path: root/49037-0.txt

*** START OF THE PROJECT GUTENBERG EBOOK 49037 ***

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    =FM 4-02.7= (FM 8-10-7)


    HEALTH SERVICE
    SUPPORT IN A NUCLEAR,
    BIOLOGICAL, AND
    CHEMICAL
    ENVIRONMENT


    TACTICS, TECHNIQUES, AND PROCEDURES


    OCTOBER 2002


    HEADQUARTERS, DEPARTMENT OF THE ARMY

    DISTRIBUTION RESTRICTION: Approved for public release; distribution
    is unlimited.




                           [*]FM 4-02.7 (FM 8-10-7)

    FIELD MANUAL                       HEADQUARTERS
    NO. 4-02.7 (8-10-7)      DEPARTMENT OF THE ARMY
                     Washington, DC, 1 October 2002


HEALTH SERVICE SUPPORT IN A NUCLEAR, BIOLOGICAL, AND CHEMICAL
ENVIRONMENT TACTICS, TECHNIQUES AND PROCEDURES




    TABLE OF CONTENTS


                                                                =Page=

    =Preface=                                                     viii


    =CHAPTER 1. NUCLEAR, BIOLOGICAL, AND CHEMICAL WARFARE ASPECT
    OF THE MEDICAL THREAT=                                         1-1

    1-1. General                                                   1-1

    1-2. Medical Threat                                            1-1

    1-3. Nuclear, Biological, Chemical, and Radiological Dispersal
         Device Threats--The Health Service Perspective            1-2


    =CHAPTER 2. COMMAND AND CONTROL=                               2-1

    2-1. General                                                   2-1

    2-2. Health Service Support Command and Control Planning
         Considerations                                            2-1

    2-3. Health Service Support Command and Control Appraisal of
         the Support Mission                                       2-2

    2-4. Health Service Support Units                              2-2

    2-5. Movement/Management of Contaminated Facilities            2-3

    2-6. Leadership on the Contaminated Battlefield                2-5

    2-7. Homeland Security                                         2-6


    =CHAPTER 3. LEVELS I AND II HEALTH SERVICE SUPPORT=            3-1

    3-1. General                                                   3-1

    3-2. Level I Health Service Support                            3-2

    3-3. Level II Health Service Support                           3-2

    3-4. Forward Surgical Team                                     3-3

    3-5. Actions Before a Nuclear, Biological, or Chemical Attack  3-3

    3-6. Actions During a Nuclear, Biological, or Chemical Attack  3-4

    3-7. Actions After a Nuclear, Biological, or Chemical Attack   3-4

    3-8. Logistical Considerations                                 3-5

    3-9. Personnel Considerations                                  3-5

    3-10. Disposition and Employment of Treatment Elements         3-6

    3-11. Civilian Casualties                                      3-6

    3-12. Nuclear Environment                                      3-7

    3-13. Medical Triage                                           3-8

    3-14. Biological Environment                                   3-8

    3-15. Chemical Environment                                     3-9

    3-16. Operations in Extreme Environments                      3-10

    3-17. Medical Evacuation in a Nuclear, Biological, and
          Chemical Environment                                    3-10


    =CHAPTER 4. LEVELS III AND IV HOSPITALIZATION=                 4-1

    4-1. General                                                   4-1

    4-2. Protection                                                4-3

    4-3. Decontamination                                           4-8

    4-4. Emergency Services                                       4-10

    4-5. General Medical Services                                 4-11

    4-6. Surgical Services                                        4-11

    4-7. Nursing Services                                         4-12

    4-8. Conventional Operations                                  4-13


    =CHAPTER 5. OTHER HEALTH SERVICE SUPPORT=                      5-1

    =Section I. Preventive Medicine Services=                      5-1

    5-1. General                                                   5-1

    5-2. Disease Incidence Following the Use of Nuclear,
         Biological, and Chemical Weapons                          5-1

    5-3. Preventive Medicine Section                               5-3

    5-4. Preventive Medicine Detachment                            5-3

    =Section II. Veterinary Services=                              5-4

    5-5. General                                                   5-4

    5-6. Food Protection                                           5-4

    5-7. Food Decontamination                                      5-4

    5-8. Animal Care                                               5-5

    =Section III. Laboratory Services=                             5-5

    5-9. General                                                   5-5

    5-10. Level II                                                 5-5

    5-11. Level III                                                5-5

    5-12. Level IV                                                 5-6

    5-13. Level V (Continental United States)                      5-6

    5-14. Field Samples                                            5-6

    =Section IV. Dental Services=                                  5-7

    5-15. General                                                  5-7

    5-16. Mission in a Nuclear, Biological, or Chemical
          Environment                                              5-7

    5-17. Dental Treatment Operations                              5-7

    5-18. Patient Treatment Considerations                         5-7

    5-19. Patient Protection                                       5-8

    =Section V. Combat Operational Stress Control=                 5-9

    5-20. General                                                  5-9

    5-21. Leadership Actions                                       5-9

    5-22. Individual Responsibilities                             5-10

    5-23. Mental Health Personnel Responsibilities                5-11

    =Section VI. Health Service Logistics=                        5-11

    5-24. General                                                 5-11

    5-25. Protecting Supplies In Storage                          5-12

    5-26. Protecting Supplies During Shipment                     5-12

    5-27. Organizational Maintenance                              5-12

    =Section VII. Homeland Security Response=                     5-13

    5-28. Chemical, Biological, Radiological, Nuclear, and
          High-Yield Explosive Response                           5-13

    5-29. Capabilities of Response Elements                       5-14


    =APPENDIX A. MEDICAL EFFECTS OF NUCLEAR, BIOLOGICAL, AND
    CHEMICAL WEAPONS AND TOXIC INDUSTRIAL MATERIAL=                A-1

    A-1. General                                                   A-1

    A-2. Physical Effects of Nuclear Weapons                       A-1

    A-3. Physiological Effects of Nuclear Weapons                  A-4

    A-4. Biological Effects of Thermal Radiation                   A-7

    A-5. Physiological Effects of Ionizing Radiation               A-8

    A-6. Handling and Managing Radiologically Contaminated
         Patients                                                 A-10

    A-7. Radiological Patients in Stability Operations and
         Support Operations                                       A-13

    A-8. Effects of Biological Weapons                            A-14

    A-9. Behavior of Biological Weapons                           A-15

    A-10. Management of Biological Warfare Patients               A-16

    A-11. Effects of Chemical Weapons                             A-17

    A-12. Behavior of Chemical Weapons                            A-17

    A-13. Characteristics of Chemical Agents                      A-19

    A-14. Management of Chemical Agent Patients                   A-23

    A-15. Management of Toxic Industrial Material Patients        A-23


    =APPENDIX B. SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT=        B-1

    =Section I. Introduction=                                      B-1

    B-1. General                                                   B-1

    B-2. Sample/Specimen Background Information                    B-2

    B-3. Sample/Specimen Collection and Preservation               B-3

    B-4. Chain of Custody                                          B-8

    =Section II. Sampling Techniques and Procedures=               B-9

    B-5. General                                                   B-9

    B-6. Expended Material                                        B-11

    B-7. Environmental Samples                                    B-11

    B-8. Collection of Air and Vapors                             B-12

    B-9. Collection of Water Samples                              B-13

    B-10. Collection of Soil Samples                              B-15

    B-11. Collection of Contaminated Vegetation                   B-16

    B-12. Medical Specimens                                       B-16

    B-13. Collection of Medical Specimens                         B-17

    B-14. Post Mortem Specimens                                   B-19

    B-15. Reporting, Packaging, and Shipment                      B-20

    B-16. Handling and Packaging Materials                        B-21

    B-17. Collection Reporting                                    B-23

    B-18. Sample/Specimen Background Documents                    B-27


    =APPENDIX C. GUIDELINES FOR OPERATIONAL PLANNING FOR HEALTH
    SERVICE SUPPORT IN A NUCLEAR, BIOLOGICAL, AND
    CHEMICAL ENVIRONMENT=                                          C-1

