1 and lower parts of the face4 ,decontaminate the patient's identification tags and chain1 if necessary4 ,,note ,complete body wash is not appropriate and may be injurious to the patient4 ,during complete body wash1 the patient would have to be rolled over to reach all areas of the skin4 ,this is not necessary for adequate decontamination4 7#b7 ,trauma specialist care4 ,during decontamination1 the clothing around bandages1 tourniquets1 and splints was cut and left in place4 ,the trauma specialist replaces the old tourniquet by placing a new tourniquet to #a inch above the old one4 ,he then removes the old tourniquet and decontaminates the patient's skin using the ,m#bia pads or a #j4e percent hypochlorite solution4 ,the trauma specialist gently cuts away bandages and decontaminates the area around the wound2 dusts the wound with the ,,sdk1 or irrigates soft tissue wounds with the #j4e percent hypochlorite solution4 ,if bleeding begins1 the trauma specialist replaces the bandage with a clean one4 ,the trauma specialist ensures splints are not removed1 but are decontaminated in place by applying the #j4e percent hypochlorite solution to them1 to include the padding and cravats4 ,splints will only be removed by a physician or under the supervision of a physician4 ---------------------------------------- ------------ ,,warnings #a4 ,,do ,,not apply the ,,sdk or irrigate wounds in the abdominal and thoracic cavities or intracranial head injuries4 #b4 ,,do ,,not remove splints4 ---------------------------------------- ------------ 7#c7 ,check patient for completeness of decontamination4 ,the patient is checked with the ,,cam or with ,m#h detector paper for completeness of decontamination4 ,,note ,other monitoring devices may be used when available4 7#d7 ,dispose of contaminated waste4 ,dispose of contaminated bandages and coverings by placing them in a contaminated waste bag4 ,seal the bag and place it in the contaminated waste dump4 h4 ,step #h4 ,transfer the patient across the shuffle pit4 7#a7 ,the patient's clothing has been cut away2 his skin1 bandages1 and splints have been decontaminated4 ,now the litter is transferred to the shuffle pit and placed upon the litter stands4 ,the shuffle pit is wide enough to prevent the patient decontamination team members from straddling it while carrying the litter4 ,four decontamination team members transfer the patient to a clean treatment litter in the shuffle pit4 ,a member of the patient decontamination team removes the bagged ,,fmc and holds it so that a trauma specialist on the clean side of the hot line can read it4 ,a trauma specialist on the clean side of the hot line prepares a new ,,fmc before the patient is moved to the clean area4 ,the old ,,fmc is disposed of with other contaminated waste4 7#b7 ,decontamination team members rinse or wipe down their aprons and gloves with the #e percent hypochlorite solution4 7#c7 ,three decontamination team members lift the patient off the decontamination litter 7see ,step #f for lifting procedures74 7#d7 ,while the patient is elevated1 another decontamination team member removes the litter from the stands and returns it to the decontamination area4 ,a trauma specialist from the clean side of the shuffle pit replaces the litter with a clean one4 ,the patient is lowered onto the clean litter4 ,two trauma specialists from the clean side of the shuffle pit move the patient to the clean treatment area4 ,the patient is treated in this area or waits for processing into the ,,cps4 ,the litter removed by the decontamination team member is wiped down with the #e percent hypochlorite solution in preparation for reuse4 ,,note ,before decontaminating another patient1 each decontamination team member drinks approximately one-half quart of water4 ,the exact amount of water consumed is increased or decreased according to the temperature 7see ,table ,g-#b below74 ,table ,g-#b4 ,heat ,injury ,prevention and ,water ,consumption4 ,,easy ,,work ,,moderate ,,work ,,hard ,,work ---------------------------------------- --- ,,heat ,,wbgt ,,work_/ ,,water ,,work_/ ,,water ,,work_/ ,,water ,,category ,,index ,,rest ,,intake ,,rest ,,intake ,,rest ,,intake ,,degrees ,f ,,min ,,qt_/,,hr ,,min ,,qt_/,,hr ,,min ,,qt_/,,hr ---------------------------------------- ----------------------- #a 7,,white7 #gh-ha4i ,,nl ,,nl #dj_/bj #b 7,,green7 #hb-hd4i ,,nl #ej_/aj #cj_/cj #a #c 7,,yellow7 #he-hg4i ,,nl #dj_/bj #cj_/cj #a #d 7,,red7 #hh-hi4i ,,nl #cj_/cj #bj_/dj #a #e 7,,black7 #ij #ej_/aj #a #bj_/dj #a #aj_/ej #a ---------------------------------------- ----------------------- ,,the ,,work_/,,rest ,,times ,,and ,,fluid ,,replacement ,,volumes ,,will ,,sustain ,,performance ,,and ,,hydration ,,for ,,at ,,least #d ,,hours ,,of ,,work ,,in ,,the ,,specified ,,heat ,,category4 ,,nl,,no ,,limit ,,to ,,work ,,time ,,per ,,hour4 ,,rest ,,means ,,minimal ,,physical ,,activity 7,,sitting ,,or ,,standing7 ,,accomplished ,,in ,,shade1 ,,if ,,possible4 ,,caution3 ,,hourly ,,fluid ,,intake ,,should ,,not ,,exceed #a ,,quart4 ,,daily ,,fluid ,,intake ,,should ,,not ,,exceed #ab ,,quarts4 ,,wearing ,,body ,,armor ,,adds #e ,f ,,to ,,wbgt ,,index4 ,,wearing ,,all ,,mopp ,,overgarments ,,adds #aj ,f ,,to ,,wbgt ,,index4 ---------------------------------------- ------------------ ,,warning ,do not exceed a fluid intake of #a quart per hour4 ,do not exceed a fluid intake of #ab quarts per day4 ---------------------------------------- ------------------ ,g-#aa4 ,decontaminate an ,ambulatory ,chemical ,agent ,patient a4 ,all ambulatory patients requiring ,,emt or ,,atm in the clean area of the ,,bas will be decontaminated4 ,a member of the decontamination team or other ambulatory patients will assist the patient in removing his clothing and decontaminating his skin4 b4 ,patients requiring only minimal care will undergo spot decontamination of their ,,mopp gear as required for their medical treatment4 ,they will be treated in the contaminated ,,emt area and returned to duty4 ,they will undergo decontamination and a ,,mopp gear exchange with their unit4 c4 ,stable patients not requiring treatment at the ,,bas1 but requiring evacuation to a higher level of care for treatment 7example3 ,a patient with a broken arm7 should be evacuated in ,,mopp ,level #d by any available transportation4 ,however1 before evacuation1 spot remove all thickened_/persistent agents from protective clothing4 ,,notes #a4 ,remember1 do not remove clothing from an ambulatory patient unless he requires treatment in the clean treatment area of the ,,bas or clearing station4 ,only spot decontaminate the patient's clothing and evacuate him to the next level of care4 #b4 ,place cutting device used in this procedure in a container of #e percent hypochlorite solution when not in use4 ,most ambulatory patients will be treated in the contaminated treatment area and returned to duty4 ,upon removal of an ambulatory patient's clothing1 he becomes a litter patient4 ,the ,,bas and clearing station do not have clothing to replace those cut off during the decontamination process4 ,the patient must be placed in a ,,ppw for protection during evacuation4 ,a battery operated blower unit with a ,,cb filter may be attached to the ,,ppw to provide fresh air to the patient2 thus reducing the carbon dioxide buildup inside the ,,ppw 7,figure ,g-#g74 ,illustration3 ,figure ,g-#g4 ,chemical warfare agent protective patient wrap4 d4 ,step #a4 ,remove load-carrying equipment4 ,remove load-carrying equipment 7,,lce7 by unfastening_/unbuttoning all connectors or tie straps2 then place the equipment in a plastic bag4 ,place the plastic bag in the designated storage area for later decontamination4 e4 ,step #b4 ,decontaminate the patient's mask and hood4 ,after the patient has been triaged and treated 7if necessary7 by the senior trauma specialist in the ,,pds1 the patient 7assisted by another ambulatory patient or a member of the patient decontamination team1 if necessary7 begins the clothing removal process4 7#a7 ,decontaminate and remove mask hood4 ,sponge down the front1 sides1 and top of the hood with a #e percent hypochlorite solution4 ,remove the hood by cutting 7,figure ,g-#c7 or1 with the quick-doff hood or other hoods1 by loosening the hood from the mask attachment points4 ,before cutting the hood1 dip the cutting device in the #e percent hypochlorite solution4 ,begin by cutting the neck cord and the small string under the voicemitter4 ,next1 release or cut the hood shoulder straps and unzip the hood zipper4 ,proceed by cutting the hood upward1 close to the filter inlet cover and eye-lens outserts1 to the top of the eye-lens outsert1 across the forehead to the outer edge of the other eye-lens outsert4 ,proceed downward toward the patient's shoulder1 staying close to the eye-lens and filter inlet4 ,cut across the lower part of the voicemitter to the zipper4 ,after dipping the cutting device in the #e percent hypochlorite solution again1 cut the hood from the center of the forehead over the top of the head and fold the right and left sides of the hood away from the patient's head1 removing the hood4 7#b7 ,decontaminate the mask and patient's face4 ,decontaminate the mask and the patient's face by using the ,,sdk or a #j4e percent hypochlorite solution4 ,wipe the external parts of the mask2 cover both mask air inlets with gauze or your hands to keep the mask filters dry4 ,continue by wiping the exposed areas of the patient's face1 to include the neck and behind the ears4 f4 ,step #c4 ,remove ,field ,medical ,card4 ,cut the ,,fmc tie wire1 allowing the card to fall into a plastic bag4 ,seal the plastic bag and rinse it with the #e percent hypochlorite solution4 ,place the plastic bag under the back of the protective mask head straps4 g4 ,step #d4 ,remove all gross contamination from the patient's overgarment4 ,remove all visible contamination spots by using the ,,sdk 7preferred method7 or a sponge dipped in a #e percent hypochlorite solution4 h4 ,step #e4 ,remove overgarments4 7#a7 ,remove the patient's personal effects4 ,place the patient's personal effects in a clean bag and label with the patient's identification4 ,if they are not contaminated1 give them to him4 ,if his personal effects are contaminated1 place the bagged items in the contaminated storage area until they can be decontaminated1 then return them to the patient4 7#b7 ,remove overgarment jacket4 ,have the patient stand with his feet spread apart at shoulder width4 ,unsnap the jacket front flap and unzip the jacket4 ,if the patient can extend his arms1 have him clinch his fists and extend his arms backward at about a #cj angle4 ,move behind the patient1 grasping his jacket collar at the sides of the neck1 peel the jacket off the shoulders at a #cj angle down and away from the patient4 ,avoid any rapid or sharp jerks that can spread contamination4 ,gently pull the inside sleeves over the patient's wrists and hands4 ,if the patient cannot extend his arms1 you must cut the jacket to aid in its removal4 ,dip the cutting device in the #e percent hypochlorite solution between each cut4 ,as with the litter patient1 cut both sleeves from the inside1 starting at the wrist1 up to the armpit4 ,continue cutting across the shoulder to the collar4 ,cut around bandages or splints1 leaving them in place4 ,next1 peel the jacket back and downward to avoid spreading contamination4 ,ensure that the outside of the jacket does not touch the patient or his inner clothing4 7#c7 ,remove overgarment trousers4 ,unfasten or cut all ties1 buttons1 or zippers before grasping the trousers at the waist and peeling them down over the patient's combat boots4 ,again1 the trousers are cut to aid in removal4 ,if necessary1 cut both trouser legs starting at the ankle1 keeping the cuts near the inside of the legs1 along the inseam1 to the crotch4 ,cut around all bandages1 tourniquets1 or splints4 ,continue to cut up both sides of the zipper to the waist and allow the narrow strip with the zipper to drop between the legs4 ,place the cutting device in the #e percent hypochlorite solution4 ,peel or allow the trouser halves to drop to the ground4 ,have the patient step out of the trouser legs1 one at a time4 ,place the trousers in the contaminated disposal bag4 7#d7 ,remove overboots4 ,remove the patient's overboots by cutting the laces with cutting device dipped in the #e percent hypochlorite solution4 ,fold the lacing eyelets flat on the ground4 ,step on the toe and heel eyelets to hold the overboot on the ground and have the patient step out of it4 ,repeat this procedure for the other overboot4 ,if the ,,gvo are worn1 first try to remove the overboots without cutting2 if necessary1 cut the overboots along the front4 ,if the overboots are in good condition1 they can be decontaminated and reissued4 7#e7 ,remove the patient's outer gloves4 ,grasp the heel of the glove1 peel the glove off with a smooth downward motion4 ,place the contaminated gloves in a plastic bag with the overgarment jacket4 ,do not allow the patient to touch his clothing or other contaminated objects with his exposed hands4 7#f7 ,remove the patient's cotton glove liners4 ,have the patient remove his cotton glove liners to reduce the possibility of spreading contamination4 ,have the patient grasp the heel of one glove liner with the other gloved hand1 peeling it off of his hand4 ,hold the removed glove by the inside and grasp the heel of the other glove1 peeling it off of his hand4 ,place both glove inserts in the contaminated waste bag4 i4 ,step #f4 ,remove patients ,,bdu4 7#a7 ,remove the patient's personal effects4 ,place the patient's personal effects in a clean bag and label with the patient's identification4 ,if they are not contaminated1 give them to him4 ,if his personal effects are contaminated1 place the bagged items in the contaminated storage area until they can be decontaminated1 then return them to the patient4 7#b7 ,remove ,,bdu jacket4 ,have the patient stand with his feet spread apart at shoulder width4 ,unbutton the front flap of the jacket4 ,if the patient can extend his arms1 have him clinch his fists and extend his arms backward at about a #cj angle4 ,move behind the patient1 grasping his jacket collar at the sides of the neck1 peel the jacket off the shoulders at a #cj angle down and away from the patient4 ,avoid any rapid or sharp jerks that can spread contamination4 ,gently pull the inside sleeves over the patient's wrists and hands4 ,if the patient cannot extend his arms1 you must cut the jacket to aid in its removal4 ,dip the cutting device in the #e percent hypochlorite solution between each cut4 ,as with the litter patient1 cut both sleeves from the inside1 starting at the wrist1 up to the armpit4 ,continue cutting across the shoulder to the collar4 ,cut around bandages or splints1 leaving them in place4 ,next1 peel the jacket back and downward to avoid spreading contamination4 ,ensure that the outside of the jacket does not touch the patient or his inner clothing4 7#c7 ,remove ,,bdu trousers4 ,unfasten or cut all ties1 buttons1 or zippers before grasping the trousers at the waist and peeling them down over the patient's combat boots4 ,again1 the trousers are cut to aid in removal4 ,if necessary1 cut both trouser legs starting at the ankle1 keeping the cuts near the inside of the legs1 along the inseam1 to the crotch4 ,cut around all bandages1 tourniquets1 or splints4 ,continue to cut up both sides of the zipper to the waist and allow the narrow strip with the zipper to drop between the legs4 ,place the cutting device in the #e percent hypochlorite solution4 ,peel or allow the trouser halves to drop to the ground4 ,have the patient step out of the trouser legs1 one at a time4 ,place the trousers in the contaminated disposal bag4 7#d7 ,remove undergarments4 ,remove the patient's tee shirt4 ,dip the cutting device in the #e percent hypochlorite solution between each cut4 ,cut both sleeves from the inside1 starting at the elbow1 up to the armpit4 ,continue cutting across the shoulder to the collar4 ,cut around bandages or splints1 leaving them in place4 ,next1 peel the tee shirt away from the body to avoid spreading contamination4 ,if the patient is wearing a brassiere1 cut it between the cups4 ,cut both shoulder straps where they attach to the cups and lay them back off of the shoulders4 ,remove the patient's under shorts_/panties by cutting from the lower side of the hip to the waist on both sides4 ,allow the shorts_/panties to fall to the ground4 ,do not remove the patient's identification tags4 j4 ,step #g4 ,check patient for contamination4 ,after the patient's ,,bdu and underwear has been removed check the skin for contamination by using ,m#h detector paper or the ,,cam4 ,carefully survey all areas of the patient's skin1 paying particular attention to areas around the neck1 wrist1 ears1 and dressings1 splints1 or tourniquets4 k4 ,step #h4 ,decontaminate skin4 7#a7 ,spot decontamination4 ,use the ,,sdk or the #j4e percent hypochlorite solution to spot decontaminate exposed neck and wrist areas1 splints1 other areas where the protective overgarment was damaged1 and where dressings or bandages were removed4 ,decontaminate the patient's identification tags1 if necessary4 ,have the patient hold his breath and close his eyes4 ,have him1 or assist him1 lift his mask at the chin4 ,wipe his face with the ,m#bia pad or the #j4e percent hypochlorite solution4 ,wipe quickly from below the top of one ear1 being careful to wipe all folds of the skin1 top of the upper lip1 chin1 dimples1 earlobes1 and nose4 ,continue up the other side of the face to the top of the other ear4 ,wipe the inside of the mask where it touches the face4 ,have the patient reseal and check his mask4 ---------------------------------------- ------- ,,caution ,keep the decontamination solution out of the patient's eyes4 ---------------------------------------- ------- 7#b7 ,trauma specialist care4 ,during clothing removal1 the clothing around bandages1 tourniquets1 and splints was cut and left in place4 ,the trauma specialist replaces the old tourniquet by placing a new one to #a inch above the old tourniquet4 ,when the old tourniquet is removed1 the skin is decontaminated with the ,,sdk or the #j4e percent hypochlorite solution4 ,do not remove splints4 ,decontaminate them by thoroughly rinsing the splint1 padding1 and cravats with the #j4e percent hypochlorite solution4 ,usually1 the trauma specialist will gently cut away bandages4 ,the area around the wound is dusted with the ,m#bia pad or rinsed with the #j4e percent hypochlorite solution1 and the trauma specialist applies the ,m#bia pad or irrigates the soft tissue wound with the #j4e percent hypochlorite solution4 ,if bleeding begins1 the trauma specialist replaces the bandage with a clean one4 l4 ,step #i4 ,dispose of contaminated waste4 ,dispose of contaminated bandages