    C-1. General                                                   C-1

    C-2. Predeployment                                             C-1

    C-3. Mobilization                                              C-2

    C-4. Establish a Medical Treatment Facility                    C-3

    C-5. Operate a Medical Treatment Facility Receiving
         Contaminated Patients.                                    C-4

    C-6. Preventive Medicine Services                              C-5

    C-7. Veterinary Services                                       C-6

    C-8. Dental Services                                           C-6

    C-9. Combat Operational Stress Control                         C-6

    C-10. Medical Laboratory Services                              C-6

    C-11. Health Service Logistics                                 C-7

    C-12. Homeland Security                                        C-8


    =APPENDIX D. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF
    NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE
    CASUALTIES=                                                    D-1

    =Section I. Introduction=                                      D-1

    D-1. General                                                   D-1

    D-2. Medical Planners' Tool                                    D-1

    =Section II. Medical Planning Guide for the Estimation of
    Nuclear, Biological, and Chemical Battle Casualties
    (Nuclear)--AMedP-8(A), Volume I=                               D-1

    D-3. General                                                   D-1

    D-4. Medical Planning Considerations                           D-2

    D-5. Triage                                                    D-3

    D-6. Evacuation                                                D-3

    D-7. In-Unit Care                                              D-3

    D-8. Hospital Bed Requirements                                 D-4

    D-9. Medical Logistics                                         D-4

    D-10. Medical Force Planning                                   D-4

    =Section III. Medical Planning Guide for the Estimation of
    Nuclear, Biological, and Chemical Battle Casualties
    (Biological)--AMedP-8(A), Volume II=                           D-4

    D-11. General                                                  D-4

    D-12. Medical Planning Considerations                          D-6

    D-13. Triage                                                   D-6

    D-14. Evacuation                                               D-6

    D-15. In-Unit Care                                             D-7

    D-16. Patient Bed Requirements                                 D-7

    D-17. Medical Logistics                                        D-7

    D-18. Medical Force Planning                                   D-8

    =Section IV. Medical Planning Guide for the Estimation of
    Nuclear, Biological, and Chemical Battle Casualties
    (Chemical)--AMedP-8(A), Volume III=                            D-8

    D-19. General                                                  D-8

    D-20. Medical Planning Considerations                         D-10

    D-21. Triage                                                  D-11

    D-22. Evacuation                                              D-11

    D-23. In-Unit Care                                            D-11

    D-24. Patient Bed Requirements                                D-12

    D-25. Medical Logistics                                       D-12

    D-26. Medical Force Planning                                  D-12


    =APPENDIX E. EXAMPLE X-__, ANNEX__, TO HSS PLAN/OPERATION
    ORDER__, MEDICAL NBC STAFF OFFICER PLANNING
    FOR HSS IN AN NBC ENVIRONMENT=                                 E-1


    =APPENDIX F. EMPLOYMENT OF CHEMICAL AND BIOLOGICAL
    COLLECTIVE PROTECTION SHELTER SYSTEMS BY MEDICAL UNITS=        F-1

    =Section I. Introduction=                                      F-1

    F-1. General                                                   F-1

    F-2. Types of Collective Protection Shelter Systems            F-1

    =Section II. Employment of the Chemically and Biologically
    Protected Shelter System=                                      F-2

    F-3. Establish a Battalion Aid Station in a Chemically
    Biologically Protected Shelter                                 F-2

    F-4. Division Clearing Station in a Chemically Biologically
    Protected Shelter                                              F-4

    F-5. Forward Surgical Team in a Chemically Biologically
    Protected Shelter                                              F-6

    =Section III. Employment of the Chemically Protected
    Deployable Medical Systems and Simplified Collective
    Protection Systems=                                            F-8

    F-6. Collective Protection in a Deployable Medical
    System-Equipped Hospital                                       F-8

    F-7. Chemically/Biologically Protecting the International
    Organization for Standardization Shelter                      F-11

    F-8. Chemically/Biologically Protecting the Vestibules        F-12

    F-9. Chemically/Biologically Protecting Air Handler Equipment F-12

    F-10. Establish Collective Protection Shelter Using the M20
    Simplified Collective Protection System                       F-12

    F-11. Casualty Decontamination                                F-12

    =Section IV. Operations, Entry, and Exit Guidelines=          F-13

    F-12. Operations                                              F-13

    F-13. Decontamination of Entrance Area                        F-13

    F-14. Procedures Prior to Entry                               F-14

    F-15. Entry/Exit for the Collective Protection Shelter System F-14

    F-16. Resupply of Protected Areas                             F-17


    =APPENDIX G. PATIENT DECONTAMINATION=                          G-1

    =Section I. Introduction=                                      G-1

    G-1. General                                                   G-1

    G-2. Immediate Decontamination                                 G-2

    G-3. Patient Decontamination and Thorough Decontamination
    Collocation                                                    G-2

    G-4. Patient Decontamination at the Battalion Aid Station
    (Level I)                                                      G-5

    G-5. Patient Decontamination at the Medical Company Clearing
    Station (Level II)                                             G-5

    G-6. Patient Decontamination at a Hospital (Level III and IV)  G-5

    G-7. Prepare Hypochlorite Solutions for Patient
    Decontamination                                                G-5

    G-8. Classification of Patients                                G-6

    G-9. Patient Treatment                                         G-6

    =Section II. Patient Decontamination Procedures=               G-7

    G-10. Decontaminate a Litter Chemical Agent Patient            G-7

    G-11. Decontaminate an Ambulatory Chemical Agent Patient      G-14

    G-12. Biological Patient Decontamination Procedures           G-18

    G-13. Decontaminate a Litter Biological Agent Patient         G-18

    G-14. Decontaminate an Ambulatory Biological Agent Patient    G-19

    G-15. Decontaminate Nuclear-Contaminated Patients             G-20

    G-16. Decontaminate a Litter Nuclear-Contaminated Patient     G-21

    G-17. Decontaminate an Ambulatory Nuclear-Contaminated
    Patient                                                       G-21


    =APPENDIX H. FIELD EXPEDIENT PROTECTIVE SYSTEMS AGAINST
    NUCLEAR, BIOLOGICAL, AND CHEMICAL ATTACK=                      H-1

    H-1. General                                                   H-1

    H-2. Protection Against Radiation                              H-1

    H-3. Expedient Shelters for Protection Against Radiation       H-2

    H-4. Expedient Shelters Against Biological and Chemical Agents H-5


    =APPENDIX I. DETECTION AND TREATMENT OF NUCLEAR, BIOLOGICAL,
    AND CHEMICAL CONTAMINATION IN WATER=                           I-1

    I-1. General                                                   I-1

    I-2. Detection of Contamination in Water                       I-1

    I-3. Procedures on Discovery of Contamination in Water         I-1

    I-4. Treatment of Contaminated Water                           I-2


    =APPENDIX J. FOOD CONTAMINATION AND DECONTAMINATION=           J-1

    J-1. General                                                   J-1

    J-2. Protection of Food From Contamination                     J-2

    J-3. Nuclear                                                   J-3

    J-4. Biological                                                J-4

    J-5. Chemical                                                  J-5


    =GLOSSARY=                                              Glossary-1


    =REFERENCES=                                          References-1


    =INDEX=                                                    Index-1


DISTRIBUTION RESTRICTION: Approved for public release; distribution
is unlimited.

[*] This publication supersedes FM 8-10-7, 22 April 1993. Change 1,
26 November 1996




PREFACE

The purpose of this field manual (FM) is to provide doctrine and
tactics, techniques, and procedures for health service support
(HSS) units and personnel operating in a nuclear, biological,
and chemical (NBC), radiological dispersal device (RDD), and
toxic industrial material (TIM) environment. The manual provides
information for use by commanders, planners, leaders, and
individuals in providing HSS under these adverse conditions.

The use of trade or brand names in this publication is for
illustrative purposes only. Their use does not constitute
endorsement by the Department of Defense (DOD).

The proponent of this publication is the United States (US) Army
Medical Department Center and School (AMEDDC&S). Send comments and
recommendations directly to Commander, US Army Medical Department
Center and School, ATTN: MCCS-FCD, 1400 East Grayson Street, Fort
Sam Houston, Texas 78234-5052.

The use of the term "level of care" in this publication is
synonymous with "echelon of care" and "role of care." The term
"echelon of care" is the old North Atlantic Treaty Organization
(NATO) term. The term "role of care" is the new NATO and American,
British, Canadian, and Australian (ABCA) term.

The use of the term TIM in this publication is inclusive of RDD.

The use of the term "Health Service Support" in this publication
is synonymous with Combat Health Support as used in other
publications. Health Service Support is the term used in Joint
Publications to describe medical support to Joint Forces.

Radiological and chemical detection devices discussed in this
publication are currently being replaced through modernization or
new device developments. The users should adapt the application of
doctrine as described to fit the new devices when issued/authorized.

Unless this publication states otherwise, masculine nouns and
pronouns do not refer exclusively to men.

This publication implements NATO Standardization Agreements
(STANAGs) 2475, Medical Planning Guide for the Estimation of
NBC Battle Casualties (Nuclear)--Allied Medical Publication
(AMedP) 8(A), Volume I; 2476, Medical Planning Guide of NBC
Battle Casualties (Biological)--AMedP-8(A), Volume II; 2477,
Planning Guide for the Estimation of NBC Battle Casualties
(Chemical)--AMedP-8 (A), Volume III. It is also in consonance with
the following NATO STANAGs and ABCA Quadripartite Standardization
Agreements (QSTAGs):

               TITLE                                     STANAG    QSTAG

    Warning Signs for the Marking of Contaminated or
    Dangerous Land Areas, Complete Equipments, Supplies
    and Stores                                             2002      501

    Emergency Alarms of Hazard or Attack (NBC and Air
    Attack Only)                                           2047      183

    Interoperable Chemical Agent Detector Kits                       608

    Emergency War Surgery                                  2068

    Commander's Guide on Nuclear Radiation Exposure of
    Groups                                                 2083      898

    Reporting Nuclear Detonations, Biological and Chemical
    Attacks, and Predicting and Warning of Associated
    Hazards and Hazard Areas--ATP-45(B)                    2103      187

    Friendly Nuclear Strike Warning                        2104      189

    Nuclear, Biological and Chemical Reconnaissance        2112

    NATO Handbook on the Medical Aspects of NBC Defensive
    Operations--AMedP-6(B)                                 2500

    Concept of Operations of Medical Support in Nuclear,
    Biological, and Chemical Environments--AMedP-7(A)      2873

    Medical Aspects of NBC Defensive Operations                     1330

    Principles of Medical Policy in the Management of a
    Mass Casualty Situation                                2879

    Medical Aspects of Mass Casualty Situations                      816

    Guidelines for Air and Ground Personnel Using Fixed
    and Transportable Collective Protection Facilities
    on Land                                                2941     2000

    Training of Medical Personnel for NBC Operations       2954




CHAPTER 1

NUCLEAR, BIOLOGICAL, AND CHEMICAL WARFARE ASPECT OF THE MEDICAL
THREAT


1-1. General

_a._ After World War II, the Soviet Union represented the
principal threat to the national security interests of the US.
During this period, the military capability of the Soviet Armed
Forces grew enormously. Starting in the later years of the 1980s,
the international security environment has undergone rapid,
fundamental, and revolutionary changes. With the collapse of Soviet
communism, the Soviet Union disintegrated as a viable economic and
political system. The Warsaw Pact dissolved as a political and
military entity. The central Soviet government was replaced by the
Commonwealth of Independent States (CIS), dominated by the Russian
Republic. The cohesion of Soviet strategic military capability has
been fractured by--

    · The dissolution of central Soviet control.

    · The formation of the CIS.

    · The unpredictability associated with uncertain loyalties and
    low morale.

The ultimate outcome of these events in terms of US national
security interests is unclear. The military capabilities of CIS
like Russia, Ukraine, Kazakstan, and Belarus remain formidable. The
capabilities include strategic nuclear and impressive conventional,
biological, and chemical warfighting capabilities.

_b._ From a global perspective, the economic power and influence
of developing and newly industrialized nations continue to grow.
Centers of power (global or regional) cannot be measured solely
in military terms. Nation states pursuing their own political,
ideological, and economic interests may become engaged in direct
or indirect competition and conflict with the US. More nations
have acquired significant numbers of modern, lethal, combat weapon
systems; developed very capable armed forces; and become more
assertive in international affairs. In the absence of a single,
credible, coercive threat, old rivalries and long repressed
territorial ambitions will resurface, causing increased tensions
in many regions. Political, economic, and social instability and
religious, cultural, and economic competition will continue to
erode the influence of the US over the rest of the world. This
erosion will also reduce the US influence of traditional regional
powers over their neighbors. This environment will encourage the
continued development, or acquisition, of modern armed forces and
equipment by less influential nations; thus raising the potential
for the use of NBC/RDD weapons during internal conflict and armed
confrontations in developing regions of the world.

_c._ A third dimension to the threat is terrorist, rogue groups,
and belligerents employing a number of chemical and biological
agents and the possible use of TIM to injure or kill US personnel.
The actions may be isolated or may be imposed by groups of
individuals. Most will have the financial backing of nations, large
organizations, or groups that have the desire to cause harm and
create public distrust in our government.


1-2. Medical Threat

Medical threat is the composite of all ongoing or potential enemy
actions and environmental conditions that will reduce combat
effectiveness through wounding, injuring, causing disease, and/or
degrading performance. Soldiers are the targets of these threats.
Weapons or environmental conditions that will generate wounded,
injured, and sick soldiers, beyond the capability of the HSS
system to provide timely medical care from available resources,
are considered major medical threats. Weapons or environmental
conditions that produce qualitatively different wound or disease
processes are also major medical threats. Added to the combat
operational and disease and nonbattle injury (DNBI) medical threats
are adversary use of the following types of weapons, agents, and
devices:

    · Biological warfare agents.

    · Chemical warfare agents.

    · Nuclear weapons.

    · Toxic industrial materials.

    · Radiological dispersal devices.

    · Directed-energy devices/weapons.

    · Chemical, biological, radiological, nuclear, and high-yield
    explosives.


1-3. Nuclear, Biological, Chemical, and Radiological Dispersal
Device Threats--The Health Service Perspective

_a._ _Nuclear Weapons and Radiological Dispersal Device Threats._
Since the breakup of the Soviet Union, the number of countries
with known nuclear capable military forces has almost doubled.
Available information suggests that a number of countries in the
Middle East, Asia, and Africa have or may have nuclear weapons
capability within the next decade. Table 1-1 lists those countries
known to have, suspected of possessing, or seeking, nuclear
weapons. Planners can expect, as a minimum, 10 to 20 percent
casualties within a division-sized force that has experienced
a nuclear strike. In addition to the casualties, a nuclear
weapon detonation can generate an electromagnetic pulse (EMP)
that will cause catastrophic failures of electronic equipment
components. Radiological dispersal devices, comprised of an
explosive device with radioactive material, can be detonated
without the need for the components of a nuclear weapon. 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 and, in most cases, the
blast effects of a nuclear detonation. For nuclear weapons effects
see Appendix A.