and coverings by placing them in a plastic bag and sealing the bag with tape4 ,place the plastic bags in the contaminated waste dump4 m4 ,step #aj4 ,proceed through the shuffle pit to the clean treatment area4 ,have the decontaminated patient proceed through the shuffle pit to the clean treatment area4 ,make sure that the patient's boots are thoroughly decontaminated by stirring the contents of the shuffle pit with his boots as he crosses it4 ,the patient will remove his combat boots and socks at the entrance of the clean treatment area or ,,cps2 remove the protective mask at the entrance to the clean treatment area or inside the ambulatory air lock of the ,,cps4 ,g-#ab4 ,biological ,patient ,decontamination ,procedures ,the decontamination station as established for chemical agent patients is also used for biologically contaminated patients4 ,the eight-man patient decontamination team is required for biologically contaminated patient decontamination procedures4 ,g-#ac4 ,decontaminate a ,litter ,biological ,agent ,patient a4 ,remove the patient's personal effects4 ,place the patient's personal effects in a clean bag and label with the patient's identification4 ,if they are not contaminated1 give them to him4 ,if his personal effects are contaminated1 place the bagged items in the contaminated storage area until they can be decontaminated1 and then return them to the patient4 b4 ,remove the ,field ,medical ,card4 ,remove the ,,fmc by cutting the tie wire and allowing the ,,fmc to drop into a plastic bag4 ,keep the ,,fmc with the patient4 c4 ,remove the patient's clothing4 ,patient decontamination team members first apply the #e percent hypochlorite solution to the patient's clothing and the litter4 ,then1 remove the patient's clothing as in decontamination of chemical agent patients4 ,bandages1 tourniquets1 and splints are not removed4 ,move patient to a clean litter as described for a chemical agent patient4 ,place patient's clothing in a plastic bag and dispose in the contaminated waste dump4 d4 ,decontaminate the patient's skin4 ,bathe the patient with soap and warm water or apply the #j4e percent hypochlorite solution4 ,the trauma specialist places a new tourniquet to #a inch above the old tourniquet1 and then he removes the old one4 ,the trauma specialist removes bandages and decontaminates the skin and wound with the #j4e percent hypochlorite solution2 he replaces the bandage1 if needed1 to control hemorrhage4 ,splints are disinfected by soaking the splint1 cravats1 and straps with the #j4e percent hypochlorite solution4 ,,note ,use a #j4e percent hypochlorite solution to decontaminate patients suspected of being contaminated with mycotoxins4 e4 ,transfer patient to hot line4 ,two decontamination team members move patient to the hot line4 ,request assistance from two other decontamination team members to transfer him to a clean litter as described for chemical agent patients4 ,place the patient's ,,fmc in the plastic bag on the clean litter with him4 ,two trauma specialists from the clean side of the hot line move the patient from the hot line to the clean treatment_/holding area4 ,g-#ad4 ,decontaminate an ,ambulatory ,biological ,agent ,patient a4 ,remove the patient's personal effects4 ,place the patient's personal effects in a clean bag and label with the patient's identification4 ,if they are not contaminated1 give them to him4 ,if his personal effects are contaminated1 place the bagged items in the contaminated storage area until they can be decontaminated1 then return them to the patient4 b4 ,remove the ,field ,medical ,card4 ,remove the ,,fmc by cutting the tie wire and allowing the ,,fmc to drop into a plastic bag4 ,keep the ,,fmc with the patient4 c4 ,remove the patient's clothing4 ,patient decontamination team members first apply the #e percent hypochlorite solution to the patient's clothing4 ,then remove the patient's clothing as in decontamination of chemical agent patients4 ,bandages1 tourniquets1 and splints are not removed4 ,place patient's clothing in a plastic bag and dispose in the contaminated waste dump4 d4 ,decontaminate the patient's skin4 ,have the patient bathe with soap and warm water or apply the #j4e percent hypochlorite solution4 ,if the patient is unable to bathe himself1 a member of the decontamination team must bathe him4 ,the trauma specialist places a new tourniquet to #a inch above the old tourniquet1 and then he removes the old one4 ,the trauma specialist removes bandages and decontaminates the skin and wound with the #j4e percent hypochlorite solution2 he replaces the bandage1 if needed1 to control hemorrhage4 ,splints are disinfected by soaking the splint1 cravats1 and straps with the #j4e percent hypochlorite solution4 ,,note ,use a #j4e percent hypochlorite solution to decontaminate ambulatory patients suspected of being contaminated with mycotoxins4 e4 ,direct patient across hot line4 ,direct the patient to cross the hot line to the clean treatment area4 ,his boots must be decontaminated at the hot line before he enters the clean treatment area4 ,,notes #a4 ,remember1 do not remove clothing from an ambulatory patient unless he requires treatment in the clean treatment area of the ,,bas or clearing station4 ,only spot decontaminate the patient's clothing and evacuate him to the next level of care4 #b4 ,place cutting device used in this procedure in a container of #e percent hypochlorite solution when not in use4 ,most ambulatory patients will be treated in the contaminated treatment area and returned to duty4 ,upon removal of an ambulatory patient's clothing1 he becomes a litter patient4 ,the ,,bas and clearing station do not have clothing to replace those cut off during the decontamination process4 ,the patient must be placed in a ,,ppw for protection during evacuation 7,figure ,g-#g74 ,g-#ae4 ,decontaminate ,nuclear-,contaminated ,patients ,the practical decontamination of nuclear-contaminated patients is easily accomplished without interfering with the required medical care4 ,,note ,patients must be monitored by using a radiac meter 7,,an_/,,vdr#b1 ,,an_/,,pdr#bg1 or ,,an_/,,pdr#gg7 before1 during1 and after each step of the decontamination procedure4 ,g-#af4 ,decontaminate a ,litter ,nuclear-,contaminated ,patient a4 ,remove patient's personal effects4 ,patient decontamination team members remove the patient's personal effects and place them in a plastic bag4 ,place plastic bag in a clean holding area4 b4 ,remove patient's clothing4 ,patient decontamination team members remove the patient's outer clothing as described for chemical agent patients4 ,do not remove bandages1 tourniquets1 or splints4 ,move the patient to a clean litter4 ,place the patient's contaminated clothing in a plastic bag and move the bagged clothing to the contaminated waste dump4 ,,note ,patients arriving at the ,,mtf in ,,mopp will only have their ,,mopp removed4 ,they can remain in their ,,bdu unless contamination is found on it4 c4 ,spot decontaminate patient's skin4 ,wash exposed skin surfaces with soap and warm water4 ,wash the hair with soap and warm water1 or clip the hair and wash the scalp with soap and warm water4 d4 ,transfer patient to hot line4 ,move the patient to the hot line4 ,two trauma specialists from the clean side of the hot line move the patient into the clean treatment area4 ,g-#ag4 ,decontaminate an ,ambulatory ,nuclear-,contaminated ,patient a4 ,remove patient's personal effects4 ,have the patient remove his personal effects and place them in a plastic bag4 b4 ,remove patient's outer clothing4 ,have the patient remove his outer clothing 7or have a decontamination team member assist him74 ,place his contaminated clothing in a plastic bag and move the bagged clothing to the contaminated waste dump4 ,,note ,patients arriving at the ,,mtf in ,,mopp will only have their ,,mopp removed4 ,they can remain ambulatory in their ,,bdu unless contamination is found on it4 c4 ,spot decontaminate patient's skin4 ,have the patient wash his exposed skin surfaces with soap and warm water4 ,wash his hair with soap and water1 or clip the hair and wash the scalp with soap and water4 d4 ,transfer patient to hot line4 ,direct the patient to move to the hot line4 ,decontaminate his boots by stirring the shuffle pit contents with his feet before he crosses into the clean treatment area4 ,,note ,if a new protective overgarment is not available1 after treatment1 the ambulatory patient must be placed in a ,,ppw for protection during ,,medevac to the next level of care ,,mtf4 ,thus1 he becomes a litter patient for evacuation4 ,,appendix ,h ,,field ,,expedient ,,protective ,,systems ,,against ,,nuclear1 ,,biological1 ,,and ,,chemical ,,attack ,h-#a4 ,general ,medical units must have protection from ,,nbc attack and contamination to survive and function effectively4 ,the extent of protection provided is only limited by the resources available and efforts of unit personnel4 ,protection as simple as an individually dug foxhole or as elaborate as the subbasement of a concrete building may be used4 ,expedient protection from the effects of biological and chemical agents are usually much less labor intensive4 ,h-#b4 ,protection ,against ,radiation ,the level of protection from radiation is expressed in terms of shielding4 ,material is available on the battlefield to construct_/prepare expedient fallout shelters that offer substantial shielding against gamma radiation 7see ,table ,h-#a74 ,generally1 the denser or heavier the material1 the better shielding it offers4 ,the degree of protection afforded by a fallout shelter is expressed as a protection factor1 or a transmission factor4 ,the protection factor is simply the fraction of the available radiation dose that penetrates the shelter and reaches those inside compared to the radiation received by an unprotected person4 ,thus1 a protection factor of #b indicates that an individual in the shelter receives one-half of the radiation dose he would receive if unprotected4 ,a protection factor of #ajj 7associated with about six half-value thicknesses7 indicates that only #a_/ajj or #a percent of the radiation dose reaches the inside4 ,transmission factors are expressed in percentages1 or in decimals4 ,either refers to that fraction of the ambient unshielded dose that is received by personnel within the shelter4 ,fallout gamma transmission factors for some common shelters are shown in ,table ,h-#b4 ,table ,h-#a4 ,shielding ,potential of ,common ,materials--,fallout ,gamma ,protection ,,material #a_/b ,,value ,,layer ,,thickness99 ---------------------------------------- --------------------- ,,steel #a4h ,,cm 74#g7 ,,concrete #e4f ,,cm 7#b4b7 ,,earth #h4d ,,cm 7#c4c7 ,,water #ab4b ,,cm 7#d4h7 ,,wood #bb4d ,,cm 7#h4h7 ---------------------------------------- --------------------- 99 #a_/b ,,value ,,layer ,,thickness--,,thickness ,,of ,a ,,given ,,material ,,which ,,reduces ,,the ,,dose ,,or ,,dose ,,rate ,,to ,,approximately ,,one-,,half ,,of ,,that ,,falling ,,upon ,,it4 ,table ,h-#b4 ,transmission factors for ,nuclear ,radiation99 ,,initial ,,environmental ,,shielding ,,neutrons ,,gamma ,,residual ---------------------------------------- -------------------------- ,,built-,,up ,,city ,,area 7,,in ,,open7 #a4j #j4e #j4g ,,foxholes #j4c #j4b #j4a ,,frame ,,house3 ,,first ,,floor #a4j #j4i #j4e ,,basement #j4e #j4c #j4a ,,multistory ,,buildings3 ,,top ,,floor #a4j #j4i #j4a ,,intermediate ,,floors #j4i #j4i #j4jb ,,lower ,,floor #j4i #j4e #j4a ,,basement #j4e #j4c #j4ja ,,shelter1 ,,closed #ia ,,cm 7#c ,,ft7 7,,earth ,,cover7 #j4je #j4jb #j4jje ,,armored ,,vehicles3 ,,armored ,,personnel ,,carrier #j4c #j4b #j4a ,,tanks #j4c #j4b #j4a ,,wooded ,,forest #a4j #a4j #j4h ---------------------------------------- -------------------------- 99 ,,inside ,,dose ,,transmission ,,factor ,,times ,,outside ,,dose4 ,h-#c4 ,expedient ,shelters for ,protection ,against ,radiation a4 ,in many cases it will be unnecessary to construct field expedient or other types of fallout shelters4 ,there are many structures and terrain features available that afford a degree of fallout protection4 ,existing fallout shelters are tunnels1 caves1 culverts1 overpasses1 ditches1 ravines1 and man-made structures4 ,the best existing shelters are basements4 ,figure ,h-#a shows typical protection provided in buildings4 ,windows can be sandbagged or covered with dirt from the outside to provide additional protection4 ,illustration3 ,figure ,h-#a4 ,typical shelter protection provided in buildings4 b4 ,planners should attempt to locate ,,hss units near existing shelters1 whenever possible4 ,however1 if an ,,hss unit is already established1 or must be established where fallout shelters are not available1 then a shelter must be constructed4 ,elaborate shelters are not required1 since they usually only need to be occupied for a few days4 ,there are a number of field expedients that will serve to save personnel and patients even though they may not be comfortable for those few days4 c4 ,when engineer support is available1 a bulldozer trench about #b4g meters 7#i feet7 wide and #a4b meters 7#d feet7 deep can be dug 7,figure ,h-#b74 ,the length of the trench will be determined by the number of patients_/personnel to be sheltered4 ,about #j4f meter 7#b feet7 length of trench is required for each person to be sheltered4 ,these trenches reduce exposure of personnel lying on the floor to about #bj to #cj percent of the radiation that they would receive in the open4 ,protection and comfort can be improved1 as time permits1 by digging the trenches deeper2 undercutting the walls 7care must be taken in this option2 the earth may cave in72 erecting tents over the trenches2 and providing improved flooring4 ,when used with other individual and collective protection measures1 bulldozer trenches provide adequate fallout shelters for most situations2 they can be provided in a minimum of time and effort4 ,trenches should not be dug in areas subject to flooding during rainstorms2 a berm should be formed on the uphill side of the trench to direct water around the trench in the event rainfall occurs in the area4 ,undercutting will not be possible in sandy soil2 also some form of support to keep the walls from caving in is required4 ,illustration3 ,figure ,h-#b4 ,dozer trench4 d4 ,dug-in tents 7,figure ,h-#c7 for hospitals provide more comfort and require less movement than the bulldozer trench2 however1 they have two drawbacks4 ,first1 they offer far less radiation protection than the bulldozer trench1 and second1 they require considerably more engineer effort4 ,this option should work well with ,,gp tents1 but will probably be hard to accomplish with the ,,temper4 ,illustration3 ,figure ,h-#c4 ,dug-in tents4 e4 ,sandbagged walls around the hospital tents1 as shown in ,figure ,h-#d1 or lightly constructed buildings provide protection from fallout4 ,sandbagged walls #a4b meters high give significant protection 7#bj to #dj percent transmission factor72 however1 the effort required to achieve the protection is such that it is marginally feasible4 ,sandbagging is an effective means for supplementing other shelters by-- ,bolstering the shielding at weak points4 ,forming baffles at entryways4 ,blocking open ends of trenches4 ,covering windows and gaps4 f4 ,when other shelters are not available1 ,,hss units must prepare foxholes and trenches for patients and unit personnel4 ,as time permits1 improve these shelters by deepening1 covering1 undercutting1 and sandbagging4 ,illustration3 ,figure ,h-#d4 ,sandbag walls around tents4 ,h-#d4 ,expedient ,shelters ,against ,biological and ,chemical ,agents a4 ,when ,,cps systems are not available1 well-sealed shelters 7,,temper1 ,,iso1 and ,,gp7 can significantly minimize or prevent the entry of ,,cb agents4 ,the ventilation system must be turned off1 and kept off1 before1 during1 and after the attack4 ,the shelter must be totally sealed during this time to maximize protection4 ,table ,h-#c provides examples of protection values for well-sealed shelters4 ,for example1 a well-sealed ,,temper will only permit #a_/fj of the ,,cb agent outside to enter the shelter4 ,if a persistent agent is used1 be aware of agent off-gassing hazards4 ,persistent agents can penetrate ,,temper fabric and create a vapor hazard inside4 ,in a ,,cb agent attack1 ensure that all staff and patients are protected by wearing their ,,mopp or are in ,p,p,ws4 ,table ,h-#c4 ,ratio at ,nonpersistent ,agent ,concentrations 7,inside_/,outside7 for ,different ,shelters ,,shelter ,,ratio ,,inside_/,,outside ---------------------------------------- ------------------------- ,,temper ,,tent #a3fj99 ,,general ,,purpose ,,tent1 ,,medium1 ,,with ,,cotton ,,liner #a3ej ,,general ,,purpose ,,tent1 ,,large1 ,,with ,,cotton ,,liner #a3cj ,,iso ,,shelter #a3fj ---------------------------------------- ------------------------- 99 ,,the ,,ventilation ,,system ,,must ,,be ,,turned ,,off ,,on ,,all ,,shelters ,,to ,,provide ,,this ,,level ,,of ,,protection4 b4 ,sealing shelters to prevent entry of ,,cb agents does not require elaborate materials or procedures4 7#a7 ,materials needed for sealing shelters include1 but are not limited to the following3 ,duct tape 7or similar tape7 for sealing4 ,velcro kits for ,,temper4 ,sand_/dirt to seal base of ,,gp tents4 ,plastic sheeting and tape to seal large openings1 such as doors and windows of ,,gp tents4 7#b7 ,all vulnerable areas must be sealed4 ,seal-- ,joints in ,,iso shelters and ,,gp tents with tape4 ,tape does not work very well on ,,temper fabrics2 use ,velcro kits4 ,base of ,,gp tents with sand_/dirt4 ,stove pipe openings with tape and plastic4 ,windows of ,,gp tents with tape and plastic4 ,seal ,,temper tent windows by aligning and securing the ,velcro border tightly2 tape may be applied to the seams to provide some additional barrier4 ,all ,,iso shelter doors that do not have ,,cb protective seals1 with tape4 ,seal ,,gp tent doors with plastic sheeting and tape4 ,all windows1 doors1 and other openings of fixed sites with plastic and tape4 ,all air ventilation system vents4 ,,notes #a4 ,do not allow any entries_/exits to shelters during a ,,cb attack4 #b4 ,in hot climates the heat load will rise in sealed shelters with the ventilation system turned off4 ,personnel must carefully monitor each other and the patients4 ,all personnel must drink plenty of water to prevent heat injuries2 see ,,fm #ba-aj4 ,,appendix ,i ,,detection ,,and ,,treatment ,,of ,,nuclear1 ,,biological1 ,,and ,,chemical ,,contamination ,,in ,,water ,i-#a4 ,general ,water supplies in areas with ,,nbc contamination and in surface water supplied by runoff from such areas will most likely be contaminated4 ,the contamination of water1 whether intentional or inadvertent1 may reach concentrations that will produce casualties4 ,by special methods of analysis1 the presence of contamination can be