_Table 1-1. 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
    ========================================================

_b._ _Biological Warfare._

    (1) Biological warfare (BW) is defined by the US intelligence
    community as the intentional use of disease-causing organisms
    (pathogens), toxins, or other agents of biological origin (ABO) to
    incapacitate, injure, or kill humans and animals; to destroy crops;
    to weaken resistance to attack; and to reduce the will to fight.
    Historically, 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 populations.

    (2) For purposes of medical threat risk assessment, we are
    interested only in those BW agents that incapacitate, injure, or
    kill humans or animals.

    (3) Known or suspect BW agents and ABOs can generally be
    categorized as naturally occurring, unmodified infectious agents
    (pathogens); toxins, venoms, and their biologically active
    fractions; modified infectious agents; and bioregulators. See Table
    1-2 for examples of known or suspected BW threat agents. Also,
    Table 1-3 presents possible developmental and future BW agents.


_Table 1-2. Examples of Known or Suspect Biological Warfare Agents_

    ============================================================
              PATHOGENS                       TOXINS
    ------------------------------------------------------------
    _BACILLUS ANTHRACIS_ (ANTHRAX)          BOTULINUM TOXIN
    _FRANCISELLA TULARENIUS_ (TULAREMIA)    MYCOTOXINS
    _YERSINIA PESTIS_ (PLAGUE)              ENTEROTOXIN
    _BRUCELLA SPECIES_ (BRUCELLOSIS)        RICIN
    _VIBRIO CHOLERAE_ (CHOLERA)
    _VARIOLA_ (SMALLPOX)
    _VIRAL HEMORRHAGIC FEVERS_
    =============================================================


_Table 1-3. The Future of Biological Warfare Agents_

    =======================================================================
          CURRENT THREAT                          FUTURE
    -----------------------------------------------------------------------
    PATHOGENS                      MODIFIED PATHOGENS
    LIMITED NUMBER OF TOXINS       EXPANDED RANGE OF TOXINS (ORGANO-TOXINS)
    AGENTS OF BIOLOGICAL ORIGIN    PROTEIN FRACTIONS
                                   AGENTS OF BIOLOGICAL ORIGIN
    =======================================================================

    (4) Many governments recognize the industrial and economic
    potential of advanced biotechnology and bioengineering. The
    same knowledge, skills, and methodologies can be applied to the
    production of second and third generation BW agents. Naturally
    occurring infectious organisms can be made more virulent and
    antibiotic resistant and manipulated to render protective vaccines
    ineffective. These developments complicate the ability to detect
    and identify BW agents and to operate in areas contaminated by the
    BW agents. For biological agent characteristics and effects see
    Appendix A. 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 (AO). See Appendix B for sampling requirements,
    sampling procedures, packaging and shipping, and chain of custody
    requirements.

_c._ Chemical Warfare.

    (1) Since World War I, most western political and military leaders
    have publicly held chemical warfare (CW) in disrepute. However,
    evidence accumulated over the last 50 years does not support the
    position that public condemnation equates to limiting development
    or use of offensive CW agents. The reported use of chemical agents
    and biological toxins in Southeast Asia by Vietnamese forces; the
    confirmed use of CW agents by Egypt against Yemen; and later by
    Iraq against Iranian forces; and the probable use of CW agents by
    the Soviets in Afghanistan indicate a heightened interest in CW as
    a force multiplier. Also, an offensive CW capability is developed
    as a deterrent to the military advantage of a potential adversary.
    For a list of common chemical agents, their characteristics,
    behavior, and effects see Appendix A. Table 1-4 lists those
    countries known or suspected of having offensive chemical weapons.

    (2) The Russian Republic has the most extensive CW capability in
    Europe. Chemical strikes can be delivered with almost any type of
    conventional fire support weapon system (from mortars to long-range
    tactical missiles). Agents known to be available in the Russian
    inventory include nerve agents (O-ethyl methyl phosphonothiolate
    [VX], thickened VX, Sarin [GB], and thickened Soman [GD]);
    vesicants (thickened Lewisite[L] and mustard-Lewisite mixture[HL]);
    and choking agent (phosgene). Although not considered CW agents,
    riot control agents are also in the Russian inventory.

    (3) The US is in the process of destroying its stockpiles of CW
    weapons. Many weapons have already been destroyed and the storage
    facilities have been rendered safe of all CW agent residues.


_Table 1-4. 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
                IRAQ[*]                              ETHIOPIA
                IRAN                                 TAIWAN
                SYRIA                                BURMA
    ------------------------------------------------------------------

    [*] FOLLOWING THE PERSIAN GULF WAR (1990-91), THE UNITED NATIONS
    (UN) BEGAN DESTROYING CW MUNITIONS DISCOVERED DURING INSPECTION
    VISITS TO IRAQ BY UN ARMS CONTROL INSPECTORS. INCLUDED AMONG THE
    CW MUNITIONS DISCOVERED WERE SOME 2,000 AERIAL BOMBS AND 6,200
    ARTILLERY SHELLS FILLED WITH MUSTARD AND SEVERAL THOUSAND 122
    MILLIMETERS (mm) ROCKET WARHEADS FILLED WITH NERVE AGENT (GB). IRAQ
    ALSO DECLARED SURFACE TO AIR MISSILE (SCUD) WARHEADS FILLED WITH
    NERVE AGENT (GB AND GF). TABLE 1-5 PROVIDES A LIST OF KNOWN CW
    AGENTS.
    ==================================================================


_Table 1-5. Chemical Warfare Agents_

  =======================================================================
  NERVE      VESICANT    INCAPACITATING     CHOKING          BLOOD
  -----------------------------------------------------------------------

  TABUN(GA)  SULFUR      CNS DEPRESSANT(BZ) PHOSGENE (CG)    HYDROGEN
            MUSTARD (HD)                                    CYANIDE (AC)
  GB         HL          CHLORINE (CL)      DIPHOSGENE (DP)  CYANOGEN
  GD         L           CHLOROPICRIN (PS)                  CHLORIDE (CK)
  GF         PHOSGENE    D-LYSERGIC ACID
            OXIME (CX)
  VX                     DIETHYLAMIDE (LSD)
  =======================================================================

_d. Toxic Industrial Materials._

Toxic industrial materials can present a medical threat for
deployed forces. Toxic industrial materials are comprised of toxic
industrial biologicals (TIB), toxic industrial chemicals (TIC),
and toxic industrial radiological (TIR) materials. These materials
are found throughout the world and are used on a daily basis
for commercial and private purposes. Large storage facilities,
transportation tankers (over the road and railcars), as well as
smaller containers of material, pose a danger to the health of
personnel. Accidental spills or releases and terrorist actions
can all lead to release of these materials into the environment
causing potential casualty producing effects. Medical treatment
facilities and nuclear power plants use radioactive materials
that can pose a health hazard if accidentally released or used
by hostile forces, terrorists, or others to contaminate an area.
Biological materials used in medical research and pharmaceutical
manufacturing may be used by hostile forces, terrorists, or
others to produce casualties. Many TICs produce the same effects
on personnel as CW agents. As a matter of fact, many TICs are of
the same chemical structure as CW agents. However, there is quite
a difference in their potency; in most TICs the potency is much
lower. For example, chlorine used to treat water supplies has also
been used as a CW agent; organophosphate pesticides can cause the
same effects as some nerve agents. Hostile forces, terrorists, or
others may use RDDs to produce casualties as well. For detailed
information on toxic industrial materials see FM 8-500.




CHAPTER 2

COMMAND AND CONTROL


2-1. General

The US forces may be attacked by or exposed to NBC, TIM, lasers,
advanced electronics, high explosives, fuel-air, thermobaric, and
conventional weapons; or a combination of these weapons/materiel.
Mass casualty situations will be the rule and not the exception.
Mass casualty situations can occur anyplace on the battlefield.
Combined NBC and conventional weapons injuries may predominate.
Command and control (C2) will be essential to prevent casualties
and to provide effective HSS. However, C2 (to include HSS
C2) elements may be primary targets. Effective HSS in an NBC
environment can be accomplished, but only if necessary preparations
to survive and to be mission capable are taken. Increased HSS C2
actions are needed to maintain HSS proximity to the supported
force; to clear the battlefield; to move and resupply the HSS
units, while managing multiple simultaneous mass casualty
incidents; and to rapidly evacuate patients. Health service
support C2 units must push HSS augmentation to mass casualty
sites, clear the site, evacuate the patients to Medical Treatment
Facilities (MTFs) that can provide essential care or out of the
AO; decontaminate and extract medical forces from NBC contaminated
areas and redistribute or redeploy the HSS forces. Within medical
units, C2 will be challenged by the use of protective clothing
and equipment, the need to move (either to the patients or out
of the contaminated area), and obtaining additional support.
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 effects. Leaders
must greatly increase coordinating, preplanning, using tactical
standing operating procedures (TSOPs), and establishing multiple
C2 mechanisms. See Appendix C for guidelines on operational
planning for health service support in an NBC or TIM environment.
See Appendix D for medical planning guide on NBC casualties. See
Appendix E for a sample format of a "medical NBC staff officer
appendix to annex Q."


2-2. Health Service Support Command and Control Planning
Considerations

_a._ Battle situational understanding is of great importance on
the NBC battlefield. The number of casualties from each NBC attack
will overwhelm any single medical unit or MTF causing the medical
commander/leader to take action. To the extent possible, the
commander/leader should be prepared for the requirement instead of
reacting to it. To ensure responsive C2 the HSS plan must consider:

    · Likely targets (C2 nodes, main supply routes (MSR), supply
    nodes, troop concentrations, key terrain features, key forces,
    or other high value targets).

    · Patient estimates (conventional, NBC, and TIM).

    · Availability of HSS resources (preestablished support plans).

    · Availability of required nonmedical support (patient
    decontamination teams).

    · Ability to maintain operations if C2 is lost at any HSS level.

    · Ability to maintain C2 operations when normal communication
    systems have been disabled due to EMP effects or other system
    failures.

    · Ability to maintain C2 operations while the unit is operating
    in mission-oriented protective posture (MOPP) Level 4 (reduced
    audio and visual acuity).

    · The requirements for immunizations, pretreatments, barrier
    creams, prophylaxis, insect repellents, and other medical
    countermeasures to protect the forces.

    · The resource requirements for treatment, MEDEVAC, and
    hospitalization (including care for enemy prisoners of war
    [EPW]).

_b._ Clearing the battlefield will require preplanning and close
coordination at all levels. Early resuscitation, stabilization, and
prompt medical evacuation (MEDEVAC) are mandatory for survival of
the sick and wounded.

_c._ For conventional operations C2 see FM 8-10. Field Manual 8-55
provides HSS planning for conventional operations.

_d._ Provisions for emergency medical care of civilians, consistent
with the military situation. 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 team. For
eligibility of care determinations guidance, see FM 8-10.

_e._ For additional information on planning operations in an NBC
environment see FMs 8-10, 4-02.10, 4-02.4, 4-02.6, 4-02.283,
8-9, 8-10-6, 8-10-26, 8-284, and 8-285. Higher headquarters must
distribute timely plans and directives to subordinate units to
ensure that the subordinate unit's HSS plan supports their plan.


2-3. 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 load. Once the appraisal has
been accomplished, HSS personnel prepare for the HSS mission by
assigning personnel responsibilities. Using triage and EMT decision
matrices for managing patients in a contaminated environment
improves treatment proficiency. See Figure 2-1 for a sample
decision matrix. Training HSS personnel in the use of simple
decision matrices should enhance their effectiveness and contribute
to a more efficient battlefield HSS process. Prior training
for designated nonmedical personnel in patient decontamination
procedures will enhance their effectiveness in the overall patient
care mission. See Appendix D for planning factors on the estimation
of NBC casualties.


2-4. Health Service Support Units

Health service support units must plan, train, and routinely
practice mass casualty management. The NBC attack or TIM event will
likely be in conjunction with enemy conventional operations. But,
the TIM event may be caused by terrorist or belligerent action.
There will likely be increased conventional casualties in addition
to the NBC/TIM related casualties. The supply and transportation
units will be using the MSR in support of the combat commander's
requirements; thus, impacting on patient MEDEVAC and HSS unit
resupply. Communications will be disrupted. Therefore, HSS C2 must
plan and prepare for conducting operations with limited or no
communications with other HSS organizations.

            +------------------------------------+
            |            GATHER DATA             |
            |        NERVE AGENT SYMPTOMS        |
            | (VISUAL/TACTILE--VERBAL/NONVERBAL) |
            +----------------+-------------------+
                             |
                    +--------+--------+
                    | 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 2-1. Sample triage and emergency medical treatment decision
matrix._


2-5. Movement/Management of Contaminated Facilities

Operations in a contaminated area require the HSS commander/leader
to operate with contaminated or potentially contaminated assets.
The following provides guidance in determining how to operate with
contaminated facilities:

_a. Fulfill Health Service Support Principles._ In making his
decision to move or continue to operate with contaminated
facilities, the commander/leader must apply the principles of
conformity, proximity, flexibility, mobility, continuity, and
control. The unit's operation must conform to the tactical
commander's operation plan (OPLAN). Health service support must
be provided to the tactical unit as far forward as possible; this
ensures prompt, timely care. Additionally, the HSS commander/leader
must be flexible; his support must be tailored to meet the
supported commander's OPLAN requirements. Therefore, HSS assets
must be as mobile as the unit they support. Finally, the HSS
commander/leader must control his assets. Dispersion on the
integrated battlefield may enhance unit survivability; but the HSS
commander/leader may not be able to maintain control of his assets,
they may become compromised.

_b. Decision to Move._ The HSS commander/leader (when deciding
to move his unit to an uncontaminated area or in support of the
tactical commander's plan) must base his decision to move on
several factors.

    (1) _Protection available._ What type of protection is available
    in the new area? Will he need to establish the units' collective
    protection shelter (CPS) systems, or are indigenous shelters
    available (for example, buildings, tunnels, caves)? Does the unit
    have sufficient individual protective equipment for unit personnel?

    (2) _Persistency._ If his unit has been in a contaminated area,
    is the contamination persistent or nonpersistent? Is the area he
    will move to contaminated or clean? Persistency determines the
    MOPP level; the degree of threat; and performance decrement caused
    by the protective measures used. The level of contamination will
    determine whether employment of CPS is viable. The MTF may be able
    to continue to operate at the location by employing CPS. Personnel
    and patient decontamination must be accomplished before processing
    into the CPS.

    (3) _Patients._ Before moving the entire facility, the HSS
    commander/leader must consider the number and types of patients
    at the MTF; his ability to redirect en route patients to the new
    MTF location; and his ability to evacuate the patients currently
    on hand. All patients should be stabilized before movement; but,
    MEDEVAC must be continued.

    (4) _Alternate facilities._ Alternate facilities may be used
    (if the facility can be configured to ensure continuity of care
    or provide a protected area for patients) until the relocating
    activity is up and operating. This is a viable consideration when
    CPS is not available or the current location is contaminated with a
    persistent agent. Patient decontamination cannot be performed in an
    area heavily contaminated with a persistent agent.