determined4 ,treatment of contaminated water requires chemicals and equipment that are only available to quartermaster water purification units2 individuals or units should not attempt to treat their water4 ,decontamination of water is only undertaken when uncontaminated sources are not available2 then ,,only with the approval of the medical authority 7,,pvntmed or surgeon74 ,i-#b4 ,detection of ,contamination in ,water a4 ,detection of nuclear contamination in water is accomplished by using the ,,an_/,,pdr#gg1 ,,an ,,pdr_/#bg or ,,an ,,vdr_/#b radiac meters4 ---------------------------------------- -------------- ,,caution ,,do ,,not allow the probe to come into contact with the water source2 allow at least one inch of air space between the probe and water surface4 ---------------------------------------- -------------- b4 ,detection of ,,bw agents in water is accomplished by the use of field biological water test kits and specially designed collection and detection kits4 ,the specialty kits will be provided as needed1 and will be available to ,,pvntmed and supporting medical laboratory personnel4 ,when required for the ,president and ,secretary of ,defense purpose1 samples must be collected and prepared for shipment to the supporting medical laboratory4 ,a chain of custody document must be prepared by the collector and maintained as the sample7s7 is being transported to the supporting medical laboratory and throughout its transit to the ,,conus laboratory4 ,see ,appendix ,f for details on suspect ,,bw sample collection1 packaging1 chain of custody1 and handling4 c4 ,the ,chemical ,agent ,water ,testing ,kit1 ,m#bgb1 provides a rapid field test to detect chemical agent contamination in water4 ,the test must be conducted before the water is treated with chlorine2 the chlorine will affect the accuracy of the test for chemical agents4 ,i-#c4 ,procedures on ,discovery of ,contamination in ,water ,when contamination is discovered the following actions are taken3 a4 ,mark the water source1 using the standard ,,nbc contamination markers1 and ensure that personnel do not consume the water until approved4 b4 ,notify the commander that the water source is contaminated and unfit for drinking1 food preparation1 and personal hygiene4 c4 ,notify the supporting water production unit1 such as the quartermaster water production and distribution unit of the contaminated water source4 d4 ,the commander establishes safeguards to prevent personnel from using the contaminated water supply4 e4 ,an alternative source of uncontaminated water is sought and used4 ,the primary source for obtaining water is from quartermaster-operated water production and distribution points4 ,other sources are considered only when quartermaster-operated faculties are not available4 ,alternative sources that may be considered include-- ,ground water sources that are least likely to be contaminated4 ,local fixed facility water supplies4 ,however1 these supplies must be tested before use4 ,if ,,nbc contamination is found do not use4 ,using another location to obtain an uncontaminated water source1 when the tactical situation permits4 f4 ,contaminated water must not be used until it has been treated by quartermaster water production and distribution units or other equally capable water purification units and approved for use by the medical authority4 ,i-#d4 ,treatment of ,contaminated ,water ,contaminated water requires additional equipment and supplies to remove the contamination4 ,quartermaster water purification and distribution units are equipped to perform these duties4 ,see ,,fm #aj-eb for details4 ,,appendix ,j ,,food ,,contamination ,,and ,,decontamination ,j-#a4 ,general a4 ,food ,susceptibility4 ,stored1 transported1 and prepared food is susceptible to ,,nbc contamination throughout the ,,to4 ,planning for any battle or operation must include food protection from contamination2 food contamination detection2 and contaminated food disposition 7decontaminate or destroy74 b4 ,countermeasures4 ,there are three primary countermeasures to overcome or reduce the ,,nbc hazard to food3 7#a7 ,contamination avoidance4 7#b7 ,nuclear1 biological1 and chemical agent detection4 7#c7 ,nuclear1 biological1 and chemical agent decontamination4 c4 ,priorities4 ,the priorities for conducting ,,nbc countermeasures are-- 7#a7 ,contamination avoidance4 ,contamination avoidance includes using natural and fabricated barriers to prevent1 or significantly reduce the spread of contamination4 ,also1 using specific procedures for entry and exit between contaminated and uncontaminated areas reduce the potential for spreading contamination4 ,use of these barriers and procedures may reduce the subsequent need for detection and decontamination4 7#b7 ,detection1 measurement1 and identification4 ,these activities are essential for determining the presence1 extent1 and nature of ,,nbc contamination4 ,this information is essential in identifying the existence of uncontaminated supplies1 or decontamination requirements4 7#c7 ,decontamination4 ,decontamination removes the contaminant and provides food that is safe for consumption4 d4 ,decontamination4 ,decontamination efforts require an extensive amount of labor1 time1 and supplies4 ,the use of hasty decontamination is emphasized4 ,that is1 decontaminate just enough to sustain operations and keep fighting1 rather than to make a contamination-free environment4 ,normally1 decontamination efforts will be limited to the packaging and packing materials4 ,food decontamination will only occur in critical situations where other food supplies are not available4 ,most decontamination is performed in or very near the ,,ao4 ,before beginning decontamination procedures1 divide exposed food items into groups based on protection of item at time of exposure4 ,these groups establish priorities based on ease of decontamination and the ability to monitor the food4 7#a7 ,group ,i--,canned or packaged items exposed only to a chemical agent vapor4 7#b7 ,group ,,ii--,canned or packaged items that are contaminated on the outside with a liquid chemical agent1 a biological agent1 or radioactive fallout4 7#c7 ,group ,,iii--,unpacked or poorly packaged items that have been exposed to any ,,nbc agent4 7#d7 ,group ,,iv--,food contaminated through the food chain4 ,j-#b4 ,protection of ,food from ,contamination ,an adequate defensive posture for a chemical attack will also protect food against biological contamination and radiation fallout4 a4 ,operational ,rations4 ,operational rations include1 but are not limited to1 ,m,r,es2 unit group ration 7,,ugr71 ,a2 unit group ration1 heat and serve2 and medical diet supplement4 7#a7 ,packaging materials and storage methods normally protect these rations4 ,the packaging and packing of operational rations protect the contents from deterioration4 ,as a result1 the contents are protected from moisture1 to include chemical liquids1 chemical vapors1 and biological agents4 ,operational rations delivered to an ,,ao will usually have increased levels of packaging and_/or packing protection4 ,operational rations are substantially protected while contained in the shipping cases1 especially if protected with an overlay of fiberboard1 shrink wrap1 or film wrap4 7#b7 ,enclosed storage is used whenever possible4 ,refrigerated warehouses1 cold storage rooms1 and even prefabricated refrigerators and trailers provide excellent protection4 ,underground shelters1 caves1 and tunnels that can be made airtight provide maximum ,,nbc protection4 ,buildings provide protection depending on how well they can be closed and sealed4 ,the basement of a building is a good storage place4 ,however1 keep in mind that chemical vapors tend to seek out low-lying areas4 ,storing rations indoors will protect them from liquid droplet and fallout contamination unless the building is damaged by an attack4 ,complete protection against chemical vapors is only offered by airtight closed spaces like cold storage facilities4 7#c7 ,chemical protective measures are to be integrated into daily logistical operation to avoid the contamination of operational rations4 ,maximum use is made of alarm and detection equipment1 overhead shelter1 shielding materials1 and protective covers4 ,back up stocks of operational rations should be dispersed to minimize the risk of destruction or contamination4 7#d7 ,an ,,nbc ,protective ,cover or similar equipment will help greatly4 ,the ,,nbc ,protective ,cover is discarded and replaced upon becoming contaminated2 it reduces overall decontamination requirements2 and it improves the survivability of supplies and equipment4 ,the ,,nbc ,protective ,cover provides #bd-;hour protection against liquid chemical contamination4 ,detection paper used on the ,,nbc ,protective ,cover will rapidly identify a contaminated cover4 b4 ,bulk and ,fresh ,foods4 7#a7 ,field expedient or improvised storage may be the only choice available under high-risk conditions4 ,expedient storage for food supplies may be a natural or man-made depression lined to protect contents against moisture1 and then covered with earth and sod4 ,the earth gives good protection against all forms of chemical or biological contamination and nuclear fallout4 7#b7 ,foods are only stored outdoors or in partially protected areas when absolutely necessary4 ,only cases of foods packed in cans1 bottles1 or airtight foil or film wraps1 and foods packed in sealed boxes or multilayered wrappings can be subjected to exposed storage4 ,partial protection is provided by open sheds1 temporary roofing1 or tents4 ,when subsistence must be stored in the open1 give as much protection as possible4 ,protection material may include ,,nbc ,protective ,covers1 tarpaulins1 tarpaulin sheds1 or any other available covering such as plastic sheeting4 ,tarpaulins and other treated or waterproof coverings do not prevent contamination by chemical vapors1 but they do reduce contamination from liquid agents4 ,canvas will keep out more than #ie percent of liquid contamination for a short period of time after the attack4 ,the canvas must be removed soon after the attack to prevent the agent from seeping through onto the subsistence2 placement of spacers between the covering and the food will greatly reduce this problem4 ,even the thinnest material will offer some protection and is better than nothing at all4 ,therefore1 food supplies must be covered by whatever material is available4 ,j-#c4 ,nuclear a4 ,contamination4 7#a7 ,following a nuclear detonation1 food can become contaminated in three ways3 ,direct contamination4 ,direct contamination results by fallout collecting on plants1 animals1 and stored food 7surface contamination74 ,fallout has two effects4 ,first1 it produces a gamma radiation field over the fallout area4 ,second1 it contaminates the surface of anything on which it is deposited4 ,the whole-body gamma irradiation hazard to an individual far outweighs any potential hazard from food contamination4 ,the basic rule is3 ,if you can safely be in the area to salvage the food1 then the food salvaged is safe to use 7although slightly contaminated74 ,indirect contamination4 ,this form of contamination can be spread throughout the food chain4 ,humans can ingest contamination by eating plants that have absorbed radioactive isotopes2 products 7milk or meat7 from animals allowed to graze on contaminated pastures2 or fish from contaminated water4 ,induced radiation4 ,it is possible that food will be exposed to sufficient neutron flux 7an increase in the number of free neutrons7 as the result of a nuclear explosion to produce considerable induced radioactivity in food without it being destroyed by blast and heat4 ,this is possible with enhanced radiation weapons in the energy range of #a ,,kt where the radiation kill radius exceeds the blast destruction zone4 ,the elements that are most prominently involved are sodium1 potassium1 sulfur1 copper1 bromine1 zinc1 and especially phosphorous4 ,thus1 in an area of induced radiation1 foods requiring the most caution are dairy products1 high salt content foods1 dry beans1 raisins1 and ready-mixed cake and biscuit flours4 ,the radioactivity has a short half-life2 therefore1 the radiation will decay very rapidly4 ,it should be possible to consume foods containing induced radiation within a week or two4 ,cans1 particularly those with ,c enamel1 may incur a high level of induced radiation 7from zinc in the enamel1 not from iron in the can74 ,glass1 because of its high salt content1 will show very high levels of activity2 clear glass will turn brown4 ,container radioactivity has no bearing on the food1 it is safe to use4 ,the radioactivity is not transferred to the contents4 ,no significant toxic by-products are formed in the exposed canned food4 7#b7 ,consumption of food contaminated with radioactive fallout may cause a risk of radiation injuries from internal radiation2 that is1 radiation from radioactive sources within the body4 ,most isotopes will pass through the digestive tract or be excreted very quickly4 ,however1 the intestinal tract may receive a considerable dose4 ,some isotopes are more hazardous because they are absorbed from the digestive tract and enter the metabolism of man and animals4 ,strontium-#hi 7,sr-#hi7 and ,strontium-#ij 7,sr-#ij7 are beta emitters and have half-lives of #ea days and #bh years1 respectively4 ,therefore1 ,sr-#ij is the greatest radiation hazard in the long term4 ,these two isotopes are absorbed in the body and used in the same way as calcium4 ,they accumulate in bone1 where bone marrow with its blood forming cells is vulnerable4 ,milk and other dairy products are the primary sources of ,sr-#hi and ,sr-#ij in the human diet4 ,iodine-#aca 7,i-#aca7 is a beta and gamma emitter and has a short physical half-life of approximately #h days4 ,it is efficiently absorbed and used by the body4 ,iodine-#aca will contaminate plants that will be eaten by grazing animals4 ,smaller amounts can also be absorbed by breathing contaminated air4 ,cattle will excrete a large amount of ,i-#aca in milk4 ,milk and other dairy products are the primary sources of ,i-#aca intake4 ,one can also get smaller amounts by eating contaminated fruits and vegetables4 ,iodine-#aca will be concentrated in the thyroid gland4 ,the intake of ,i-#aca will have its greatest impact the first few days to weeks following a nuclear explosion4 ,cesium-#acg 7,cs-#acg7 is a beta emitter and has a half-live of #cj years1 but is eliminated relatively quickly from the body4 ,the biological half-live is #gj to #adj days4 ,cesium-#acg is found in most tissues of the body1 but it will concentrate in muscle tissue4 ,cesium-#acg is absorbed and used the same way as potassium4 ,meat and milk are the primary sources of ,cs-#acg4 ,much precipitation1 lack of minerals in the soil1 and extensive cultivation increase the plants' absorption of ,cs-#acg2 thus1 the contamination of plant products4 7#c7 ,operational rations are safe when surface decontamination is performed before breaking the package4 ,operational rations stored close to ground zero may become radioactive from induced radiation4 ,it is more likely1 however1 that the food will be damaged or destroyed by the blast and thermal effects of the nuclear explosion4 7#d7 ,bulk and fresh food stored in the open without protection will be contaminated4 ,decontamination is very difficult and time-consuming4 ,efforts should be made to ensure proper packing to prevent food contamination from radioactive fallout4 ,packing made from hard and nonporous materials1 such as plastic or multilayer cardboard with a smooth surface1 should be used4 ,in addition1 storage facilities should be enclosed to avoid the entry of fallout4 ,any material used as a protective cover will give some protection against nuclear fallout4 ,protection against induced radiation1 blast1 and thermal effects requires a hardened shelter or underground storage4 7#e7 ,food supplies require protection throughout the chain of production or procurement4 ,protection of the civilian-based food supply includes countermeasures along the production chain4 ,meats and milk are the most vulnerable products because of the possibility for concentration of radioactive isotopes 7,strontium1 ,cesium1 and ,iodine74 ,the primary1 and possibly the only1 protection of animal products is to keep the animals indoors and to avoid contaminated fodder4 ,immediate slaughter of food animals is recommended if there is a shortage of uncontaminated fodder4 ,also1 food animals exposed to fallout should be considered fit for consumption and slaughtered using routine procedures4 ,unharvested crops cannot be protected4 b4 ,inspection and ,monitoring4 7#a7 ,fallout close to ground zero1 especially after a surface burst1 may be visible as dust4 ,the presence of dust is an immediate indicator of contamination4 ,fallout on unprotected food produces a grittiness that is unpleasant and warns against eating the food4 ,the degree and means of food protection 7packaging and storage faculties7 must be considered4 ,food in a building that remains intact should not receive enough contamination to be dangerous when eaten4 7#b7 ,veterinary units have the ,,an_/,,vdr#b ,radiac ,set and ,,udr#ac dosimeter to conduct ground or aerial surveys for gamma radioactive contamination levels in an area4 ,the measurement of the external gamma radiation in the fallout area is an indication1 but not a quantitative measure1 for the degree of hazard from food contamination4 ,these units also use the ,,an_/,,vdr#b ,radiac ,set for point detection of gamma and beta radiation sources4 ,food monitoring is conducted in an area with low background radiation4 ,if the storage area is contaminated1 the food must be moved to a cleaner area for monitoring4 ,with the ,,an_/,,vdr#b1 the initial food monitoring is performed with the probe cover in place and the probe passed approximately #f inches from the surface4 ,if the reading is twice the background dose rate1 the food is considered contaminated4 ,if the reading is not above the background level but contamination is still suspected1 place the probe closer to the food with the beta probe cover off4 ,monitor meat and fish with the probe cover off2 pass the probe approximately one-half inch from the surface of the food4 7#c7 ,monitoring food contaminated through the food chain is more complicated2 depending on the detection instrument used1 special procedures must be followed4 ,gamma and beta emitting radionuclides in small volumes may be detected using radiac sets such as the ,,an_/,,vdr#b2 however1 alpha emitting ones cannot4 ,they are rough instruments and may be used only for screening surface contaminated food4 ,to evaluate the hazards2 the isotopes contributing to the radioactivity must be identified4 ,surface contaminated food will contain a mixture of isotopes with some more hazardous