    (5) _Medical evacuation._ Consideration must always be given to the
    patient. Routes of MEDEVAC must be disseminated to supported and
    supporting units. The ability to evacuate patients during the move
    must continue. All MEDEVAC considerations must be addressed before
    any move.

    (6) _Mobility._ An MTF that is not 100 percent mobile requires
    movement support. Thus, the commander/leader must coordinate
    movement support requirements with higher headquarters.

    (7) _Mission._ The primary consideration is the support mission of
    the MTF. The tactical commander requires continuous HSS for his
    personnel; when a move jeopardizes the quality of care, the move
    may be delayed.

    (8) _Sustainability._ Hand-in-hand with the mission is
    sustainability (the ability of the unit to continue its support
    mission). If the current location of the MTF hinders the unit's
    ability to sustain its support mission, then the MTFs support to
    the unit is in question. Similarly, if moving the MTF will result
    in a disruption of support, then the move may not be viable.

    (9) _Decontamination._ When a nonpersistent agent hazard exists and
    a CPS is not available, patients may be directed to another MTF
    until the hazard is gone; or the MTF can move to a contamination
    free area. Certain facilities may be decontaminated, patient
    protection procedures applied, and the operation continued.
    However, an MTF contaminated with a persistent agent requires
    time-consuming and resource-intensive decontamination operations;
    it may include replacement of contaminated shelters.

_c. Management of Contaminated and "Clean" Facilities._ Facilities
contaminated with a persistent agent may be too resource intensive
to decontaminate. Operating with a combination of contaminated
assets and "clean" assets may be necessary. Mark contaminated
assets with standard warning tags. Use these assets in contaminated
environments and along contaminated routes. Keep clean assets in
operation in clean areas. Of primary importance is proper marking
and the avoidance of cross contamination.

_d. Medical Supplies and Equipment for Patient Treatment._ Are
sufficient medical supplies and equipment available to perform the
anticipated mission? Does the unit have special medical equipment
sets available (chemical agent patient decontamination and chemical
agent patient treatment medical equipment sets)?


2-6. Leadership on the Contaminated Battlefield

_a._ Operating on a contaminated battlefield will stress
leadership. Heat stress from being in higher levels of MOPP for
long periods of time may lead to dehydration. The commander/leader
must ensure that his personnel rest, drink, and eat sufficiently
to allow them to continue with the mission. In the midst of
activity, rest, hydration, and nutrition are often overlooked;
however, a good leader will ensure that his personnel needs
are met. See FM 21-10 for work/rest cycles and water drinking
requirements. Individuals may suffer hyperventilation because
of the enclosed feelings. Personnel remaining in MOPP Level 4
around the clock may suffer from increased sleep loss. Use of CPS
can reduce this problem by allowing the personnel to rest out of
their MOPP gear. Leaders must share leadership responsibilities
and delegate responsibilities as much as possible so that each
one gets sufficient rest to maintain unit effectiveness. Further,
leaders should concentrate on supervision or unit mission, rather
than on generation of new procedures during and after an attack.
The NBC battlefield will, therefore, require more proactive and
dedicated leaders who can balance the needs of their personnel and
the mission. Further, leaders will be challenged by an additional
logistics burden of providing nontraditional respiratory protection
for personnel against TIMs. For detailed information on combat
operational stress control (COSC) see FM 8-51 and FM 22-51.

    +---------------------------------------------------+
    |                   DANGER                          |
    |                                                   |
    | The standard NBC protective mask will not protect |
    | personnel from most TICs.                         |
    +---------------------------------------------------+

_b._ Leadership must plan for and establish procedures to maintain
personnel performance during NBC operations. Personnel performance
while wearing MOPP is degrading. At MOPP Level 3 or 4, 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 (fine motor skill).

    · MOPP impedes the ability to move about (gross motor skills).

    · The mask reduces visual fields and acuity (visual skills).

    · The mask and hood greatly reduces vocalization and hearing
    abilities (auditory skills).

    · The MOPP creates significant heat and mental stress
    (stamina). Heat injuries can occur in a very short period of
    time.


2-7. Homeland Security

Commanders and leaders must plan for and be prepared to support
homeland security efforts; especially, for response to chemical,
biological, radiological, nuclear, and high-yield explosive (CBRNE)
events. Depending upon the location of the event, the response
may be to a military installation in support of the weapons of
mass destruction--installation support team (WMD-IST) or to an
event site off a military installation. 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 (usually from the incident commander or
lead federal agency [Federal Bureau of Investigation or Federal
Emergency Management Agency]). See Appendix C for planning
considerations.




CHAPTER 3

LEVELS I AND II HEALTH SERVICE SUPPORT


3-1. General

_a._ The use of NBC weapons is a condition of battle and HSS
personnel must prepare to operate in these environments. Added
is the dimension of TIM releases/incidents in the operational
area. The importance of preventive medicine (PVNTMED) measures
and first aid (self-aid, buddy aid, and combat lifesaver [CLS]
support) are even more critical. Heat and stress injuries related
to MOPP wear are issues for the HSS leadership as well as the force
he is supporting. The stress load on personnel is increased by
the concerns of being exposed to TIM releases. Considering that
staffing of HSS units is based upon the minimum required to provide
support on a conventional battlefield, they will be challenged to
provide the same level of HSS in these environments.

_b._ The HSS leadership must quantify the HSS capability to
their commanders. The medical staff must review OPLANS and make
recommendations to reduce the number of patients. Medical NBC
training programs must stress the essential imperative of immediate
decontamination, the need to monitor your buddy for NBC and heat
or combat/operational stress injury effects, and the proper use of
NBC defense prophylaxis, pretreatments, insect repellents, barrier
creams, and immunizations.

_c._ Maintaining close proximity to the supported force has been
a major tenet of HSS doctrine and a critical factor in reducing
the mortality rate. Maintaining this proximity and finding a
place clean enough to provide necessary care requires intense
coordination with the supported force. Alternate casualty
collection points, decontamination sites, medical treatment
sites, and MEDEVAC routes must be established, coordinated and
communicated to the lowest level practical. Communication will be
much more difficult, but must be maintained. Timely reports through
the HSS technical channels will allow an optimal HSS response.
Replacements for HSS front line losses must be rapidly filled after
NBC weapons are employed.

_d._ Contamination (NBC and TIMs) can significantly hinder
HSS operations. To maximize the unit's survivability and HSS
capabilities and to avoid such contamination, leaders must use--

    · Contamination avoidance techniques.

    · Alarms and detection equipment.

    · Unit dispersion techniques.

    · Overhead shelter, shielding material, protective cover, and
    buildings of opportunity. However, these shelters may not
    provide protection from chemical vapor or BW hazards.

    · Collective protection shelters, if available. See Appendix F.

    · Chemical agent resistant coatings on equipment.

_e._ On the NBC battlefield, as on the conventional battlefield,
HSS is focused on keeping soldiers in the battle. Effective and
efficient PVNTMED measures, triage, emergency medical treatment
(EMT), decontamination, advanced trauma management (ATM), and
contamination control in the AO saves lives, assures judicious
MEDEVAC, and maximizes the return to duty (RTD) rate.


3-2. Level I Health Service Support

_a._ Level I (unit-level) HSS may consist of a combat medic
section, a MEDEVAC section, and a treatment squad. The treatment
squad operates the Level I MTF (battalion aid station [BAS]). Level
I HSS is supported by first aid in the form of self-aid/buddy aid
and the CLS. See FM 4-02.4 for detailed information on conventional
Level I HSS.

_b._ When operating under an NBC threat or when NBC attack is
imminent, the BAS must prepare for continuation of its mission.
Should an attack occur or a downwind hazard exist, the BAS must
seek out a contamination free area to establish a clean treatment
area, or must establish collective protection to continue the
mission. Some BASs have Chemically Biologically Protected
Shelter (CBPS) Systems. When available, these systems serve as
the primary shelter for the BAS; they are operated in the full
chemical/biological (CB) mode when attack is imminent or has
occurred. See Appendix F for information on establishing a BAS
in a CBPS system. When operating in the CB mode only patients
requiring life- or limb-saving procedures are allowed entry at
the BAS. Patients that have minor injuries that can be managed
in the contaminated EMT area of the patient decontamination site
will receive treatment in this area. After treatment, these
patients will have the integrity of their MOPP restored by taping
the damaged area and returned to duty. Patients with injuries
that require further treatment, but who can survive evacuation
to the Level II MTF will have their MOPP spot decontaminated,
their injuries managed, the integrity of their MOPP restored,
and be directed to an evacuation point to await transport to the
Level II MTF (example, an individual with a splinted broken arm).
When patients or personnel are contaminated or are potentially
contaminated, they must be decontaminated before admission into
the clean treatment area (see FM 3-5 for personnel decontamination
procedures and Appendix G for patient decontamination procedures).


3-3. Level II Health Service Support

_a._ In the brigade, Level II HSS consists of--

    · Evacuating patients from the BAS and MEDEVAC on an area
    support basis from within the brigade support area (BSA).

    · Providing area support Level I medical treatment.

    · Operating the medical company clearing station (hereafter
    referred to as the division clearing station [DCS]), which
    provides a patient holding capability for up to 40 patients for
    72 hours. See FM 4-02.6 and FM 8-10-24 for detailed information
    on Level II conventional operations.

    · Providing limited dental service.

    · Providing limited PVNTMED support in the areas of medical
    surveillance, occupational and environmental health
    surveillance, food service sanitation, water quality control
    (including NBC contamination surveillance), and communicable
    disease control.

    · Providing limited COSC; these patients are returned to duty
    as far forward as their condition permits.

_b._ In the division, HSS is the same as for the brigade, except
patients may be evacuated from the BSA DCS, but not evacuated from
the BAS.

_c._ When operating under an NBC threat or when NBC attack is
imminent, the DCS must prepare for continuation of its mission.
Should an attack occur or a downwind hazard exist the DCS must
seek out a contamination free area, or must establish collective
protection to continue the mission. The DCS in some medical
companies have four CBPS Systems; they are complexed to provide
space for DCS operations. These systems are operated in the
CB mode when attack is imminent or has occurred. See Appendix
F for information on establishing a DCS in CBPS Systems. When
operating in the CB mode only patients requiring life- or
limb-saving procedures are allowed entry. Patients with minor
injuries that can be managed in the contaminated EMT area of the
patient decontamination site will receive treatment in this area.
After treatment, these patients will have the integrity of their
MOPP restored by taping the damaged area and returned to duty.
Patients with injuries that require further treatment, but who
can survive evacuation to the Level III MTF will have their MOPP
spot decontaminated, their injuries managed, and be directed to an
evacuation point to await transport to the Level III MTF (example,
an individual with a splinted broken arm). When personnel and
patients are contaminated or are potentially contaminated, they
must be decontaminated before admission into the clean treatment
area (see FM 3-5 for personnel decontamination procedures and
Appendix G for patient decontamination procedures).


3-4. Forward Surgical Team

Forward surgical teams (FST) are either organic to divisional and
nondivisional medical units or are forward deployed in support of
divisional or nondivisional medical companies to provide a surgical
capability. Field Manual 8-10-25 describes FST operations. However,
when forward deployed and NBC contamination is imminent the FST
must employ collective protection in order to continue their
support mission. When operating in a contaminated area the FST
CBPS Systems must be complexed with the DCS CBPS. The FST cannot
operate in an NBC environment without the support of the DCS. They
do not have the capability to decontaminate patients. All patients
are decontaminated in the DCS patient decontamination area. They
are then processed into the EMT section of the DCS; where they
are triaged and routed to the FST for surgery, if required. See
Appendix F for FST employment of collective protection procedures.


3-5. Actions Before a Nuclear, Biological, or Chemical Attack

_a._ Given the disruption of transportation, communications, and
operations during and following an NBC attack, it should be clear
that preparation is the key to survival and effectively providing
HSS. Preparing a simple and complete TSOP and HSS plan that really
integrates NBC is the first step. Critical training for medical
personnel before an NBC attack is how to--

    · Survive the attack individually and as a unit.

    · Operate the Level I or Level II MTF in the environment.

    · Effectively care for NBC patients.

_b._ Even minimal site preparation (nuclear hardening or CB
protecting) may improve survival, greatly reduce contamination,
and maintain the ability to continue to provide HSS. See the
discussion below for more information on each environment. As
with other military personnel, HSS personnel must keep their
immunizations current; use available prophylaxis against suspect CB
agents; use pretreatments for suspect chemical agents; use insect
repellents, and have antidotes and essential medical supplies
readily available for known or suspected NBC effects. The best
defense for HSS personnel is to protect themselves, their patients,
medical supplies, and equipment by applying contamination avoidance
procedures. They must ensure that stored medical supplies and
equipment are in protected areas or in their storage containers
with covers in place. One method of having supplies and equipment
protected is to keep them in their shipping containers until
actually needed. When time permits and warnings are received that
an NBC attack is imminent, or that a downwind hazard exists,
HSS personnel should employ their CPS (see Appendix F) or seek
protected areas (buildings, tents, or other ABOVE ground shelters
for biological or chemical attack; culverts, ravines, basements, or
other shielded areas for nuclear) for themselves and their patients.

_c._ Other tasks include:

    · Verifying NBC defense HSS inventories are complete.

    · Reviewing supported units NBC plans, procedures, casualty
    collection points, decontamination sites, and resources
    available to support the HSS mission.

    · Coordinating with the S2/G2, S3/G3 and S4/G4 of the supported
    unit to develop the medical courses of action; to obtain
    necessary materiel to support extended operations without
    resupply (MSR contamination or transportation support not
    available).

    · Coordinating with supported units for at least eight
    nonmedical personnel for patient decontamination augmentation
    at the Level I and II MTFs.


3-6. Actions During a Nuclear, Biological, or Chemical Attack

While it is possible that the NBC attack will be discrete short
events, the more likely scenario is the enemy will use NBC
throughout the conflict. The warning and reporting system will
provide as much notice as is possible. Using the information
provided, HSS personnel will continue their mission by using the
best available protected areas. If warned of a nuclear attack, they
take up positions within the best available shelter; movement out
of these positions will be directed by leadership when it is safe
to do so.


3-7. Actions After a Nuclear, Biological, or Chemical Attack

All personnel must survey their equipment to determine the
extent of damage and their capabilities to continue the mission.
Initially, patients from nuclear detonations will be suffering
thermal burns or blast injuries. Also, expect patients and HSS
personnel to be disoriented. Nuclear blast and thermal injuries
will immediately manifest, most radiation-induced injuries
will not be observed for several hours to days. Chemical agent
patients will manifest their injuries immediately upon exposure
to the agent, except for blister agents. Biological agent
patients may not show any signs of illness for hours to days
after exposure, except for trichothecene (T_{2}) mycotoxins. All
patients arriving at Levels I and II MTFs must be checked for NBC
contamination. Patients are decontaminated before treatment (see
Appendix G) to reduce the hazard to HSS personnel, unless life- or
limb-threatening conditions exist. Patients requiring treatment
before decontamination are treated in the EMT area of the patient
decontamination station. Examples of patient conditions that may
require treatment at the contaminated treatment station of the
patient decontamination area--

    · Massive hemorrhage.