than others1 depending upon whether they are used by the body4 ,milk will contain mostly ,i-#aca1 ,cs-#acg1 ,sr-#hi1 and ,sr-#ij4 ,meat and fish will contain mostly ,cs-#acg4 ,to verify ,i-#aca1 ,cs-#acg1 ,sr-#hi1 and ,sr-#ij contamination1 samples must be sent to laboratories equipped to analyze the samples4 7#d7 ,all newly selected food supplies must be surveyed4 ,begin continuous monitoring immediately following receipt of a fallout warning1 or when increased levels of radiation are detected by periodic monitoring4 7#e7 ,periodic monitoring is needed to establish baseline levels of background radiation in the environment and various food products4 ,this monitoring is performed during peacetime1 when possible1 and throughout the time ,,us forces are deployed in a ,,to4 ,,note ,the ,,an_/,,vdr#b is being replaced by the ,,an_/,,pdr#gg ,radiac ,set4 c4 ,decontamination4 ,there are two methods for nuclear decontamination3 aging and removing4 ,aging is the process of allowing natural radiation decay to occur4 ,the time necessary for this decay to take place depends upon the isotopes present2 each has a different decay rate 7half-life74 ,aging may not be possible when there is a short food supply4 ,in some instances1 such as with induced radioactivity1 it may be the only way to decontaminate4 ,removing nuclear contamination from areas1 personnel1 food1 or moving equipment to another location eliminates the immediate hazard4 ,to determine which decontamination method is required1 food supplies are divided into groups4 ,see ,table ,j-#a for additional information on food items and decontamination4 7#a7 ,group ,,ii--,food in sealed and dust-proof packing such as cans1 jars1 fiberboard1 and cellophane4 ,these products are easily decontaminated by removing the radioactive dust covering the packing2 brush1 wash with soap and water1 or remove the packing 7depending on the type of packing material74 ,if radiation is still detected after removing the dust1 repeat the brush_/wash procedure and remonitor4 ,if radiation is still present1 the food itself is then considered radioactive 7induced radiation7 and is unfit for consumption4 ,decontamination of induced radiation is possible only through aging4 ,after aging one to two weeks1 the food should be safe for consumption4 ,after surface decontamination1 the contents are safe to eat unless the food has induced radiation4 7#b7 ,group ,,iii--,unprotected food4 ,the method chosen to decontaminate unprotected food items will depend upon whether or not the food supply is critical4 ,if the food supply is not critical1 the contaminated items are isolated and allowed to decontaminate by aging4 ,if the food supply is critical1 food with surface contamination can1 in principle1 be decontaminated by removing the contaminated surface1 or by washing4 7#c7 ,some products can be decontaminated by washing1 peeling1 or trimming the outer skin or leaves4 ,decontaminate potatoes and hard-skinned fruits and vegetables by washing or scrubbing under running water1 followed by peeling or scraping1 then washing again4 ,potatoes1 carrots1 beets1 and turnips can be washed at the supply depot4 ,however1 do not wash beans1 rice1 and onions until they are delivered to the field kitchen2 washing reduces their storage quality and shelf life4 ,citrus fruits1 pineapples1 corn1 peas1 beans1 melons1 pumpkins1 cabbage1 and nuts can be peeled4 ,decontaminate cucumbers1 tomatoes1 cherries1 cranberries1 grapes1 pears1 plums1 and thin-skinned squash by soaking in a water or detergent solution and rinsing with vigorous agitation or brushing4 ,apricots1 peaches1 most berries1 asparagus1 broccoli1 and leafy vegetables cannot be satisfactorily decontaminated because of fuzzy surfaces1 irregular shapes1 or small size1 which makes washing difficult4 ,fresh carcass meat1 sausages1 and fish can be decontaminated by several washings with cold water4 ,the exterior layer of the food item is removed if radioactivity is still present4 ,there is1 however1 a risk of contaminating the inner parts of the foodstuff in the process4 ,cooking with several changes of water is the last step in decontamination4 ,table ,j-#a4 ,decontamination of ,food ,supplies ,,type ,,of ,,contamination ,,surface ---------------------------------------- -------------- ,,or ,,material ,,chemical ,,biological ,,nuclear ---------------------------------------- ------------------------------ ,,canned1 ,,bottled1,,immerse ,,in ,,wash ,,with ,,soap ,,and ,,wash ,,with ,,soap ,,or ,,protected ,,by ,,boiling1 ,,water1 ,,then ,,immerse ,,and ,,water1 ,,rinse4 ,,impermeable ,,soapy ,,water ,,in ,,disinfectant ,,container4 ,,for #cj ,,minutes ,,solution4 7,,immerse ,,in ,,brush1 ,,wipe ,,and ,,rinse4 ,,boiling ,,water ,,for #cj ,,chlorine1 ,,food ,,minutes4 ,,food ,,dis- ,,contamination ,,infectant1 ,,or #a_/c ,,from ,,surface ,,of ,,canteen ,,cup ,,of ,,house- ,,container4 ,,hold ,,bleach ,,in #aj ,,gal ,,of ,,water74 ,,spray ,,with ,,ds#b ,,and ,,rinse ,,wash ,,in ,,hot1 ,,boil ,,in ,,water #ae ,,soapy ,,water1 ,,minutes2 ,,not ,,effective ,,rinse1 ,,and ,,on ,,toxins ,,and ,,some ,,aerate4 ,,spores4 ,,immerse ,,in #e ,,sodium ,,carbonate 7#d ,,lb ,,washing ,,soda ,,in #aj ,,gal ,,water71 ,,rinse ,,with ,,potable ,,water4 ,,immerse ,,in ,,household ,,bleach ,,solution 7#a_/b ,,gal ,,bleach ,,in #be ,,gal ,,water7 ,,for #cj ,,minutes ,,then ,,rinse ,,and ,,aerate ,,for #aj ,,minutes4 ,,immerse ,,in ,,hth ,,solution 7#a_/b ,,lb ,,in #be ,,gal ,,water7 #bj ,,minutes1 ,,then ,,rinse4 ,,immerse ,,in ,,stb ,,solution 7#a ,,lb ,,in #be ,,gal ,,water7 #cj ,,minutes1 ,,then ,,rinse4 ,,immerse ,,in #b ,,peracetic ,,acid ,,for #aj ,,minutes1 ,,rinse1 ,,and ,,aerate ,,for #aj ,,minutes4 ,,not ,,canned ,,or ,,food ,,known ,,or ,,boil ,,in ,,water #ae ,,minutes4,,wash ,,or ,,trim ,,impermeable ,,suspected ,,to ,,cook4 ,,contamination ,,container4 ,,be ,,contaminated ,,from ,,unpack- ,,should ,,not ,,be ,,immerse ,,in ,,or ,,spray ,,with ,,aged ,,food4 ,,consumed ,,until #b ,,household ,,bleach ,,approved ,,by ,,solution4 ,,packaged1 ,,veterinary ,,peeled1 ,,or ,,pared ,,food ,,may ,,personnel4 ,,be ,,immersed ,,or ,,sprayed4 ,decontaminate hard cheeses1 margarine1 and butter by cutting off the outer layer to a depth of #b4e to #c cm4 ,let cooking oils stand for #c to #e days1 then pour off the contaminated layer2 use a funnel to control spillage4 ,nonperishable items that are hard to decontaminate1 such as flour1 sugar1 and salt1 can be set aside allowing natural radioactive decay4 ,when supplies are short1 dilute the contamination by mixing with uncontaminated food4 ,this will reduce the total amount of radioactive exposure in foods prepared using these contaminated items4 ,decontaminate air permeable1 double-sacked goods by removing the outer sack4 ,if the inner sack is free of radiation1 double sack the food again to restore protection4 ,however1 when contamination is present on the inside bag1 the food in contact with the bag is likely to be contaminated4 ,three methods can be used to handle this type of contaminated product4 ,the easiest method involves spraying the bag of dry goods 7except sugar or salt7 with water4 ,this will wet a layer of the food inside the bag4 ,the wet layer can be removed when the bag contents are emptied4 ,the uncontaminated contents are scooped back into clean packaging4 ,another method involves using melted paraffin to uniformly coat the outside of the bag4 ,the paraffin solidifies after #cj to #dj minutes1 and then the bag with the radioactive contamination can be removed from the contents4 ,although this method will seal the radioactive substance in the wax1 it probably will not remove the layer of contaminated food product inside the bag4 ,for the third method1 form a piece of sheet metal into a cylinder the same height as the bag and #d to #f cm smaller in diameter4 ,insert the cylinder into the bag1 then remove the top #c to #d cm of the contaminated product4 ,carefully scoop the remaining product out into a clean sack4 ,with the cylinder still in place1 fold the bag down catching the contaminated product on plastic sheeting1 or a tarpaulin4 ,when using this method1 mixing the contaminated portion with the uncontaminated portion is a problem4 ,check for contamination remaining in the product4 ,boiling or cooking has no effect on radioactive contamination4 7#d7 ,group ,,iv--,food contaminated through the food chain4 ,it is not practical to decontaminate this food4 ,meat and milk are the two most common foodstuffs contaminated in this way4 ,milk may be decontaminated to a safe level by a complicated ion exchange process4 ,the ,i-#aca activity will decline rapidly during storage of milk and milk-products1 although the ,cesium and ,strontium activity will remain almost constant for years4 ,in an area with high-level fallout1 milk is withdrawn from human consumption4 ,the duration of withdrawal will be dependent upon the type of fallout and levels4 ,meat may be decontaminated to a safe level by soaking in water or brine4 ,cesium is loosely bound in the meat4 ,by repeated soaking of meat cut in small pieces1 most of the ,cesium activity will be removed4 ,traditional meat preserving1 such as salting with brine1 will remove up to #fj to #gj percent of the ,cesium activity4 ,see ,table ,j-#b4 ,fruits1 vegetables1 root crops1 and grain products may also contain hazardous amounts of radioactivity if ingested4 7#e7 ,food animals4 ,food animals that have been exposed to fallout should be considered fit for consumption and slaughtered using routine inspection and slaughter procedures4 ,in those cases where the animal has been exposed to fallout1 but is not scheduled for immediate slaughter1 the radiation burden can be reduced by moving the animal to an uncontaminated area 7barn if available7 and washing it with soap and water4 ,mild radiation sickness does not necessarily mean that the animals cannot be used for food4 ,if the animals have been exposed to an internal radiation hazard1 the meat can be eaten if the internal organs are discarded4 ,chickens that have eaten radioactive material may lay contaminated eggs1 but most of the radioactivity will be concentrated in the shells4 ,the white and yolk will be free of harmful amounts of radiation and can be eaten4 ,chickens will not lay eggs if the radioactive body burden is large enough that their eggs are unfit to eat4 ,table ,j-#b4 ,traditional ,salt ,preserving ,brine ,,meat1 ,,whole #d-e ,,kg #be ,na,cl 7,,salt7 ,,brine #e-,,liter ,,brine ,,per ,,kg4 ,,keep ,,meat ,,in ,,brine ,,for #c ,,weeks1 ,,temperature ,,below #aj;,c4 ,,soak ,,in ,,water ,,for #a-b ,,days4 #fe-gj ,,of ,,cs ,,activity ,,will ,,be ,,removed4 ---------------------------------------- ------------------------------ ,,meat1 ,,cut #a-b ,,kg #be ,na,cl ,,brine #e-,,liter ,,brine ,,per ,,kg4 ,,keep ,,meat ,,in ,,brine ,,for #d ,,days4 ,,soak ,,in ,,water ,,for #d ,,hours4 #fe-gj ,,of ,,cs ,,activity ,,will ,,be ,,removed4 ---------------------------------------- ------------------------------ ,,mutton_/,,lamb ,,rib ,,piece ,,of ,,rib #a-e ,,kg4 #be ,na,cl ,,brine #e-,,liter ,,brine ,,per ,,kg4 ,,keep ,,in ,,brine ,,for #b ,,days4 ,,soak ,,in ,,water ,,for #b ,,hours4 ,,air-,,drying ,,for #aj ,,days4 ,,soak ,,in ,,water ,,for #b ,,hours4 ,,boil ,,in ,,water ,,for #c ,,hours4 #he-ij ,,cs ,,activity ,,will ,,be ,,removed4 ---------------------------------------- ------------------------------ ,,decontamination ,,of ,,coarsely ,,chopped ,,meat #j4i ,na,cl ,,solution4 #b-,,liter ,,solution ,,per ,,kg4 ,,soak ,,in ,na,cl ,,solution ,,for #aj ,,min4 #fj-gj ,,cs ,,activity ,,will ,,be ,,removed4 ,,repeated ,,procedures ,,will ,,remove ,,the ,,same ,,percentage ,,of ,,cs ,,activity4 ,,six ,,times ,,repeated ,,treatment ,,will ,,remove ,,nearly #ajj ,,of ,,cs ,,activity4 d4 ,considerations ,when ,decontamination is ,not ,possible4 ,when food cannot be decontaminated1 sealing the product in a wrapping material or container may be needed4 ,sealing the product can reduce or shield the emanation of the contamination and_/or fix the contamination in place4 ,the hazard from contaminated food is small compared with that from external gamma radiation4 ,hungry people or animals should not be denied food because of possible fallout contamination4 ,it is not practicable or desirable to preset maximum permissible limits of gross fallout radioactivity as a basis for judging whether or not food should be used4 ,common sense must be applied in establishing priorities for distribution of available food4 ,for example1 use the least contaminated and the most protected food first2 hold milk products for #a to #b weeks before use4 ,j-#d4 ,biological a4 ,contamination4 ,biological warfare agents exist in the form of toxins and microorganisms4 ,the normal packaging and packing of food 7to protect against moisture1 dust1 and bacterial or other contamination7 provides protection against most biological agents4 ,the exception may be toxins and biologically derived substances4 ,however1 the protective methods used for chemical agents will also protect against toxins and derived substances4 ,food in freezers1 refrigerators1 and in refrigerated trucks or rail cars will be safe if these containers remain sealed until the outer surfaces are decontaminated4 7#a7 ,it is unlikely that a biological agent will affect the appearance1 taste1 or smell of the food enough for the change to be apparent4 7#b7 ,packaging and packing materials are not life supportive to pathogenic agents and are1 therefore1 self-decontaminating with the exception of spore-forming organisms4 7#c7 ,most operational rations are packaged in metal containers1 or encased in heavy aluminum laminated plastics that can withstand boiling water2 also1 they are impervious to arthropod penetration4 ,this food is highly resistant to biological agents4 7#d7 ,the use of unpackaged items 7unwrapped meats1 fresh fruits1 and vegetables7 should be restricted2 use only operational rations4 ,unprotected fresh food stored in the open and close to the source of dissemination will become contaminated4 b4 ,detection4 7#a7 ,rapid identification of agents used is absolutely essential to implement effective countermeasures4 ,agent identification must be achieved quickly2 it is the first step in answering critical management questions4 ,what adjustments must be made in food preparation and distribution8 ,what are the essential countermeasures8 ,what is the expected outcome of the incident8 7#b7 ,samples of food that are suspected of being contaminated are transported to the designated supporting laboratory4 ,samples must be accompanied by a description of the samples1 the sample collection procedures1 and the circumstances1 which prompted the collection4 ,the designated medical laboratory in the ,,to will provide a field confirmation identification of the agent7s74 ,designated ,,conus laboratories accomplish definitive identification4 ,see ,appendix ,b for sampling procedures4 ,,note ,new biological detection equipment is under development that will enable units to conduct presumptive identification of biological warfare agents4 ,however1 samples must also be collected and processed as described in ,appendix ,b4 c4 ,decontamination4 7#a7 ,food contaminated with toxins is handled in the same manner as food contaminated with chemical agents4 ,food contaminated with microorganisms is handled in the same manner as when contaminated with the more common foodborne disease-producing microorganisms4 7#b7 ,several methods are available to decontaminate food items contaminated with biological agents4 ,the following decontamination methods are considered to be the minimum4 ,see ,table ,j-#a4 7#c7 ,group ,,ii food that is sealed in containers that are resistant to the passage of biological agents requires only that the exterior of the container be decontaminated4 ,decontamination of these items is as follows3 7a7 ,for containers made of metal1 glass1 plastic1 or porcelain3 #a4 ,thoroughly wash the container in potable water and soap1 or in a disinfectant solution4 ,if the water used for washing is contaminated1 the soap and water wash may increase1 not reduce1 the contamination hazard4 ,after which1 the food containers are immersed in a disinfectant solution for #cj minutes 7see ,table ,j-#c72 then rinsed with potable water1 if available and time permits4 ,chlorine solutions are not as reactive or corrosive as ,,ds#b4 #b4 ,place the containers in boiling soapy water for #ae minutes2 then rinse with potable water4 ,,notes #a4 ,the chemical field decontamination kits do not meet the requirements to decontaminate food supplies exposed to biological agents4 #b4 ,the same procedures should be followed even if there is only suspicion of a biological warfare attack4 7b7 ,thoroughly wipe containers that will not withstand soaking with a cloth soaked in a chlorine detergent solution4 ,remove the food from the container and place it in ,group ,,iii4 7c7 ,metal or glass containers determined to have trichothecenes 7,yellow ,rain7 present can be decontaminated using ,,ds#b4 ,allow a contact time of #e to #cj minutes for the ,,ds#b to neutralize the toxin4 ,then rinse the container with potable water4 7#d7 ,group ,,iii food items that are not protected by the packaging material are decontaminated or disposed of as follows3 7a7 ,decontaminate foods that can be peeled or pared by immersing them in a disinfectant solution for #cj minutes1 and then rinsing them with potable water 7see ,table ,j-#c74 ,peel or pare the items after decontamination1 then wash and1 if appropriate1 cook before eating4 7b7 ,with the exception of certain heat-stable toxins1 heat is the most practical means of decontaminating food4 ,several heating methods may be used1 but the method chosen depends upon the type of food to be decontaminated4 ,the key is to apply as much heat as possible without rendering the food unfit4 #a4 ,cook in a pressure-type cooker with #ae pounds of pressure at #bej;,f 7#aba;,c7 for #ae minutes4 #b4 ,cook in a low-pressure cooker at #bbh;,f 7#aji;,c7 for #a hour4 #c4 ,bake bread or related items at #djj;,f 7#bjd;,c7 for #dj minutes4 ---------------------------------------- -------------- ,,caution ,bread made with toxin-contaminated flour 7especially with trichothecenes7 is still toxic4 ---------------------------------------- -------------- #d4 ,bake or roast meat at #cbe;,f 7#afc;,c7 for #b hours4 #e4 ,boil for at least #ae minutes when no other method is available4 7c7 ,although decontamination methods are provided above1 vegetables such as lettuce1 broccoli1 and cauliflower1 or unwrapped meats that have been exposed to biological agents should not be eaten4 7d7 ,foods1 such as butter1 ice cream1 and bread that will not withstand any of the above treatments must be destroyed4 7#e7 ,established meat inspection procedures are followed when animals exposed to biological agents must be used for food4 ,the meat must be thoroughly cooked4 ,table ,j-#c4 ,chlorine ,solutions for ,decontamination of ,biological ,warfare ,agents ,,chlorine ,,mixture ,,to ,,produce #bjj ,,ppm ,,source ,,solution ,,of ,,available ,,chlorine ---------------------------------------- ------------------- ,,household ,,bleach #a_/b ,,gal_/#be ,,gal ,,water ,,high-,,test ,,hypochlorite #a_/b ,,lb_/#be ,,gal ,,water 7,,calcium ,,hypochlorite7 ,,supertropical ,,bleach #a ,,lb_/#be ,,gal ,,water ,j-#e4 ,chemical a4 ,contamination4 7#a7 ,contamination of foodstuffs by a chemical agent may occur at any point on the battlefield4 ,this contact may render the food unpalatable also4 ,in many cases1 decontamination is difficult1 thus1 emphasis must be placed on protection4 ,keep food supplies covered at all times4 ,take special precautions to protect food that is not packed in protective packages4 ,unprotected food1 forage1 and grain supplies may be so contaminated that their consumption will produce gastrointestinal irritation1 or systemic poisoning4 ,nerve agents1 vesicants1 and arsenicals are the most dangerous4 ,field concentrations of phosgene1 hydrocyanic acid1 irritants1 and smokes will seldom be high enough to cause serious food contamination4 ,the effect of ,,ck on food is not known4 ,as a precaution1 foods exposed to ,,ck should be considered toxic4 7#b7 ,the effects of chemical agents on food depend on the nature of the agent and the type of the food4 ,the extent to which chemical agents penetrate food also depends on the amount1 form of dispersal 7liquid droplet size1 or vapor7 and duration of exposure4 ,nerve agents and mustard will penetrate deeply into unprotected fatty foods and will readily penetrate granular products such as grain and sugar4 ,liquid food products can be completely contaminated4 ,arsenicals readily hydrolyze to poisonous arsenical oxides in some foods4 ,foods can be divided into three categories based on their water content1 fat content1 and crystalline structure3 7a7 ,foods having a high water content1 a low fat content1 and_/or a crystalline structure 7fresh vegetables1 fruits1 sugar1 salt1 and eggs7 will absorb mustard and nerve agents1 either as a liquid or as a vapor4 ,nerve agents will be hydrolyzed slowly4 7b7 ,foods having a low fat content and an irregular 7amorphous7 structure 7flour1 bread1 grain1 rice1 cereals1 dried fruits1 dried vegetables1 tea1 coffee1 peas1 and beans7 readily absorb mustard and nerve agents in liquid form4 ,as a vapor1 these agents are absorbed to some extent1 but are easily removed by airing4 7c7 ,foods having a low water content and a high fat content1 such as butter1 fat1 fatty oils1 ham1 cheese1 milk1 bacon1 fatty meat1 and fish1 absorb mustard and nerve agents such that removal of the agents is virtually impossible4 7#c7 ,chemical agents can be physically and chemically absorbed into food4 ,in addition to the toxic effect1 they often adversely affect taste1 smell1 and the appearance of the food4 ,however1 chemical agents can cause the food to become very toxic without causing any other changes in the food4 ,table ,j-#d shows the effects of a number of chemical agents on food4 ,since food can be contaminated without any outward change in appearance1 the possibility of contamination must be assumed in a chemical agent environment4 ,treat the food with the same precautions as established for known contaminated items4 7#d7 ,the protective properties of packaging materials are dependent upon a number of factors4 ,the factors include the form of the agent 7liquid versus vapor72 concentration and exposure time2 weather 7temperature1 wind speed1 and humidity72 and packaging material 7the type of material1 thickness1 and the presence of folds1 tears1 and small holes74 ,even the thinnest material will offer some protection and is better than nothing at all4 ,therefore1 always cover food supplies with whatever material is available4 ,table ,j-#e summarizes the protection values of various packaging materials against vapors and liquids4 7a7 ,operational rations are substantially protected while contained in the shipping cases and especially if stored in the original palletized unit load with an overlay of fiberboard1 shrink wrap1 or film wrap4 ,the worst case is pallets of subsistence contaminated by liquid droplets during an attack4 ,after the attack1 high vapor concentrations will exist in the vicinity of the palletized loads4 ,if the outer barrier is permeable such as fiberboard1 it is possible that a liquid agent can seep through the overlay fiberboard and contact the shipping containers in liquid form4 ,normally1 with seepage resistant materials1 such as shrink wrap as the outer barriers1 only the vapors of the agent are found within the pallet4 7b7 ,while ,m,r,es are stored1 the food is protected by up to six layers of material4 ,multilayer barriers result in a complex diffusion process of the agent from the outside towards the interior4 ,vapor penetration into nonhermetically sealed spaces is a simple gaseous diffusion process4 ,permeation through packaging is a much more complex process regardless of whether the challenge is a liquid or a vapor4 #a4 ,liquid is adsorbed into permeable materials such as fiberboard or chipboard4 ,with permeation-resistant materials 7such as shrink wrap71 the agent dissolves into1 seeps through1 and then desorbs from the barrier material4 ,shrink wrap provides adequate protection4 ,fiberboard sheathing provides adequate protection against mustard agents1 but not against nerve agents4 #b4 ,the low-density polyethylene used to construct the menu bag can absorb chemical agents and possibly toxins4 ,if the menu bag is removed from the shipping container and is exposed to liquid contamination1 enough agent may pass through the bag to create a health hazard4 ,keep ,m,r,es in the shipping container until issued to the soldier4 ,the menu bags should then be kept under the same degree of protection as the soldier4 #c4 ,the aluminum-laminated materials used to construct the ,,mre 7retort and nonretort7 pouches protect food from chemical contamination if hermetically sealed4 ,the only item in the ,,mre meal bag that is not adequately protected is the spoon4 7#e7 ,mylar and cellophane are resistant to chemical agents4 ,table ,j-#d4 ,effects of ,chemical ,agents on ,food ,,influence ,,on -------------------------------------- ,,residual ,,agent ,,taste ,,smell ,,color ,,toxicity ---------------------------------------- --------------------------- ,,mustard ,,bad ,,bad ,,discolors ,,meat ,n-,,mustards ,,bad ,,bad ,,doesn',t ,,discolor ,,meat ,,arsenicals ,,acid ,,bad ,,discolors ,,meat ,,and 1 ,,arsenic ,,vegetables ,,nerve ,,agents ,,bad ,,none ,,none ,,phosgene ,,acid ,,none 8 - ,,after ,,weathering ,,cyanogen ,,agents ,,bitter ,,bad ,,none - ,,after ,,weathering ,,irritants ,,acid ,,bad ,,none ,,smoke ,,acid ,,bad 8 - ,,white 8 8 8 ,,phosphorous ---------------------------------------- --------------------------- ,,indicates ,,the ,,presence ,,of ,,residual ,,toxicity4 - ,,denotes ,,that ,,residual ,,toxicity ,,is ,,not ,,present4 8 ,,the ,,influence ,,has ,,not ,,been ,,determined4 ,table ,j-#e4 ,protection from ,chemical ,contamination by ,packaging ,methods and ,materials ,,chemical ,,vapors ,,liquids ---------------------------------------- ------------ ,,bottles ,,and ,,cans ,,airtight ,,bottles ,,complete ,,complete ,,sealed ,,metal ,,cans ,,complete ,,complete ,,glass ,,bottles ,,good ,,good ,,metal ,,containers ,,good ,,good ,,boxes ,,cardboard ,,moderate ,,moderate ,,wooden ,,crates ,,moderate ,,poor ,,or ,,none ,,wrappings ,,metal ,,foil ,,laminates ,,complete ,,complete ,,paper ,,poor ,,none ,,textiles ,,none ,,none ,,waxed ,,paper ,,good ,,moderate ,,multilayer ,,bags ,,good ,,moderate ,,cellophane ,,good ,,good ,,cellophane1 ,,wet ,,none ,,none ,,canvas ,,poor ,,poor b4 ,detection4 7#a7 ,currently1 a field method for detecting chemical agent contamination in food does not exist4 ,contamination is not always spread evenly throughout food2 this makes it impossible to take a single sample and determine the presence or absence of chemical agents in the entire lot4 ,additionally1 standardized laboratory tests have not been developed for determining levels of chemical agents in food4 ,until a specific method to detect chemical agents in food is available1 reliance will have to be made upon determination of contamination1 or lack thereof1 on the packaging material2 the integrity of the packaging material2 the protective qualities of the packaging material2 and the penetration characteristics of the suspected chemical agents4 7#b7 ,food may become toxic without any change in outward appearance4 ,never taste or smell food to determine if contamination is present in food4 7#c7 ,veterinary and subsistence units have the following equipment available to detect chemical agents in the field3 7a7 ,the ,m#h ,automatic ,chemical ,agent ,alarm ,system consists of the ,m#dc detector unit and the ,m#db alarm unit4 ,the detector unit is a portable1 automatic1 point-monitoring device that is designed to be hand carried from point to point4 ,the ,m#h is used to provide early warning of a toxic agent position and detects the presence of chemical vapors and aerosols4 ,the ,m#dc detects all nerve1 blood1 and choking agents1 and some blister agents4 ,the ,m#dc;,a#a 7the replacement for the ,m#dc7 only detects nerve agents4 7b7 ,the ,m#bef ,chemical ,agent ,detector ,kit detects and identifies nerve1 blood1 and blister agents4 ,the ,m#bef is the most sensitive of the chemical agent vapor detectors available4 ,however1 it is not a continuous1 real-time monitoring system4 ,it requires #ae to #bj minutes for sampling and analysis4 7c7 ,the ,,abc-,m#h ,,vgh ,chemical ,agent ,detector ,paper can detect and differentiate between nerve and blister agents by color change4 ,it is intended to be used by blotting and wiping surfaces suspected of contamination4 ,the ,m#h paper will respond with a visual color change in #aj seconds or less4 7d7 ,the ,m#i ,chemical ,agent ,detector ,paper will detect liquid nerve 7,g ,v7 and blister agents 7,h ,l71 but will not identify the specific agent or differentiate between nerve and blister agents4 ,the ,m#i tape is sensitive to droplets as small as #ajj 1 and will respond with a visual color change in #aj seconds or less4 7#d7 ,all subsistence in a chemical attack area are considered contaminated until a survey can be conducted1 preferably by veterinary and chemical personnel4 ,personnel must be at ,,mopp ,level #d while conducting the survey4 ,concentrate the initial portion of the survey on the adequacy of the storage facility and other protective measures in preventing chemical agent contact with subsistence items4 ,the area surrounding the storage facility is examined for the presence of animals1 rodents1 birds1 and arthropods acting unusual1 or dead in unusual numbers4 ,if animals are present and assistance is required in identifying the ,,nbc agent1 specimens can be collected and submitted to the area medical laboratory4 ,damage such as broken windows1 holes1 or loss of structural integrity of the storage facility is noted4 ,this information combined with knowledge of the agent form 7liquid or vapor71 type of agent 7which will indicate the degree of persistency71 and approximate time of attack will provide a risk assessment4 ,liquid agents should not significantly penetrate an intact facility1 but may produce vapor contamination by off-gassing4 7a7 ,upon entering the storage facility1 the ,m#h can be used to determine the presence of chemical vapors4 ,however1 precautions must be taken4 ,the ,m#db alarm is not to be used inside shelters1 vehicles1 vans1 or other interior modes4 ,therefore1 when checking food storage facilities1 the alarm unit must be left outside1 turned off1 or disconnected4 ,do not tilt the ,m#dc detector more than #de degrees 7because of the liquids it contains74 ,this is not a problem with the improved ,m#dc;,a#a1 but the ,m#dc;,a#a requires attachment of an exit port filter when used indoors4 ,the ,m#bef ,chemical ,agent ,detector ,kit can be used to sample the air4 7b7 ,pre-position ,m#i chemical agent detector paper in food storage areas2 especially on the least protected pallets and in areas where droplets may enter1 such as near doors or windows4 ,examine the ,m#i paper for indications of liquid chemical agents4 ,if the ,m#i paper is positive1 or if the packaging materials show the presence of liquids or stains1 use the ,m#h detector paper to determine the type of the agent4 ,if an agent is not indicated by the detector paper1 then the amount of agent present will be insufficient to cause secondary contamination when the outer package is removed4 7#e7 ,detection procedures become more complicated if a chemical agent has penetrated or permeated through the packaging and packing materials4 ,unless liquid has seeped through the cardboard1 any agent in the interior of the shipping case will be in a vapor form4 ,liquid seeping should be obvious4 ,the sampler-detectors in the ,m#bef ,chemical ,agent ,detector ,kit do not have an aspirator for sampling the interior of the case4 ,however1 there are several procedures that can be used4 ,one is to open the case1 place the activated sampler-detectors inside the case1 and then reclose the case4 ,another is to punch holes in the case1 place the activated sampler-detector over the holes1 and cover the sampler-detector with an empty box or can 7open end down7 to concentrate the vapors escaping from the case4 ,alternatively1 remove the food from the case and place it in a plastic bag with the sampler-detectors to concentrate the vapors4 ,these procedures require two sampler-detectors2 one for blood agents and one for nerve and blister agents4 ,neither method is very sensitive in low concentrations of vapor as is expected to be present inside shipping containers4 ,a better method is to modify the ,m#dc detector with a field expedient probe of ,teflon tubing attached to the detector's air inlet4 ,insert the open end of the tubing into a hole in the case or package to sample the interior air4 ,when available1 the improved chemical agent monitor 7,,icam7 can be used2 its design will allow aspiration of air from inside shipping cases4 ,the ,,icam can also be used to detect and identify liquid agents on a surface provided the agent is vaporizing in sufficient quantity4 ,the ,,icam gives a visual representation of a hazard evaluation4 c4 ,decontamination4 7#a7 ,decontamination is only required for contamination remaining #aj minutes or longer4 ,decontamination efforts on subsistence items will normally be limited to removal of the containers and carton overwrap material4 7#b7 ,the need for decontamination is primarily dictated by the type of chemical agent used4 ,the method of decontamination selected will depend upon the type of packaging material used and the urgency with which the food is required4 7#c7 ,food supplies in storage are not likely to be seriously contaminated if reasonable protection precautions are taken4 ,for this reason1 large supplies of food are not to be condemned as a whole simply because they have been exposed to possible chemical contamination4 ,a prompt and careful survey of the supplies may reveal that only a few items have been contaminated to a level that decontamination is required4 ,prompt segregation of the heavily contaminated portions will prevent1 or minimize1 contamination of the remainder4 ,foods without protective packages constitute the major difficulty4 7#d7 ,individual decontamination is performed by each soldier on those subsistence items in his possession at the time of the attack4 ,individual decontamination is limited to operational rations that are in original1 intact containers4 ,unit-level decontamination is performed by unit personnel under the supervision of unit ,,nbc personnel4 ,support decontamination is attempted at major subsistence storage facilities4 ,again1 decontamination is limited to packing material4 ,decontamination of food itself is only attempted in emergency situations when alternative supplies are not available4 7#e7 ,start decontamination operations with the easiest method and proceed to the most difficult4 ,this allows for the removal of a relatively large portion of the contamination in a minimum of time4 ,the simplest procedure is to allow the materials to age and air 7weather74 ,substantial self-decontamination will occur with most agents4 ,exceptions are thickened mustard1 thickened ,,gd1 and ,,vx4 ,table ,j-#f provides the length of time for which contaminated subsistence supplies may present a contact hazard4 ,weather elements that affect decontamination are-- 7a7 ,warm temperatures speed liquid agent off-gassing and hasten the dispersion of chemical agents into the air4 7b7 ,high winds rapidly disperse chemical agent vapors and speed off-gassing from surfaces4 7c7 ,moisture causes chemical agents to react with water to form nontoxic or less toxic chemicals4 ,heavy rain or rain of long duration can aid decontamination by mechanically removing chemical agents4 7d7 ,even in cold weather1 direct sunrays warm surfaces above the air temperature and hasten the off-gassing and decomposition of chemical agents4 ,table ,j-#f4 ,persistency of ,selected ,liquid ,chemical ,agents ,,weather ,,conditions ---------------------------------------- -------- ,,agent ,,sunny1 ,,wet ,,and ,,windy1 ,,calm1 ,,sunny1 ,,around #bj;,c1 ,,around #aj;,c ,,lying ,,snow1 ,,light ,,breeze ,,around -#aj;,c ,,mustard7,,hd7 #b-g ,,days #a_/b-b ,,days #b-h ,,weeks ,,tabun7,,ga7 #a-d ,,days #a_/b-f ,,hours #a ,,day-#b ,,weeks ,,sarin7,,gb7 #a_/d-d ,,hours #a_/d-a ,,hour #a-b ,,days ,,soman7,,gd7 #b-a_/b -#e ,,days #c-cf ,,hours #a-f ,,weeks ,,nerve7,,vx7 #c-ba ,,days #a-ab ,,days #a-af ,,weeks 7#f7 ,active decontamination is attempted only when weathering will not decontaminate the packaging material in sufficient time4 ,decontamination procedures can be enhanced by using heat to vaporize the chemical agent2 by reaction with decontaminants2 or by removing with hot soapy water4 7a7 ,the simplest 7standard7 decontamination materials are water and detergents4 ,an effective decontaminant is hot water used with the addition of soap or detergent and scrubbing4 ,commercial abrasive powdered cleansers are effective decontaminants for many surfaces 7metal1 glass1 ,formica71 but not wood or soft plastics4 7b7 ,water can be used to flush chemical agents from surfaces4 ,high-pressure application produces a better cleansing action than low pressure4 ,if the surface has absorbed the agent1 flushing will remove the surface contamination1 but will not affect the agent that is absorbed4 7c7 ,soaking contaminated items in boiling water is an excellent decontamination method for some agents4 ,water alone will not be sufficient to decontaminate all chemical agents4 ,soaking in warm or cold water may reduce the contamination slightly2 however1 the hazard may not be reduced sufficiently even after prolonged soaking4 ,if hot water is not available1 or if it might cause damage to the item1 other methods of decontamination should be considered1 such as decontaminating solutions or a caustic solution followed by thorough rinsing4 7d7 ,fibrous materials such as cloth and canvas are best decontaminated by washing and scrubbing4 7e7 ,glass1 metal1 porcelain1 and plastic surfaces are best decontaminated by using hot water or hot soapy water4 ,some toxic materials are readily removed with no more than slight abrasion or brushing4 7f7 ,painted1 varnished1 and waxed surfaces are generally smooth and nonporous4 ,dust and liquids are readily removed by wiping1 brushing1 or vacuuming4 ,absorbed materials are removed by hot water1 detergent1 or complexing agents4 ,none of these surfaces stand up well to heavy abrasive techniques4 ,agents can be attacked and removed by caustics1 acids1 and organic chemicals4 ,some of these surfaces readily absorb agents1 so weathering following decontamination is advisable4 7g7 ,rubber is a porous material that can absorb agents4 ,it is not easily decontaminated by abrasive techniques4 ,warm1 soapy water used with brushing is effective since it removes some absorbed contamination4 ,strong acids1 alkalies1 and organic solvents may deteriorate and decompose rubber articles4 7#g7 ,operational rations are the primary rations issued2 always issue uncontaminated stocks first4 ,this allows for decontamination of contaminated stocks without interrupting supply support4 ,normally1 contaminated stocks are not issued4 ,the decision to issue contaminated items is based on the tactical situation1 criticality of the items1 type and extent of contamination1 and the time and resources available for decontamination4 ,decontamination efforts on subsistence items are limited to the containers and carton overwrap material4 7a7 ,the ,,mre retort and nonretort food pouch may be decontaminated with soap and water wash4 ,the chemical agents will be removed by the solutions4 7b7 ,semipermeable materials 7polyethylene menu bag1 shrink wrap1 and film wrap7 may have chemicals deposited not only on the surface1 but also dissolved into the matrix of the material4 ,the chemicals can be removed from the surface by washing with hot soapy water1 but contaminant dissolved in the material is not removed4 ,the remaining agent can only be removed by weathering which can be accelerated through the use of heat and sweeping the surface with air4 7c7 ,fiberboard is both sorbent and permeable and acts like a blotter4 ,liquid decontaminants can force the contaminant further into the fiberboard4 ,any attempt to decontaminate fiberboard would be futile4 ,the only alternatives are to remove the fiberboard1 or to allow it to weather4 7d7 ,palletized unit loads of ,,mre and ,,ugr outerwraps can be decontaminated through the aid of a forced clean air sweep in #d to #e days1 compared to #c weeks or more under natural conditions without a forced air sweep4 7#h7 ,contaminated food supplies are only handled by personnel trained in decontamination methods and in ,,mopp ,level #d4 ,contaminated food items are divided into three groups as described below 7see ,table ,j-#a for additional information74 7a7 ,group #a consists of canned and unopened packaged items which have been exposed only to agent vapors4 ,most items in this group will be safe to issue after a brief period of outdoor airing to remove clinging vapors4 ,table ,j-#g lists the decontamination procedures for packaging materials contaminated with nerve agents1 mustards1 and arsenicals4 ,table ,j-#g4 ,chemical ,decontamination of ,packaged ,material ,,packaging ,,material ,,contamination ,,decontamination ,,procedures ---------------------------------------- ------------------------------ ,,airtight ,,metal ,,vapor ,,and ,,air ,,for #bd ,,hours4 ,,wash ,,containers1 ,,glass ,,liquid ,,with ,,hot ,,soapy ,,water1 ,,bottles1 ,,foil ,,soda1 ,,or ,,bleach ,,solution4 ,,aluminated ,,laminated ,,rinse ,,with ,,water4 ,,materials4 ,,polyester1 ,,pvf4 ,,vapor ,,remove ,,contaminated ,,wooden ,,boxes1 ,,crates1 ,,package4 ,,air ,,contents ,,for ,,board1 ,,multilayer #bd ,,hours4 ,,bags4 ,,cardboard1 ,,liquid ,,contaminated ,,contents--,,treat ,,polyethylene4 ,,as ,,unpackaged ,,food4 7b7 ,group ,,ii consists of canned and unopened packaged items which have been contaminated with a liquid chemical agent4 #a4 ,attempts to decontaminate porous packaging materials1 such as cardboard or wood1 are likely to be unsuccessful and may result in spreading the contamination4 ,the best procedure in handling such items is to strip off the outer contaminated coverings and examine the inner layer to see if penetration of the agent has occurred4 ,if it has1 continue stripping off layers until an uncontaminated layer is reached and place it in ,group ,i4 ,if the agent has penetrated to the food1 place it in ,group ,,iii4 #b4 ,food in cans or in other sealed1 impermeable containers is not in danger of chemical contamination4 ,because contamination is confined to the outer surface of the sealed container1 decontamination is accomplished by3 immersion in boiling1 soapy water for #cj minutes and rinse2 immersion in boiling water for #cj minutes2 spray with ,,ds#b2 or to wash in hot soapy water1 rinse1 and aerate4 ,under no conditions should contaminated containers be opened before they have been decontaminated and monitored4 #c4 ,supertropical bleach and ,,ds#b can be used on the polyethylene menu bag for up to #bd hours without a significant change in appearance1 tensile properties1 and size of the plastic4 ,the use of ,,ds#b will cause significant degradative changes to most other plastics1 while ,,stb will cause little or no change4 ,also1 ,,ds#b may cause false positive readings when using ,m#h or ,m#i paper1 or the ,m#bef ,detector ,kit to check completeness of decontamination4 7c7 ,group ,,iii will consist of unpackaged or poorly packaged items which have been exposed to an agent in either vapor or liquid form4 ,foodstuffs in this group should be decontaminated only when absolutely necessary4 ,the decision to use foods that have been contaminated is to be made by the commander4 ,decontamination procedure to be followed1 in order1 is3 trim surface fat and grossly contaminated areas2 wash with water or #b-percent sodium bicarbonate solution2 then boil in water4 #a4 ,boiling in water may be eliminated when the contamination has been only with the vapors of irritant agents4 ,when such an exposure has been light1 aeration for a short time may be used for decontamination4 #b4 ,frying1 roasting1 or broiling will not remove traces of blister agents from meats4 ,in general1 salvage of foods heavily contaminated with droplets of the blister agents1 especially the arsenical blister agents1 is not practical4 ,foods of high water or fat content are unfit for consumption and reclamation is not practical when contaminated with liquid mustard or a liquid nitrogen mustard4 #c4 ,when foods have been exposed to blister agent vapor1 they can be reclaimed by washing with sodium bicarbonate solutions and rinsing with clear water1 by intensive cooking1 or in the case of dry provisions1 by #bd to #dh hours of aeration4 ,lean meat contaminated with mustard vapor can be reclaimed by boiling in water for #cj minutes or more4 ,with nitrogen mustard vapor contamination1 the meat should be boiled in a #b-percent sodium bicarbonate solution4 ,discard the water used to boil the meat4 #d4 ,nerve agent contamination is treated the same as blister agent contamination4 #e4 ,foods1 such as potatoes and hard-skinned fruits and vegetables1 can be decontaminated by washing or scrubbing1 followed by peeling or scraping1 then washing again4 #f4 ,prepared food in open containers will be contaminated2 it must be temporarily isolated1 or disposed of 7bury or as directed by commander74 #g4 ,a food ,item that is contaminated with irritants can be decontaminated by airing4 ,consumability is determined by taste rather than toxicity4 #h4 ,phosgene is rapidly hydrolyzed1 therefore1 washing the food with water or airing it will usually suffice4 #i4 ,food contaminated with white phosphorous should be destroyed4 #aj4 ,normally1 hydrocyanic acid will have little effect on food supplies4 ,the exposures will most likely be as a vapor4 ,however1 foods with a high water content may become unfit for consumption after exposure to high concentrations4 #aa4 ,the effect of ,,ck on foods is not known4 ,foods exposed to ,,ck vapors are considered toxic4 #ab4 ,table ,j-#h lists the decontamination procedures for unpackaged food contaminated with a chemical agent4 7#i7 ,decontaminating cattle1 poultry1 and other livestock is only attempted when other sources of food are not available4 ,heavily contaminated animals should be destroyed4 ,livestock contaminated lightly by phosgene1 nerve agents1 mustards1 and arsenicals 7such as vapor or liquid7 may be slaughtered in the early stages of poisoning before the full effects of exposure are shown4 ,if these animals are slaughtered in the preliminary stages of poisoning and all tissues exposed to the agent 7the head1 blood1 lungs1 organs1 and local areas7 are discarded1 there is no danger in consumption of the meat1 provided the animal passes a pre-slaughter and slaughter inspection4 ,this is true even of animals poisoned by arsenical agents since the edible tissue will contain amounts of arsenic too small to be toxic4 ,organs 7liver1 brain1 heart1 kidney1 and lungs7 will contain more arsenic than the musculature and are discarded4 ,the meat must be well cooked4 ,personnel involved in slaughtering procedures must be careful to prevent spreading contamination to the meat and to themselves4 7#aj7 ,decontaminating forage and grain exposed to only chemical agent vapors is by aeration4 ,aerated supplies1 especially if mixed with larger amounts of uncontaminated supplies1 produces no ill effects when fed to animals4 ,forage or grain heavily contaminated by liquid vesicants1 especially arsenicals1 should not be used4 ,table ,j-#h4 ,chemical ,decontamination of ,unpackaged ,food ,,fatty ,,foods ,,nonfatty ,,foods1 ,,nonfatty ,,foods1 7,,butter1 ,,bacon1 ,high ,,water ,,content ,,low ,,water ,,content1 ,,chemical ,,agent ,,milk1 ,,cheese1 ,,crystalline 7,,fruits1 ,,amorphous 7,,flour1 ,,ham74 ,,vegetables1 ,,salt1 ,,cereals1 ,,bread1 ,,sugar74 ,,peas74 ---------------------------------------- -------------------------------- ,,nerve ,,agents ,,vapor1 ,,heavy ,,destroy ,,destroy1 ,,unless ,,air ,,for #dh ,,hours1 ,,possible ,,to ,,boil ,,then ,,boil4 ,,after ,,airing #dh ,,hours4 ,,vapor1 ,,light ,,destroy ,,air ,,for #dh ,,hours1 ,,air ,,for #dh ,,hours1 ,,then ,,boil4 ,,then ,,boil4 ,,liquid ,,destroy ,,destroy ,,destroy ,,mustards ,,vapor ,,remove #a-c cm ,,wash ,,with ,,water4 ,,wash ,,with ,,water4 ,,of ,,outer ,,layer ,,air ,,for #dh ,,hours4 ,,air ,,for #dh ,,hours4 ,,and ,,wash ,,with #b ,,sodium ,,bicarb- ,,onate ,,solution4 ,,boil ,,for ,,at ,,least #cj ,,minutes4 ,,destroy ,,milk4 ,,liquid ,,destroy ,,destroy ,,destroy ,,arsenicals ,,destroy ,,destroy ,,destroy ,,glossary ,,abbreviation1 ,,acronyms1 ,,and ,,definitions ,,abca ,american1 ,british1 ,canadian1 and ,australian ,,abo agents of biological origin ,,ac hydrogen cyanide ,,afjman ,air ,force ,joint ,manual amb ambulance ,,amedd ,army ,medical ,department ,,ameddc,s ,army ,medical ,department ,center and ,school ,a,med,p ,allied ,medical ,publication ,,aml area medical laboratory ,,an_/,,pdr#bg radiac meter ,,an_/,,pdr#gg radiac meter ,,an_/,,vdr#b radiac meter ,,ao area of operations ,,ar ,army regulation ,,atm advanced trauma management ,,attn attention ,,axp ambulance exchange point ,,bas battalion aid station ,,bat ,biological ,augmentation ,team ,,bc blood culture bde brigade ,,bdu battle dress uniform ,,bi battle injury ,,bids ,biological ,integrated ,detection ,system ,biological ,warfare ,agent ,field ,confirmation ,identification ,identification of a suspect biological warfare agent by means of devices_/materials_/technologies that are based on detecting biological markers using two or more independent biomarker results4 ,examples might include the findings of the presumptive biomarker identification with the addition of a positive ,,pcr1 ,,elisa1 or electrochemiluminescence 7,,ecl7 results1 using specific target nucleic acid sequences for the organism and antibody recognition of agent-specific antigen sites1 respectively4 7,field sample_/ specimen identification by forward deployed or forward positioned laboratories such as the ,,us ,air ,force ,biological ,augmentation ,team 7,,bat71 theater army medical laboratory1 or forward deployed preventive medicine unit 7,,us ,navy7 and homeland security ,laboratory ,response ,network 7,,lrn7 ,level ,b or ,c1 ,,us ,army ,community ,hospitals or ,medical ,centers47 ,biological ,warfare ,agent ,definitive ,identification ,and ,confirmation ,the specific identification of a suspect biological agent as to genus and species1 serological type1 or toxin4 ,this level of identification is by means of devices_/materials_/technologies that are based on two or more independent biomarker results and using different methodologies4 ,this level of identification is performed in a reference laboratory with a broader variety of methodologies available and highly skilled testing personnel1 thus providing the highest levels of accuracy4 7,sample_/specimen identification is accomplished by homeland security ,,lrn ,level ,c and ,d and nationally recognized laboratory such as the ,,us ,army ,medical ,research ,institute of ,infectious ,disease or ,centers for ,disease ,control and ,prevention47 ,biological ,marker ,characteristics of a biological agent 7organism1 virus1 toxin1 or product7 that are specific to the agent4 ,this includes 7#a7 recognition of specific nucleic add sequences 7,,dna or ribonucleic acid ,,rna7 unique to the bacteria or virus by a technique such as ,,pcr2 7#b7 identification of specific ,,ecl assay2 7#c7 specific growth properties as seen on selective media such as characteristic colony morphology on culture along with phage inhibition2 7#d7 ,identification using specific microscopic characteristics such as ,gram stain1 fluorescent antibody stain1 immunohistochemical stain1 or cytopathic effects4 ,biological ,warfare ,agent ,presumptive ,identification ,identification of a suspect biological warfare agent by means of devices_/materials_/technologies that are based detecting biological markers 7biomarkers7 using a single methodology4 ,the biomarkers and_/or methodologies used at this level of testing have significant limits to their accuracy4 ,agent identification to species level1 or differentiation among a family of similar agents1 may not be possible4 ,this is equivalent to the ,,lrn ,level ,a and the ,,us ,army ,,bids4 7,,examples3 ,identification by sensor triggering1 hand-held devices hand-held assays or initial systems1 or laboratory analysis employing one screening methodology such as microscopic morphology1 antibody_/protein1 or nucleic acid-based test47 bot_/pkg bottle_/package ,,bsa brigade support area ,,bw biological warfare ,,bz an incapacitating chemical warfare agent ,c ,centigrade_/,celsius ,c#b command and control ,c#d;,i ,command1 ,control1 ,communications1 ,computers1 and ,intelligence ,ca,cl calcium hypochlorite cal_/cm#b calories per square centimeter cal_/cm#b_/sec calories per square centimeter per second ,,cam chemical agent monitor ,,cana convulsant antidote for nerve agent 7diazepam7 ,,cb chemical_/biological ,,cbda ,chemical ,biological ,defense ,agency ,,cbps chemically biologically protected shelter ,,cbrne chemical1 biological1 radiological1 nuclear1 and high-yield explosive ,,cbscc ,chemical-,biological ,sampling ,control ,center ,,cbsce ,chemical-,biological ,sampling ,control ,element cc cubic centimeter ,,cg phosgene c,gy centigray ,,cis ,commonwealth of ,independent ,states 7,russia7 ,,ck cyanogen chloride ,cl chlorine ,,class ,,viii ,classification of medical supplies and equipment within the ,federal ,stock ,classification ,system ,,cls combat lifesaver cm centimeter cm#b square centimeter ,,cns central nervous system ,,co#b carbon dioxide ,,conus continental ,united ,states ,,cosc combat operational stress control ,,cp chemically protected ,,cp ,,depmeds chemically protected deployable medical system ,,cps collective protection shelter ,,crest ,casualty ,requirements ,estimation ,tool ,,cs combat support ,cs-#acg ,cesium #acg ,,csf cerebrospinal fluid ,,csh combat support hospital ,,css combat service support ,,cw chemical warfare ,,cx phosgene oxime ,,da ,department of the ,army ,,dap decontamination apparatus1 portable ,,dcs division clearing station ,,dd ,department of ,defense decon decontamination ,,depmeds ,deployable ,medical ,system ,,dna deoxyribonucleic acid ,,dnbi disease and nonbattle ,injury ,,dod ,department of ,defense ,,dp diphosgene ,,ds#b decontaminating solution ,number #b ,,dtf dental treatment facility ,e ,,edta ,,eac echelons above corps ,,ecl electochemiluminescence ,,ecp entry control point ,,ecu environmental control units ,,edta ethylenediaminetetraacetate ,,eee eastern equine encephalitis ,,elisa enzyme-linked immunosorbent assay ,,em electron microscopy ,,emp electromagnetic pulse ,,ems emergency medical services ,,emt emergency medical treatment ,,eod explosive ordnance disposal ,,epw enemy prisoner of war ,,er emergency room evac evacuation ,f ,fahrenheit ,f-#a ,fraction-#a ,,fa fluorescent antibody ,,fdecu field deployable environmental control unit ,,fh field hospital ,,flot forward line of own troops ,,fm field manual ,,fmc ,field ,medical ,card ,,fsop field standing operating procedures ,,fst forward surgical team g gram ,g#a ,assistant ,chief of ,staff 7,adjutant7 ,g#b ,assistant ,chief of ,staff 7,intelligence7 ,g#c ,assistant ,chief of ,staff 7,operations and ,training7 ,g#d ,assistant ,chief of ,staff 7,logistics7 ,,ga ,tabun gal gallon ,,gb ,sarin ,,gd ,soman ,,gf a nerve agent ,,gh general hospital gm gram ,,gp general purpose ,,gvo green vinyl overboots ,gy gray 7#ajj c,gy7 ,h heparin ,,hd sulfur mustard 7a blister agent7 ,,hg chemical symbol for mercury ,,hl mustard and ,lewisite mix ,,hmmwv high mobility multi-purpose wheeled vehicle ,,hn nitrogen mustard ,,hplc high-pressure liquid chromatography ,,hsl health service logistics ,,hss health service support ,,hub hospital unit base ,,huh hospital unit holding ,,hum hospital unit medical ,,hus hospital unit surgical ,,hth high test hypochlorite 7#gj available chlorine7 ,i-#aca ,iodine-#aca ,,iata ,international ,air ,transportation ,association ,,iaw in accordance with ,,ic intensive care ,,icam improved chemical agent monitor ,,icc incident command center ,,icu intensive care unit ,,icw intensive care ward ,,id ,incapacitation dose ,ig,g immunoglobulin class ,g ,ig,m immunoglobulin class ,m ,,ima installation medical authority ,,iso ,international ,organization for ,standardization ,,iv intravenous ,j#b ,joint ,intelligence ,directorate ,j#c ,joint ,operations ,directorate kg kilogram km kilometer7s7 kph kilometers per hour ,,kt kiloton ,l ,lewisite ,,lab laboratory lb pound ,,lce load-carrying equipment ,,ld lethal dose ,,ld #ej_/fj lethal dose for #ej percent of exposed persons within a period of #fj days ,,lrn ,laboratory ,response ,network ,,lsd d-lysergic acid diethylamide ,,lz landing zone micron m meters m#c milligrams per minute ,,mcrp ,marine ,corps ,reference ,publication ,,medevac medical evacuation ,medical ,countermeasures ,those measures taken to maintain soldier sustainability through the prevention and pretreatment of injury from ,,nbc agent hazards2 and following injury those measures taken to treat ,,nbc casualties and improve medical capability for diagnosis1 physiological resuscitation and continued medical management of ,,nbc casualties4 ,,mes medical equipment set ,,mf#b,k ,medical ,force #bjjj 7,army of ,excellence ,organizations7 mg milligram mg_/kg milligrams per kilogram ,,milvan military-owned demountable container ml milliliter mm millimeter ,,mopp mission-oriented protective posture ,,mos military occupational specialty ,,mre meal ready-to-eat ,,mri ,medical ,reengineering ,initiative ,,msr main supply route m_/sec meters per second ,,mt megaton ,,mtf medical treatment facility ,na,cl sodium chloride 7salt7 ,,nato ,north ,atlantic ,treaty ,organization ,,navmed ,p ,naval ,medical ,publication ,,nbc nuclear1 biological1 and chemical ,,nbcc nuclear1 biological1 and chemical control ,,nbcwrs nuclear1 biological1 and chemical warning and reporting system ,,nco noncommissioned officer ,,nl no limit ,,nttp ,navy ,tactics ,techniques and ,procedures ,o#b oxygen ,,oeg operational exposure guide ,,oplan operation plan ,,opsec operations security ,patient ,decontamination--,the removal and_/or the neutralization of hazardous levels of nuclear1 biological1 and chemical contamination from patients at a medical treatment facility4 ,patient decontamination is performed under the supervision of medical personnel to prevent further injury to the patient and to maintain the patient's health status during the decontamination process4 ,patient decontamination serves multiple purposes2 it protects the patient from further injury1 it prevents exposing medical personnel to the contamination1 and it prevents contamination of the medical treatment facility4 ,,pcr polymerase chain reaction ,,pds patient decontamination station p,h symbol relating the hydrogen ion activity in gram equivalents per liter used in expressing the acidity and alkalinity on a scale whose values run from #j to #ad with #g representing neutrality4 ,numbers less than #g indicate increasing acidity1 and numbers greater than #g indicate increasing alkalinity4 ,,pmm preventive medicine measures pnt patient ppm parts per million ,,ppw patient protective wrap ,,ps chloropicrin ,,pvf polyvinyl fluoride ,,pvntmed preventive medicine ,,qsta ,quadripartite ,standardization ,agreement ,,rdd radiological dispersal device recon reconnaissance ,,res radiation exposure status ,,rna ribonucleic acid ,,rowpu reverse osmosis water purification unit ,,rt red top ,,rt-,,pcr reverse transcriptase_/polymerase chain reaction ,,rtd return to duty ,s#a ,adjutant 7,,us ,army7 ,s#b ,intelligence ,officer 7,u4,s4 ,army7 ,s#c ,operations and ,training ,officer 7,u4,s4 ,army7 ,s#d ,supply ,officer 7,u4,s4 ,army7 ,,scud ballistic missile ,,sdk skin decontaminating kit ,,sfg ,special ,forces ,group ,,smart special medical assistance response team ,,sof ,special ,operations ,forces ,,sop standing operating procedure ,sr-#hi ,strontium-#hi ,sr-#ij ,strontium-#ij ,,stanag ,standardization ,agreement 7,,nato7 ,,stat statim ,,stb supertropical bleach ,sv ,sievert ,t#b trichothecene ,,taml theater ,army medical laboratory ,,tc training circular ,,teu technical escort unit ,,temper tent1 expandable1 modular1 personnel ,toxic ,industrial ,biological 7,,tib7 ,biological materials 7bacteria1 viruses1 and toxins7 found in medical research1 pharmaceutical1 and other manufacturing processes that are toxic to humans and animals1 or cause damage to plants4 ,toxic ,industrial ,chemical 7,,tic7 ,chemical compounds used or produced in industrial processes that are toxic to humans and animals1 or cause damage to plants4 ,,examples include fuels1 solvents1 heavy metals1 and chemicals used in manufacturing processes4 ,toxic ,industrial ,material 7,,tim7 ,toxic industrial materials may be toxic industrial chemical 7,,tic71 toxic industrial biological 7,,tib7 and toxic industrial radiological 7,,tir7 materials4 ,toxic ,industrial ,radiological 7,,tir7 ,radiation-emitting materials used in research1 power generation1 medical treatment1 and other non-weapon developmental activities that are harmful to humans and animals if released outside their controlled environment4 ,,tir toxic industrial radiological ,,tm technical manual ,,tm trademark ,,toe table of organization and equipment 7,,us ,army organizational structure document7 ,,to theater of operations trmt treatment ,,tsop tactical standing operating procedures ,,tt tiger top microns ,,ugr unit group rations ,,un ,united ,nations ,,us ,united ,states ,,usaf ,united ,states ,air ,force ,v-agent a nerve agent ,,vee ,venezuelan equine encephalitis ,,vx a persistent nerve agent ,,wbgt wet bulb globe temperature ,,wee western equine encephalitis ,,wmd-,,ist weapons of mass destruction--installation support team ,,references ,,nato ,,nato ,emergency ,war ,surgery ,handbook4 #aihh4 ,,nato ,s,t,a,n,a,gs ,these agreements are available on request 7using ,,dd ,form #adbe7 from the ,standardization ,documents ,order ,desk1 #gjj ,robins ,avenue1 ,building #d1 ,section ,d1 ,philadelphia1 ,pennsylvania #aiaaa-ejid4 #bjjb4 ,warning ,signs for the ,marking of ,contaminated or ,dangerous ,land ,areas1 ,complete ,equipments1 ,supplies and ,stores4 ,edition #h4 #bi ,january #aiii4 #bjdg4 ,emergency ,alarms of ,hazard or ,attack 7,,nbc and ,air ,attack ,only74 ,edition #g4 #bd ,july #aiih4 7,latest ,amendment1 #g ,february #bjjj47 #bjfh4 ,emergency ,war ,surgery4 ,edition #d4 #bh ,october #aihf4 7,latest ,amendment1 #ag ,october #aiia47 #bjhc4 ,commander's ,guide on ,nuclear ,radiation ,exposure of ,groups4 ,edition #e4 #ai ,september #aihf4 7,latest ,amendment1 #bf ,june #aiid47 #bajc4 ,reporting ,nuclear ,detonations1 ,biological and ,chemical ,attacks1 and ,predicting and ,warning of ,associated ,hazards and ,hazard ,areas--,,atp #de7;,a74 ,edition #h4 #ca ,august #bjjj4 #bajd4 ,friendly ,nuclear ,strike ,warning4 ,edition #g4 #bh ,june #aiid4 7,latest ,amendment1 #bh ,june #aiie47 #baab4 ,nuclear1 ,biological1 and ,chemical ,reconnaissance4 ,edition #d4 #f ,march #aiih4 #bdge4 ,medical ,planning ,guide for the ,estimation of ,,nbc ,battle ,casualties 7,nuclear7--,amed,p-#h7;,a71 ,volume ,i4 ,december #bjjj4 #bdgf4 ,medical ,planning ,guide of ,,nbc ,battle ,casualties 7,biological7--,amed,p-#h7;,a71 ,volume ,,ii4 ,march #bjja4 #bdgg4 ,planning ,guide for the ,estimation of ,,nbc ,battle ,casualties 7,chemical7--,amed,p-#h7;,a71 ,volume ,,iii4 ,march #bjja4 #bejj4 ,,nato ,handbook on the ,medical ,aspects of ,,nbc ,defensive ,operations--,a,med,p-#f7;,b74 ,edition #d4 #aa ,february #aiig4 #bhgc4 ,concept of ,operations of ,medical ,support in ,nuclear1 ,biological1 and ,chemical ,environments--,amed,p-#g7;,a74 ,edition #c4 #af ,october #aiif4 #bhgi4 ,principles of ,medical ,policy in the ,management of a ,mass ,casualty ,situation4 ,edition #c4 #g ,september #aiih4 #bida4 ,guidelines for ,air and ,ground ,personnel ,using ,fixed and ,transportable ,collective ,protection ,facilities on ,land4 ,edition #b4 #ai ,june #aiib4 7,latest ,amendment1 #cj ,october #aiie47 #bied4 ,training of ,medical ,personnel for ,,nbc ,operations4 ,edition #a4 #bh ,december #aihg4 7,latest ,amendment1 #f ,june #aiie47 ,,abca ,q,s,t,a,gs ,these agreements are available on request 7using ,,dd ,form #adbe7 from the ,standardization ,documents ,order ,desk1 #gjj ,robins ,avenue1 ,building #d1 ,section ,d1 ,philadelphia1 ,pennsylvania #aiaaa-ejid4 #ahc4 ,emergency ,warning ,signals and ,alarms for ,,nbcd ,hazards or ,attacks 7,,nbc and ,air ,attacks ,only74 ,edition #c4 #ab ,august #aiia4 #ahg4 ,reporting ,nuclear ,detonations ,biological and ,chemical ,attacks and ,predicting and ,warning of ,associated ,hazards and ,hazard ,areas4 ,edition #e4 #ba ,may #aiih4 #ahi4 ,friendly ,nuclear ,strike ,warning4 ,edition #c4 #ab ,august #aiia4 #eja4 ,warning ,signs for the ,marking of ,contaminated or ,dangerous ,land ,areas1 ,complete ,equipment1 ,supplies and ,stores4 ,edition #b4 #aa ,may #aihb4 #fjh4 ,interoperable ,chemical ,agent ,detector ,kits4 ,edition #c4 #ac ,december #bjjj4 #haf4 ,medical ,aspects of ,mass ,casualty ,situations4 ,edition #a4 ,august #aiij4 #accj4 ,medical ,aspects of ,,nbc ,defensive ,operations4 ,draft4 #bjjj4 ,guidelines on ,entry and ,exit ,procedures for ,using ,collective ,protection ,facilities4 #ag ,december #aiif4 ,,joint ,,or ,,multiservice ,,publications ,,ar #dj-ece4 ,worldwide ,aeromedical ,evacuation4 ,,afr #afd-e2 ,,opnavinst #dfcj4i;,c2 ,,mco ,p#dfcj4i;,a4 #a ,december #aige4 7,reprinted with basic including ,change #a1 #aj ,may #aigi47 ,,ar #dj-efb4 ,immunizations and ,chemoprophylaxis4 ,,afji #dh-aaj2 ,,bumedinst #fbcj4ae2 ,,cg ,,comdtinst ,m#fbcj4d;,e4 #a ,november #aiie4 ,,ar #dj-fef4 ,veterinary ,surveillance ,inspection of ,subsistence4 ,,navsupinst #dcee4aj2 ,,mco #ajaaj4de4 #ae ,october #aihf4 ,,ar #dj-feg4 ,veterinary_/,medical ,food ,inspection and ,laboratory ,service4 ,,navsupinst #dcee4d;,f2 ,,mco ,p#ajaaj4ca;,g4 #f ,november #aiig4 ,,fm #c-c4 ,chemical and ,biological ,contamination ,avoidance4 ,,fmfm #aa-ag4 #af ,november #aiib4 7,change #a1 #bi ,september #aiid47 ,,fm #c-d4 ,,nbc ,protection4 ,,fmfm #aa-i4 #bi ,may #aiib4 7,reprinted with basic including ,changes #a-b1 #ba ,february #aiif47 ,,fm #c-e4 ,,nbc ,decontamination4 ,,mcwp #c-cg4c4 #bh ,july #bjjj4 ,,fm #c-f4 ,field ,behavior of ,,nbc ,agents 7,including ,smoke and ,incendiaries74 ,,amf #aje-g2 ,,fmfm #g-aa ,h4 #c ,november #aihf4 ,,fm #c-i4 ,potential ,military ,chemical_/,biological ,agents and ,compounds4 ,,navfac ,p-#dfg1 ,,afr #cee-g4 #ab ,december #aiij4 ,,fm #c-aa4cd4 ,multiservice ,procedures for ,nuclear1 ,biological1 and ,chemical 7,,nbc7 ,defense of ,theater ,fixed ,sites1 ,ports1 and ,airfields4 ,,mcwp #c4cg4e2 ,,nttp #c-aa4bc2 ,,afttp7,i7 #c-b4cc4 #bi ,september #bjjj4 ,,fm #c-ai4 ,nuclear1 ,biological and ,chemical ,reconnaissance4 ,,fmfm #aa-bj4 #ai ,november #aiic4 ,,fm #c-ajj4 ,chemical ,operations1 ,principles and ,fundamentals4 ,,mcwp #c-c4g4a4 #h ,may #aiif4 ,,fm #d-jb4cc4 ,control of ,communicable ,diseases ,manual4 #agth ,edition4 ,,navmed ,p-#ejch4 #ca ,december #aiii4 ,,fm #d-jb4bhc4 ,treatment of ,nuclear and ,radiological ,casualties4 ,,ntrp #d-jb4ba2 ,,afman #dd-afa7;,i72 ,,mcrp #d-aa4a;,b4 #bj ,december #bjja4 ,,fm #f-bb4e4 ,combat ,stress4 ,,mcrp #f-aa;,c2 ,,nttp #a-ae,m4 #bc ,june #bjjj4 ,,fm #h-i4 ,,nato ,handbook on the ,medical ,aspects of ,,nbc ,defensive ,operations ,a,med,p-#f7;,b71 ,part ,i--,nuclear1 ,part ,,ii--,biological1 ,part ,,iii--,chemical4 ,,navmed ,p-#ejei2 ,,afjman #dd-aea,v#a,v#b,v#c4 #a ,february #aiif4 ,,fm #h-bhd4 ,treatment of ,biological ,warfare ,agent ,casualties4 ,,navmed ,p-#ejdb2 ,,afman7,i7 #dd-aef2 ,,mcrp #d-aa4a;,c4 #ag ,july #bjjj4 7,change #a1 #h ,july #bjjb47 ,,fm #h-bhe4 ,treatment of ,chemical ,agent ,casualties and ,conventional ,military ,chemical ,injuries4 ,,navmed ,p-#ejda2 ,,afjman #dd-adi2 ,,fmfm #aa-aa4 #bb ,december #aiie4 ,,fm #ba-aj4 ,field ,hygiene and ,sanitation4 ,,mcrp #d-aa4a;,d4 #ba ,june #bjjj4 ,,department ,,of ,,defense ,,dod #eajj4eb-,m4 ,nuclear ,weapon ,accident ,response ,procedures 7,,narp74 ,september #aiij4 ,,dod ,directive #caej4h4 ,,dod ,response to ,radiological ,accidents4 #ac ,june #aiif4 ,,dd ,form #achj4 ,,us ,field ,medical ,card4 ,december #aiia4 ,,dd ,form #aiaa4 ,material ,courier ,receipt4 ,may #aihb4 ,,department ,,of ,,the ,,army ,,form ,,da ,form #dacg4 ,evidence_/,property ,custody ,document4 #a ,july #aigf4 ,,army ,,publications ,,ar #dj-e4 ,preventive ,medicine4 #ae ,october #aiij4 ,,ar #dj-fa4 ,medical ,logistics ,policies and ,procedures4 #be ,january #aiie4 ,,ar #dj-ff4 ,medical ,records ,administration and ,health ,care ,documentation4 #c ,may #aiii4 ,,ar #dj-djj4 ,patient ,administration4 #ab ,march #bjja4 ,,fm #c-jf4aa4 ,combined ,arms ,operations in ,urban ,terrain4 #bh ,february #bjjb4 ,,fm #c-g4 ,,nbc ,field ,handbook4 #bi ,september #aiid4 ,,fm #c-ej4 ,smoke ,operations4 #d ,december #aiij4 7,change #a1 #aa ,september #aiif74 ,,fm #c-aja4 ,chemical ,staffs and ,units4 #ai ,november #aiic4 ,,fm #c-aja-d4 ,biological ,detection ,platoon ,operations--,tactics1 ,techniques1 and ,procedures4 #i ,june #aiig4 7,reprinted with basic including ,changes #a-b1 #a ,september #bjjj47 ,,fm #d-jb4a4 ,combat ,health ,logistics4 #bh ,september #bjja4 ,,fm #d-jb4d4 ,medical ,platoon ,leaders' ,handbook--,tactics1 ,techniques1 and ,procedures4 #bd ,august #bjja4 ,,fm #d-jb4f4 ,the ,medical ,company--,tactics1 ,techniques1 and ,procedures4 #a ,august #bjjb4 ,,fm #d-jb4aj4 ,theater ,hospitalization4 #bi ,december #bjjj4 ,,fm #d-jb4ag4 ,preventive ,medicine ,services4 #bh ,august #bjjj4 ,,fm #d-jb4ai4 ,dental ,service ,support in a ,theater of ,operations4 #a ,march #bjja4 ,,fm #d-be4ab4 ,unit ,field ,sanitation ,team4 #be ,january #bjjb4 ,,fm #h-aj4 ,health ,service ,support in a ,theater of ,operations4 #a ,march #aiia4 ,,fm #h-aj-a4 ,the ,medical ,company--,tactics1 ,techniques1 and ,procedures4 #bi ,december #aiid4 ,,fm #h-aj-f4 ,medical ,evacuation in a ,theater of ,operations--,tactics1 ,techniques1 and ,procedures4 #ad ,april #bjjj4 ,,fm #h-aj-h4 ,medical ,intelligence in a ,theater of ,operations4 #g ,july #aihi4 ,,fm #h-aj-i4 ,combat ,health ,logistics in a ,theater of ,operations--,tactics1 ,techniques1 and ,procedures4 #c ,october #aiie4 ,,fm #h-aj-ad4 ,employment of the ,combat ,support ,hospital--,tactics1 ,techniques1 and ,procedures4 #bi ,december #aiid4 ,,fm #h-aj-ae4 ,employment of the ,field and ,general ,hospitals--,tactics1 ,techniques1 and ,procedures4 #bf ,march #aiig4 ,,fm #h-aj-ah4 ,veterinary ,service--,tactics1 ,techniques1 and ,procedures4 #bb ,august #aiig4 ,,fm #h-aj-bd4 ,area ,support ,medical ,battalion--,tactics1 ,techniques1 and ,procedures4 #ac ,october #aiic4 ,,fm #h-aj-be4 ,employment of ,forward ,surgical ,teams--,tactics1 ,techniques1 and ,procedures4 #cj ,september #aiig4 ,,fm #h-aj-bf4 ,employment of the ,medical ,company 7,air ,ambulance74 #af ,february #aiii4 7,change #a1 #bj ,may #bjjb47 ,,fm #h-cj4 ,veterinary ,food ,inspection ,specialist4 #ab ,august #aihf4 ,,fm #h-db4 ,combat ,health ,support in ,stability ,operations and ,support ,operations4 #bg ,october #aiig4 ,,fm #h-ej4 ,prevention and ,medical ,management of ,laser ,injuries4 #h ,august #aiij4 ,,fm #h-ea4 ,combat ,stress ,control in a ,theater of ,operations--,tactics1 ,techniques1 and ,procedures4 #bi ,september #aiid4 ,,fm #h-ee4 ,planning for ,health ,service ,support4 #i ,september #aiid4 ,,fm #h-bej4 ,preventive ,medicine ,specialist4 #bg ,january #aihf4 7,reprinted with basic including ,change #a1 #ab ,september #aihf47 ,,fm #h-ejj4 ,hazardous ,materials ,injuries3 ,a ,manual for ,pre-,hospital ,care4 ,edition #d4 #ag ,january #aiig4 ,,fm #aj-eb4 ,water ,supply in ,theaters of ,operations4 #aa ,july #aiij4 ,,fm #ba-aa4 ,first ,aid for ,soldiers4 #bg ,october #aihh4 7,reprinted with basic including ,changes #a-b1 #d ,december #aiia47 ,,fm #bb-ea4 ,leaders' ,manual for ,combat ,stress ,control4 #bi ,september #aiid4 ,,fm #ca-ga4 ,northern ,operations4 #ba ,june #aiga4 ,,fm #ij-c4 ,desert ,operations4 ,,fmfm #g-bg4 #bd ,august #aiic4 ,,fm #ij-e4 ,jungle ,operations4 #af ,august #aihb4 ,,fm #ij-aj4 ,military ,operations on ,urbanized ,terrain 7,,mout74 #ae ,august #aigi4 ,,stp #h-ia ,w#ae-,,sm-,,tg4 ,soldier's ,manual1 ,skill ,levels #a_/b_/c_/d_/e and ,trainer's ,guide1 ,,mos #ia,w1 ,health ,care ,specialist4 #aj ,october #bjja4 ,,tc #h-ac4 ,deployable ,medical ,systems--,tactics1 ,techniques1 and ,procedures4 #g ,december #aiij4 ,,tm #c-dbdj-bhh-ab,p4 ,operator's and ,unit ,maintenance ,manual including ,repair ,parts and ,special ,tool ,list for ,collective ,protection ,equipment ,,nbc1 ,simplified ,m#bj 7,,nsn #dbdj-ja-aff-bbed74 ,,navfac ,p-#dge4 #bj ,august #aihg4 7,reprinted with basic including ,changes #a-b1 #c ,may #aihi47 ,,tm #aj-edaj-bbh-aj4 ,operator's ,manual for ,chemical ,biological ,protective ,shelter ,system4 #ca ,august #bjja4 ,,tm #aj-edaj-bhc-ad,p4 ,operator's ,unit1 ,direct ,support1 and ,general ,support ,maintenance ,manual 7,including ,repair ,parts and ,special ,tools ,lists7 for ,chemically ,protected ,deployable ,medical ,system 7,,cp ,,depmeds7 7,,nsn #edaj-ja-dgi-igcj7 7#edaj-ja-dgi-igbg7 and ,,cp ,,depmeds ,training ,set 7#fiaj-ja-dgi-bdfd74 #cj ,november #bjja4 ,,index ,references are to paragraph numbers unless otherwise indicated4 advanced trauma management1 #c-a;e1 #c-i ,allied medical publications1 viii1 ,d-#a1 ,d-#c;d1 ,d-#aa;b1 ,d-#ai;e animals consumption1 for1 #e-h1 ,j-#c;a7#e71 ,j-#c;b7#e71 ,j-#e;c7#i7 contamination of1 ,j-#c decontamination of1 #e-h1 ,j-#c;d1 ,j-#d;d1 ,j-#e;d7#i7 government-owned1 #e-e1 #e-h1 ,c-#g protection of1 #e-h1 ,j-#c;a7#e7 specimens1 from1 #e-i1 #e-ad1 ,j-#e;b7#d7 treatment of1 #e-e1 #e-h area of operations1 #a-c;b7#d7 attack1 nuclear1 biological1 or chemical actions after1 #b-f;a1 #c-a;c1 #c-g before1 #c-e detection of1 #e-g1 ,a-#a1 ,f-#ad1 ,i-#b1 ,j-#a1 ,j-#c;b1 ,j-#d;b1 ,j-#e;b during1 #b-f;a1 #c-f1 #c-i1 #c-aj;b monitoring1 #c-aj;d1 #d-b;d7#b77;a71 #d-g;h1 #e-g1 ,a-#f;a1 ,c-#d--e1 ,appendix ,e1 ,f-#d1 ,f-#ae;b1 ,g-#aj;f1 ,j-#c;b1 ,j-#d;b1 ,j-#e;b personnel considerations1 #c-i prediction for1 ,d-#c;d1 ,d-#bf;b responsibilities1 #b-c1 #b-f;a1 #e-bb1 #e-bc supplies1 #c-e;b1 #c-h;b1 #d-a--b1 #e-b;a1 #e-c1 #e-e--f1 #e-ad1 #e-bd--bf1 ,c-#b--c1 ,c-#e--ab survey1 #c-g1 #c-ad;c1 ,c-#d1 ,d-#d;c1 ,g-#aa;j7#d71 ,j-#c;b1 ,j-#e;b7#d7 treatment1 #c-g1 #d-a;a7#c71 #d-d1 #d-g;g disposition1 #c-aj1 #c-ae;b elements1 #b-a;b7#c71 #c-aj operations1 #b-b;a battlefield1 #a-c;a1 #b-a1 #b-b;a1 #b-c1 #b-e;a1 #b-f1 #c-a1 #c-i1 #c-ab1 #d-a1 #e-a1 #e-e1 #e-ae1 #e-bd1 ,a-#a1 ,d-#c1 ,d-#ai1 ,g-#c1 ,h-#b contaminated1 #a-c;a1 #b-a1 #b-f;a1 #c-a;e1 #c-i1 #c-ab;d1 #d-a1 #e-a1 #e-e1 #e-ae1 #e-bd1 ,a-#a1 ,d-#c1 ,d-#ai;f1 ,d-#be1 ,g-#h1 ,j-#e;a conventional1 #c-a;a and e1 #c-aj care1 in unit1 ,d-#g1 ,d-#ae1 ,d-#bc casualties biological1 ,c-#b1 ,c-#e1 ,d-#a1 ,d-#bj chemical1 ,d-#a civilian1 #c-aa estimates1 ,d-#c;b1 ,d-#aa mass casualties1 #b-a nuclear1 #c-g1 ,a-#f1 ,d-#a1 ,d-#f;b1 ,d-#h requirements estimation tool1 ,d-#b chemical1 biological1 radiological1 nuclear1 and high-yield explosive1 #e-bh1 ,c-#a collective protection systems advanced simplified1 ,f-#b;c1 ,f-#aj alternate facilities1 #b-e;b7#d7 available1 #b-e;b decontamination of entrance area1 ,f-#ac employment battalion aid station1 #c-b;b1 ,f-#b;a1 ,f-#c division clearing station1 #c-c;c1 ,f-#b;a1 ,f-#d forward surgical team1 #c-d1 ,f-#b;a1 ,f-#e in ,,depmeds hospital1 #d-a;a1 ,f-#b;b1 ,f-#f--i operation1 entry1 and exit guidelines1 #c-b;b1 ,f-#ab procedures1 #c-b;b1 #c-c;c1 #c-d entry_/exit1 ,f-#ad--ae ambulatory patients1 #c-b;b1 ,f-#ae litter patient1 #c-b;b1 ,f-#ae;b establish1 #b-e;b7#a71 ,f-#c--f radiation exposure1 #c-ab;b and d1 #e-c1 ,a-#f;a resupply of protected areas1 ,f-#af shielding1 #d-b;b7#b77;b7 water supply1 in1 ,f-#f;b combat operational stress control1 #c-c;a1 #e-bj1 ,c-#i effects of1 #c-a;a1 #e-bj leadership actions1 #c-a;b1 #c-c;a1 #e-ba preventive1 #e-bc;b reactions1 #e-bc;c responsibilities1 #e-bj1 #e-bb1 #e-bc sleep plans1 #e-ba;f command and control1 #b-a1 #b-e;a1 #d-a;a appraisal of the support mission1 #b-c health service support units1 #b-d homeland security1 #b-g leadership1 #b-f1 #c-a;b operations1 #b-b;a1 #b-d--e1 #b-f;b planning considerations1 #b-b communications1 #b-d1 #c-a;c contaminated environment1 #d-a;a facility1 #b-e;c patients1 ,a-#f contamination1 #c-a;d1 #e-c avoidance1 #b-e;c1 #c-a;d1 #c-ag;e control1 #b-e;c1 #c-ad;c detection1 #c-a;d1 ,i-#b food1 #d-a;a1 ,a-#i;c1 ,j-#a free area1 #c-b;b1 #c-c;b1 #c-aj;d1 #c-ae hinder ,,hss operations1 #c-a;d persistency1 #b-a;b7#b7 water1 #d-a;a1 ,a-#i;c1 ,i-#a decontamination augmentation1 #c-e;c1 #d-a;a7#c71 #d-d;a1 ,c-#d1 ,g-#c;b1 ,g-#d;b1 ,g-#e1 ,g-#f biological1 ,a-#aj;c1 ,d-#ab;a1 ,d-#ac;b1 ,g-#ab ambulatory patients1 ,g-#ad litter patient1 ,g-#ac chemical ambulatory patients1 ,g-#aa litter patients1 ,g-#aj clothing removal1 ,g-#a,oc1 ,g-#aa;a and i1 ,g-#ac;c1 ,g-#ad;b1 ,g-#ag;b collocation with thorough decontamination1 ,g-#c complicating factors1 #d-d;a dental1 #c-c;a1 #c-ae1 ,c-#h facility1 #b-e;b7#i71 #c-a;c1 #d-a;a7#b71 #d-c--d1 ,g-#c;f ,field ,medical ,card1 ,g-#b1 ,g-#aj;a7#d71 ,g-#aa;f1 ,g-#ac;b1 ,g-#ad;b food1 #e-g gross contamination removal1 ,g-#aj;a1 ,g-#aa;h heat injury prevention1 during1 ,g-#h immediate1 ,g-#b litter1 ,g-#aj;e mask1 #d-b;b7#d71 ,g-#aj;a7#a71 ,g-#aa;e materials needed1 #b-e;d1 #d-c1 ,g-#a;c medical treatment facility1 at1 ,g-#d--f monitor for completeness1 ,g-#aj;g1 ,g-#aa;j1 ,g-#ae nuclear1 #d-d;a-c1 ,a-#f;c1 ,g-#ae ambulatory patients1 ,g-#ag litter patients1 ,g-#af operations1 ,g-#a1 ,g-#c;a1 ,j-#e;c7#e7 patient protective wrap1 ,g-#aa;c patients1 #b-e;b7#b7 and 7#d71 #b-e;d1 #c-b;b1 #c-ad;d1 #c-ae;c1 #d-a;a7#b71 ,f-#aa1 ,g-#a;a1 ,g-#h1 ,g-#ac personal effects1 ,g-#aj;c1 ,g-#ac;a1 ,g-#ad;a1 ,g-#af;a1 ,g-#ag;a personnel_/equipment1 #b-e;b7#b71 #c-b;b1 #c-i1 #d-c1 ,g-#aa;d1 ,g-#ad;a shuffle pit1 ,g-#aj;g1 ,g-#aal1 ,g-#ac;e1 ,g-#ad;e1 ,g-#af;d1 ,g-#ag;d skin1 ,g-#aj;a and f1 ,g-#aa1 ,g-#ac;d1 ,g-#ad;d1 ,g-#af;c1 ,g-#ag;c solution preparation1 ,g-#a;c1 ,g-#g spot1 #c-b;b1 #d-c;c1 ,g-#aj;f1 ,g-#aa;g treatment during1 ,g-#aj1 ,g-#aa;a and k7#b7 bandages1 ,g-#aj;c7#b7 and f7#b71 ,g-#aak7#b7 splints1 ,g-#aj;c7#b7 and f7#b71 ,g-#aak7#b7 tourniquet1 ,g-#aj;c7#b7 and f7#b71 ,g-#aak7#b7 unit1 ,g-#b waste1 dispose of1 ,g-#aj;f7#d71 ,g-#aak water1 ,g-#g defense1 #c-ad;b dental services1 #c-c;a1 #e-ae1 ,c-#h decontamination1 #e-ag--ah1 ,c-#h mission1 #e-af operations1 #e-ag patient protection1 #e-ai treatment1 #c-c;a1 #e-af1 #e-ag1 #e-ah detection1 #c-a;d diseases1 #a-c;b7#d71 #e-a1 #e-b;b1 #e-c1 ,a-#h;b7#e71 ,d-#ab;c1 ,d-#ag;b emergency medical treatment1 #c-a;e1 #c-b;b1 #c-c;c1 #c-d1 #c-g1 #c-i1 #c-ae;b1 #d-a;a7#c71 ,d-#d;a1 ,d-#ab;a enemy prisoners of war1 #b-b;a environment biological1 #c-ad chemical1 #c-ae nuclear1 #c-ab operations in extreme environments1 #c-af desert1 #c-af;d jungle1 #c-af;c mountain1 #c-af;a ,,nbc1 #c-af snow and extreme cold1 #c-af;b urban terrain1 #c-af evacuation1 #c-ag1 ,d-#f1 ,d-#i1 ,d-#ab;a1 ,d-#ad1 ,d-#bb aircraft1 #c-ag;b and e contaminated areas1 in1 #c-ag;b ground vehicles1 #c-ag;b nonmedical vehicles1 #c-ag;b7#a71 #d-a;a7#c7 personnel1 #c-ag;b facilities1 #b-e;b7#i71 #c-a;c clean1 #c-a--c1 #c-aj1 #c-ae1 #c-ag;b7#d7 contamination1 #c-b1 #c-c;c1 #c-ae;a7#d7 move alternate facilities1 #b-a;b7#d71 #c-a;d decision to1 #b-a;b7#c7 mobility1 #d-a;a1 #d-b;a1 ,d-#f;a1 ,d-#ad;a1 ,d-#bc;a1 ,f-#a patients1 #b-a;b7#c7 protection available1 #b-a;b7#a7 and 7#d7 principles1 #d-b;b7#d77;d7 field expedient protective systems1 ,h-#a1 ,h-#d foxholes and trenches1 ,h-#c protection biological agent1 against1 ,h-#d;a chemical agent1 against1 ,h-#d;a factors1 ,h-#b radiation1 against1 ,h-#b shielding1 ,h-#b shelters1 expedient1 ,h-#a1 ,h-#c--d building of opportunity1 #b-a;b7#a71 ,h-#c cave1 #b-a;b7#a71 ,h-#c culverts1 ,h-#c ditches1 ,h-#c dozer trenches1 ,h-#c dug-in tents1 ,h-#c;d engineer support1 ,h-#c;c overpasses1 ,h-#c sandbagging1 ,h-#c;e tents1 ,h-#c;e tunnels1 #b-a;b7#a71 ,h-#c ,field ,medical ,card1 ,g-#b1 ,g-#aj;a7#d71 ,g-#aa;f1 ,g-#ac;b1 ,g-#ad;b first aid1 #c-a;a1 #c-b;a1 #c-i1 ,d-#g;b buddy aid1 #c-a;a1 #c-b;a1 ,d-#d;a1 ,d-#g;b1 ,d-#ab;a1 ,d-#bj;c combat lifesaver1 #c-a;a1 #c-b;a self-aid1 #c-a;a1 #c-b;a1 ,d-#d;a1 ,d-#g;b1 ,d-#ab;a1 ,d-#bj;c food animal1 ,j-#c;c7#e7 considerations1 ,j-#c;d contamination avoidance1 ,j-#a;c7#a7 contamination of1 #d-a;a1 ,j-#c;a1 ,j-#d;a1 ,j-#e;a countermeasures1 ,j-#a;b decontamination of1 ,j-#a;a1 c7#c71 and d1 ,j-#c;c1 ,j-#d;d1 ,j-#e;c detection in1 ,j-#a;a1 ,j-#d;b1 ,j-#e;b disposition of1 ,j-#a;a1 ,j-#e;d7#i7 monitoring1 ,j-#c;b operational rations1 ,j-#b;a priorities1 ,j-#a;c protection of1 ,j-#a;a1 ,j-#b storage bulk1 ,j-#b;b expedient1 ,j-#b;b fresh food1 ,j-#b;b susceptibility of1 ,j-#a;a forward surgical team1 #c-d guidelines chemical1 biological1 radiological1 nuclear1 and high-yield explosives1 ,c-#a conduct operations1 ,a-#b evacuation1 ,a-#g health service support planning1 ,c-#a mobilization1 for1 ,a-#b operational exposure1 #c-ab;d planning1 ,a-#a predeployment1 ,a-#b health service logistics1 #e-bd1 ,a-#aa organizational maintenance1 #e-bg protection of supplies shipment1 during1 #e-bf storage1 in1 #e-be1 ,a-#aa health service support1 ,d-#i1 ,d-#ab;a appraisal1 #b-c casualty collection point1 #c-a;c conventional operations1 #b-d evacuation1 #b-b;b1 #b-e;b7#e71 #c-b--c1 #c-af;a1 #c-ag1 #d-a1 #d-b;b7#b71 #d-g;i1 ,a-#g1 ,a-#ad;b1 ,a-#ae;b1 ,d-#a--b1 ,d-#d;a1 ,d-#f1 ,d-#g;b1 ,d-#h1 ,d-#ab;a1 ,d-#ac;b1 ,d-#ad1 ,d-#af1 ,d-#ai;a1 ,d-#bj;c1 ,d-#bb1 ,d-#bd1 ,d-#bf;d1 ,appendix ,e1 ,f-#b;a1 ,f-#c1 ,f-#e1 ,g-#b1 ,g-#aj1 ,g-#aa;c1 ,g-#ad;e1 ,g-#ag;d factors1 medical planning1 #b-c levels of1 #c-b1 #c-c1 #d-a;a operations in ,,nbc1 #b-b;g1 #b-e1 #b-f;b1 #c-a--d1 #c-ag;d1 #d-a;a personnel protection1 #b-f;a1 #c-h planning1 #c-h proximity1 #c-a;c replacements1 #c-a;c survival1 #c-e;a1 #c-af;c1 #e-ae1 #e-bb;a1 ,d-#g;b technical channels1 #c-a;c treatment1 #c-g1 #d-a;a7#c7 heat stress1 #b-f;a homeland security1 #b-g1 #e-bh1 ,c-#ab hospitalization bed requirements1 ,d-#h1 ,d-#af1 ,d-#bd blood services1 #e-aa conventional operations1 #d-h decontamination1 #d-a;a7#e7 defensive measures1 #d-a;b emergency services1 #d-d general medical services1 #d-e integrated battlefield1 on1 #d-a;a intensive care1 #e-aa locations1 #d-a;a7#a7 logistics support1 #d-a;b7#b71 ,a-#aa nursing services1 #d-g protection1 #d-a;a7#e7 and b7#b71 #d-b;b7#b77;b71 #d-d protective procedures1 #d-a;a7#e7 and b7#a7 biological1 #d-a;b7#c7 chemical1 #d-b;b7#d7 ,,mopp levels1 #d-a;b nuclear1 #d-b;b7#b7 response1 #d-b;a surgical services1 #d-f1 #e-aa warning system1 #d-a;b7#d7 initial effects alternate operational sites1 #c-aj detection1 #c-a;d1 #e-g1 #e-bg1 ,a-#a1 ,c-#b1 ,c-#d1 ,c-#f--g1 ,c-#aa1 ,appendix ,e1 ,f-#ab;c1 ,f-#ad1 ,i-#b1 ,j-#a1 ,j-#b;a1 ,j-#d;b installation medical authority1 #e-bh ,international ,standardization ,agreements1 ,d-#a ,,stanag #bdge1 p4 viii1 ,d-#c ,,stanag #bdgf1 p4 viii1 ,d-#aa ,,stanag #bdgg1 p4 viii1 ,d-#ai laboratory services1 #e-i--aa1 ,a-#a,oa1 ,appendix ,e biological specimens1 #e-aa1 #e-ad chain of custody1 #e-ad clinical1 #e-aa levels1 #e-aa samples1 #e-aj animals1 small1 #e-ad environmental1 #e-ad field1 #e-ad food1 #e-ad soil1 #e-ad vegetation1 #e-ad support1 #e-aa theater ,army medical laboratory1 #e-aa leadership logistics1 #b-f1 #c-h1 #d-b;b7#d77;c71 #e-f1 ,d-#i1 ,d-#ab;a1 ,d-#ag1 ,d-#be1 ,appendix ,e main supply routes1 #c-e;c mass casualties1 #b-a1 #e-ae--af1 #e-bi1 ,a-#aj;b1 ,a-#ad;b1 ,a-#ae;b1 ,d-#d;a1 ,d-#ab;a1 ,d-#bj;b medical equipment sets chemical agent patient decontamination1 #c-h;b1 #d-c;c7#c71 ,c-#b1 ,c-#d chemical agent patient treatment1 #c-h;b1 #d-c;c7#c71 ,c-#b1 ,c-#d medical evacuation1 #b-e;b7#c7 and 7#e71 #c-a;c and e1 #c-b;a1 #c-c;a1 #c-aj;b1 #c-ab;b1 #c-ag1 #d-a1 #e-bh medical surveillance1 #c-c;a1 #c-ad;f medical treatment facility1 #b-a1 #b-b;a1 #b-e;b1 #c-c;c mission-oriented protective posture clothing1 #b-e;b1 #c-a;a--b1 #c-i--aj1 #c-ae;a1 #e-ai;b1 #e-ba;e1 ,c-#c1 ,f-#b;a equipment1 #b-e;b performance degradation1 #b-f movement and management of contaminated facilities1 #b-e;b1 #c-aj;d nuclear1 biological1 and chemical battlefield considerations1 ,c-#a defense1 #c-a;b1 #e-ba leadership1 #b-f1 #c-a1 #c-f1 #c-ag;a1 #e-ba1 ,appendix ,e operational exposure guide1 nuclear1 #b-e;a1 #c-a;b operations in1 #a-c;b7#d71 #b-b;a1 #b-d--e1 #c-e;a1 #c-i1 #c-ab;d1 #c-af1 #d-b;b7#a77;c71 7#b71 and 7#d77;c71 #d-c;a1 #e-ad--ae1 #e-ag1 ,a-#g1 ,c-#b1 ,c-#aa1 ,appendix ,e1 ,f-#d--e strikes1 #d-a;a warning and reporting system1 #d-a;b nursing services1 #d-g1 ,a-#aj operational exposure guide1 nuclear1 #b-e;a1 #c-a;b1 #c-ab;d1 #c-ag;b plans1 #b-e;a1 #c-a;a operations1 #d-b;b7#a77;c7 and 7#b77;a71 #d-c;a7#b71 ,a-#a1 ,a-#g1 ,c-#a1 ,c-#e1 ,c-#aa1 ,d-#c;d1 ,f-#c--e1 ,f-#aa--ab1 ,g-#a;a1 ,j-#a;d1 ,j-#e;c7#e7 security1 #d-a;b7#a71 #d-b;b passive defense measures1 #c-ad;b patient chemical agent1 ,a-#ad contaminated1 #c-aj;c1 #c-ab1 #d-a;a7#c71 ,c-#e decontamination1 #c-c;b1 #c-aj1 #d-a;a7#c7 and b1 ,a-#ad;c1 ,a-#ae;c externally contaminated1 #c-ab;a holding1 #c-c;a internally contaminated1 #c-ab;a irradiated1 #c-ab;a management of1 ,a-#aj;c number of1 #b-a;b7#c7 protective wrap1 #c-ag;f1 ,f-#ae;b7#b77;a71 ,g-#aa;c stability operations and support operations1 in1 ,a-#g types of1 #b-a;b7#c71 #c-ab;b1 ,c-#d personnel protection of1 #b-a;b7#i71 #b-f;a replacement of1 #c-a;c planning considerations for1 ,d-#d1 ,d-#bj;a estimates1 ,d-#b1 ,d-#d1 ,d-#aa;c1 ,d-#ag1 ,d-#ai health service support1 #c-i medical force1 for1 ,d-#aj1 ,d-#ah1 ,d-#bj1 ,d-#bf medical ,,nbc staff officer1 ,appendix ,e mobilization1 ,c-#b--c ,,nbc1 #c-e;c1 p4 ,d-#a predeployment1 ,c-#b tool1 medical1 ,d-#b plans establish a medical treatment facility1 ,c-#a ,,hss1 #c-ag;d load1 ,c-#c movement1 ,c-#c operation1 #b-e;a1 #c-a;a tactical1 #c-ag;d preventive medicine arthropods1 #e-b;b1 #e-c climate1 #e-b;a detachments1 #e-d determining factors1 #e-a1 #e-b;a disease1 #e-a divisional1 #c-c;a1 #e-c field hygiene and sanitation1 #e-c field sanitation team1 unit1 #e-c--d immunizations1 #e-c1 ,d-#aa;f incidents and morbidity1 #e-b;b measures1 #c-a;e1 #e-a1 #e-d1 #e-aa--ab medical surveillance1 #e-d occupational and environmental health threat1 #e-c--d operations1 #e-a--b1 #e-d pest management1 #e-b;b1 #e-d prophylaxis1 ,d-#aa;f services1 #c-c;a1 #e-a1 #e-ad1 ,c-#f1 ,appendix ,e water and food1 #e-b;a1 #e-c--d protection buildings of opportunity1 use of1 #c-a;d1 #c-e;b1 #c-ab collective1 #c-a;d1 #c-b;b1 #c-c;b1 #c-d1 #c-aj;a1 #c-ae1 #d-g1 ,c-#b1 ,c-#d covers1 #c-a;d1 #c-ab environmental1 #d-b;b7#b71 #d-e1 #d-f;a and c1 #d-g;c hospital1 #d-b;a individual1 #d-b;b1 #e-ba;d mask-only1 #d-b;b7#d77;a71 #d-g;b materiel1 #c-a;d1 #d-b;b7#d77;d7 overhead1 #c-a;d1 #c-ab patient1 #c-e;d1 #d-b;b7#d77;c71 ,a-#f personnel1 #c-e;b1 #d-b;b7#d77;a7 proximity1 #c-a;c shielding1 #c-e;b1 #d-b;b7#b7 site selection1 #c-ab supplies1 #c-e;b types of1 #c-a;d warning system1 #d-b;b7#d7 expedient1 #b-e;b7#a71 #c-e;b1 #c-ab shielding1 #d-b;b7#b77;b7#c radiation exposure status1 #c-ab;d1 #c-ag;b radiological dispersal devices1 #a-a;a1 #d-a;a1 ,a-#a rations1 ,f-#f;b1 ,j-#e;a7#d7 reporting1 ,appendix ,e return to duty1 #c-a;e samples1 #e-c--d1 #e-i1 ,c-#f--g1 ,c-#aj1 ,appendix ,e analysis of1 ,b-#a--b chain of custody1 #e-i1 #e-ad;a and b7#a71 ,c-#f--g documentation1 #e-i collection1 #e-i1 ,b-#a--b1 ,b-#d;b description of1 ,b-#b environmental1 #e-i1 #e-ad1 ,b-#a1 ,b-#c;b1 ,b-#e air1 #e-ab;b7#a71 #e-ad1 ,b-#a1 ,b-#h soil1 #e-ab;b7#a71 #e-ad1 ,b-#a1 ,b-#aj vapor1 ,b-#h vegetation1 #e-ab;b7#a71 #e-ad1 ,b-#a1 ,b-#d water1 #e-ab;b7#a71 #e-ad1 ,b-#a1 ,b-#c;c1 ,b-#i food1 #e-i;b7#a71 #e-ad1 ,j-#d;b7#a71 ,b-#a1 ,b-#c;d handling1 #e-i history of1 ,b-#b identification1 #e-i;b7#a71 #e-ac labeling1 #e-i1 #e-ac1 ,b-#d;b preservation1 #e-i;b7#a71 ,b-#b1 ,b-#d;b1 ,c-#f--g transportation1 #e-i;b7#a7 sleep loss1 #b-f;a special medical response teams1 #e-bh--bi specimens1 ,appendix ,e analysis1 #e-aj--aa1 #e-ab;b1 ,a-#aj1 ,b-#a--c ante mortem1 ,b-#c;a background documents1 ,b-#ah biological1 #e-c--d1 #e-i1 ,a-#aj1 ,b-#a1 ,b-#e1 ,b-#ab--ac1 p4 ,c-#f--g chain of custody1 #e-i;a1 #e-aa--ab1 #e-ad;b7#a71 ,b-#d1 ,b-#ag1 ,c-#f--g1 ,c-#aj--aa civilians1 from1 ,b-#a;b1 ,b-#ac collection of1 #e-c--d1 #e-i;b7#a71 #e-aj--ab1 #e-ad1 ,b-#a1 ,b-#d;b1 ,b-#ab--ac1 ,c-#g1 ,c-#aj--aa description of1 ,b-#b documentation of1 ,b-#b field1 #e-ad history of1 ,b-#b1 ,b-#ae identification1 #e-i;b7#a71 #e-ab;b1 #e-ac1 ,a-#aj;a post mortem and forensic1 ,b-#c;b1 ,b-#ad preservation1 #e-i;b7#a71 #e-aa--ab1 ,b-#b--c1 ,b-#d;b1 ,b-#ae--af1 ,c-#f--g1 ,c-#aj--aa reporting1 #e-ab;b1 ,b-#ae1 ,b-#ag transportation1 #e-i;a and b7#a71 #e-ab types of1 ,b-#c stability operations and support operations1 ,a-#g ,standardization ,agreement 7,,stanag74 ,see ,international ,standardization ,agreements4 stress1 #b-f;a supply1 ,class ,,viii tactical standing operating procedures1 ,c-#b threat1 #a-a;a biological warfare1 #a-b1 #a-c;b1 #c-ad chemical1 biological1 radiological1 nuclear1 and high-yield explosive1 #a-b chemical warfare1 #a-b1 #a-c;c directed energy1 #a-b medical1 #a-b nuclear1 #a-b1 #a-c;a radiological dispersal device1 #a-b1 #a-c;a toxic industrial material1 #a-a;b1 #a-c;d toxic industrial material1 #a-a;b1 #a-b1 #c-a;a and d1 #d-a;a1 #e-c1 ,a-#a1 ,a-#ae1 ,appendix ,e training1 #c-a;b1 ,c-#c treatment1 #c-a--b1 #c-g1 #c-i--aj1 #c-ac--af1 #e-bi1 ,a-#c;a7#c71 ,a-#f;e1 ,a-#aj;d1 ,a-#ad;d1 ,a-#ae;d1 ,appendix ,e advanced trauma management1 #c-a;e1 #c-i clean area1 #c-a--c1 #c-aj1 #c-ae1 #c-ag;b7#d7 emergency medical treatment1 #c-a;e1 #c-c;b1 #c-g1 #c-i1 #c-ae;b1 #d-a;a7#c71 ,d-#d;a1 ,d-#ab;a triage1 #b-c1 #c-ac1 #d-a;a7#c7 and b1 #d-d;b1 #e-bj1 #e-bi1 ,c-#b1 ,c-#e1 ,d-#d;a1 ,d-#e1 ,d-#ab;a1 ,d-#ac1 ,d-#ba veterinary services1 #e-e1 #e-ad1 ,c-#g1 ,appendix ,e animal care1 #e-h food protection1 #e-f waste disposal1 ,f-#f;b water supply1 #d-a;a1 ,c-#b1 ,f-#f;b1 ,i-#a--d actions to protect1 ,i-#c detection in1 ,i-#b treatment of1 ,i-#d weapons1 #a-c1 #c-a;b and c1 #d-a;a1 ,a-#a biological1 #d-b;b7#c71 #e-b;b1 ,a-#h1 ,d-#aa;e1 ,d-#ab;b agents1 ,a-#h behavior1 ,a-#i dispersion1 ,a-#h--i effects1 #c-g1 ,a-#g1 ,a-#aj1 ,d-#aa;c incubation period1 ,a-#h;a7#c7 individual1 ,f-#ad infection1 ,a-#h;a7#b7 live agents1 ,a-#h;a spore-forming1 ,a-#h;b toxins1 ,a-#h;c categories nonpersistent1 ,a-#ab;a7#b7 persistent1 ,a-#ab;b7#a7 protection against1 #c-aj vapor hazard1 #c-aj;d chemical1 #d-b;b7#d7 agents1 #c-g1 ,a-#aa;b attacks types of1 ,a-#aa;b behavior1 ,a-#ab blister1 ,table ,a-#ab1 ,a-#ac;b1 ,d-#bj;e blood1 ,table ,a-#ab1 ,a-#ac;d characteristics1 ,a-#ab--ac incapacitating1 ,a-#ab;a1 ,table ,a-#ab lung damaging1 ,table ,a-#ab1 ,a-#ac;c nerve1 ,table ,a-#ab1 ,a-#ac;a effects1 #c-e;b1 ,a-#aa employment of1 ,a-#a nuclear1 #d-b;b7#b7 biological effects1 ,a-#d blast1 #c-g1 #c-ab;a1 ,a-#b;c1 ,a-#c;a burns1 ,a-#d detonation of1 ,d-#c;e effects of1 ,d-#c;d electromagnetic pulse1 ,a-#b;a1 ,d-#d;d eye injuries1 ,a-#d;c fallout1 #c-ab;b overpressure1 ,a-#c;a7#b7 physical effects1 ,a-#b physiological effects1 ,a-#c1 ,a-#e radiation injury1 #c-g1 #c-ab;a thermal injury1 #c-g1 #c-ab;a1 ,d-#d;a radiological dispersal device1 #a-a;b1 #a-c1 ,a-#a1 ,a-#c threat1 #a-a1 #c-a;a1 #c-b;b work_/rest cycles1 #b-f;a ,,fm #d-jb4g 7,,fm #h-aj-g7 #a ,,october #bjjb ,by ,order of the ,secretary of the ,army3 ,,eric ,k4 ,,shinseki ,general1 ,united ,states ,army ,chief of ,staff ,official3 ,illustration3 7signature7 ,,joel ,b4 ,,hudson ,administrative ,assistant to the ,secretary of the ,army #jbbedbd ,,distribution3 ,active ,army1 ,u4,s4 ,army ,reserve and ,army ,national ,guard3 ,to be distributed in accordance with the initial distribution ,number1 #aadhii1 requirements for ,,fm #d-jb4g4 ,,transcriber',s ,,note ,italic text is denoted by underscores4 ,blank space in some sample documents in the text is also denoted by 4 ,bold text is denoted by equal signs4 ,superscripts are denoted by eg abc,,tm4 ,subscripts in chemical formulae are denoted by eg ,,co#b4 ,footnotes are all within a specific ,table1 including the ,table of ,contents4 ,they are positioned at the bottom of that ,table1 as in the original text1 and are denoted by 99 or 99994 ,obvious punctuation errors have been corrected after careful comparison with other occurrences within the text and consultation of external sources4 ,column headings in ,tables1 all bolded in the original text1 are unbolded here for clarity4 ,fractions in the original text are mostly full-height format1 eg #a_/b1 and have been left in that form4 ,some are half-height and have been converted to ,unicode fractions eg whenever possible4 ,except for those changes noted below1 all misspelling in the text1 and inconsistent or archaic usage1 have been retained4 ,chapter-,paragraph3 #b-a4 'thermoberic' replaced by 'thermobaric'4 #c-c4 'proves' replaced by 'provides'4 #c-h4 'company's' replaced by 'companies'4 #d-c4 'are also' replaced by 'is also'4 ,appendix3 ,table ,a-#a4 ',,radiaton' replaced by ',,radiation'4 ,table ,a-#g4 ',cal_/cm#b_/sec' replaced by ',cal_/cm#b_/sec'4 ,table ,a-#aj4 '#j4h-b ,,cancer4' replaced by '#j4h-b'4 ,table ,a-#ac4 ',characteristics' replaced by ',characteristics of'4 ,para ,b-#aa4 'handsful' replaced by 'handful'4 ,para ,b-#ah4 ',,bluffed ,,vision' replaced by ',,blurred ,,vision'4 ,para ,j-#e4 'modify to ,m#dc' replaced by 'modify the ,m#dc'4 ,index3 heat injury prevention4 '#f-aj;g7#d7' replaced by ',g-#h'4 monitor for completeness4 '#f-aj;f' replaced by ',g-#aj;g'4