    · Respiratory distress.

    · Severe shock.


3-8. Logistical Considerations

_a._ Health service logistics (HSL) personnel must train and
prepare to operate in all battlefield situations. Operating in an
NBC environment requires the issue of chemical patient treatment
medical equipment set and chemical patient decontamination medical
equipment set. Expect disruption of MSR and communications systems
and plan accordingly. See FM 4-02.1 and FM 8-10-9 for details on
HSL operations.

_b._ The medical platoon (Level I) is authorized two chemical
agent patient treatment medical equipment sets and one chemical
agent patient decontamination medical equipment set. Each chemical
agent patient treatment medical equipment set has enough supplies
to treat 30 patients. Each chemical agent patient decontamination
medical equipment set has enough consumable supplies to
decontaminate 60 patients.

    NOTE

    The chlorine granules in the chemical agent patient
    decontamination set are used to prepare the hypochlorite
    solutions for use to decontaminate patients.

_c._ The brigade, divisional, and nondivisional medical companies
are authorized five chemical agent patient treatment medical
equipment sets and three chemical agent patient decontamination
medical equipment sets. These medical equipment sets are for use at
the DCS patient decontamination station.


3-9. Personnel Considerations

During NBC actions, HSS personnel requirements increase; thus,
HSS reinforcement or replacements are necessary. Plans for HSS
in a NBC battlefield must include efforts to conserve available
HSS personnel and ensure their best use. HSS personnel will be
fully active in providing EMT or ATM care; they will provide
more definitive treatment as time and resources permit. However,
to provide care they must be able to work in a shirt-sleeved
environment, not in MOPP Levels 3 or 4. Nonmedical personnel
conduct search and rescue operations for the injured or wounded;
they provide immediate first aid and decontamination. See FM 3-5,
for detailed information on personnel and equipment decontamination
operations. See FMs 4-02.283, 8-284, and 8-285 for detailed
information on treatment of NBC patients.


3-10. Disposition and Employment of Treatment Elements

_a._ Select sites for the BAS and DCS that are located away from
likely enemy target areas. Cover and concealment is extremely
important; they increase protection for operating the MTF.

_b._ Operating a CBPS System in the CB mode at the BAS requires
at least eight medical personnel. The senior NCO performs patient
triage and limited EMT and minor injury care in the patient
decontamination area. One trauma specialist supervises patient
decontamination and manages patients during the decontamination
process. Two trauma specialists work on the clean side of the hot
line and manage the patients until they are placed in the clean
treatment area or are sent into the CBPS for treatment. They also
manage the patients that are awaiting MEDEVAC to the DCS. The
physician, physician assistant, and two trauma specialists provide
ATM in the clean treatment area or inside the CBPS. See Appendix F
for CPS entry/exit procedures.

_c._ When the BAS or DCS are receiving NBC contaminated patients,
they require at least eight nonmedical personnel from supported
units to perform patient decontamination procedures. These
facilities are only staffed to provide patient care under
conventional operational conditions. Without the augmentation
support, they can either provide patient decontamination or patient
care, but not both.

_d._ A patient decontamination station is established to handle
contaminated patients (see Appendix G). The station is separated
from the clean treatment area by a "hot line" and is located
downwind of the clean treatment area or CPS. Personnel on
both sides of the "hot line" assume a MOPP level commensurate
with the threat agent employed (normally MOPP Level 4). The
patient decontamination station should be established in a
contamination-free area of the battlefield. However, it may be
necessary to establish a patient decontamination station that is
collocated with an MTF that is employing a CBPS, in a chemical
vapor hazard area in order to decontaminate patients and clear the
battlefield before moving the MTF to a clean area. When CPS systems
are not available, the clean treatment area is located upwind 30
to 50 meters of the contaminated work area. When personnel in the
clean working area are away from the hot line, they may reduce
their MOPP level. Chemical monitoring equipment must be used on the
clean side of the hot line to detect vapor hazards due to slight
shifts in wind currents; if vapors invade the clean work area, HSS
personnel must re-mask to prevent low-level CW agent exposure and
minimize clinical effects (such as miosis).


3-11. Civilian Casualties

Civilian casualties may become a problem in populated or built-up
areas, as they are unlikely to have protective equipment and
training. The BAS and DCS may be required to provide assistance
when civilian medical resources cannot handle the workload.
However, aid to civilians will not be undertaken without command
approval, or at the expense of health services provided to US
personnel.


3-12. Nuclear Environment

_a._ The HSS mission must continue in a nuclear environment;
protected shelters are essential to continue the support role.
Well-constructed shelters with overhead cover and expedient
shelters (reinforced concrete structures, basements, railroad
tunnels, or trenches) provide good protection from nuclear attacks
(see Appendix H). Armored vehicles provide some protection against
both the blast and radiation effects of nuclear weapons. Patients
generated in a nuclear attack will likely suffer multiple injuries
(combination of blast, thermal, and radiation injuries) that will
complicate medical care. Nuclear radiation patients fall into three
categories:

    · The _irradiated_ patient is one who has been exposed to
    ionizing radiation, but is not contaminated. They are not
    radioactive and pose no radiation threat to medical care
    providers. Patients who have suffered exposure to initial
    nuclear radiation will fit into this category.

    · The _externally contaminated_ patient has radioactive dust
    and debris on his clothing, skin, or hair. This radioactive
    debris can cause burns if not removed quickly. This usually
    presents a "housekeeping" problem to the MTF, similar to the
    lice-infested patient arriving at a peacetime MTF. However,
    an accumulation of radioactive debris, from several patients
    admitted to the MTF, may present a threat to other personnel.
    The externally contaminated patient is decontaminated at the
    earliest time consistent with required medical care. Lifesaving
    care is always rendered, when necessary, before decontamination.

    · The _internally contaminated_ patient is one that has
    ingested or inhaled radioactive material, or radioactive
    material has entered the body through an open wound. The
    radioactive material continues to irradiate the patient
    internally until radioactive decay and/or biological
    elimination removes the radioactive isotope. Attending medical
    personnel are shielded, to some degree, by the patient's
    body. Inhalation, ingestion, or injection of quantities of
    radioactive material sufficient to present a threat to health
    care providers is highly unlikely.

_b._ Medical units operating in a radiation fallout environment
will face three problems:

    · The MTF may be immersed in fallout, requiring decontamination
    and relocation efforts.

    · Patients may continue to be produced from continued radiation
    exposure.

    · The contaminated environment hinders MEDEVAC.

_c._ Decontamination of most radiological contaminated patients and
equipment can be accomplished with soap and water. Soap and water
will not neutralize radioactive material. However, it will remove
the material from the skin, hair or material surface. See Appendix
G for specific patient decontamination procedures. The waste can
become a concentrated point of radiation and must be managed and
monitored.

_d._ Commanders and leaders must consider the radiation exposure
levels for themselves, their staffs, and patients when operating
in or determining if the unit will enter a radiologically
contaminated area. The commander and leader must establish
an operational exposure guide for their unit and personnel.
The operational exposure guide (OEG) is established for either
battlefield exposures as shown in Table 3-1 or for exposures in
stability operations and support operations as shown in Table 3-2.
The tables present radiation exposure status (RES) categories;
however, they can be used to establish OEGs based on the same
exposure criteria.


_Table 3-1. Radiation Exposure Status Categories for Tactical
Operations_

  ===============================================================
   =RES-O=  THE UNIT HAS HAD NO RADIATION EXPOSURE.
   =RES-1=  THE UNIT HAS BEEN EXPOSED TO GREATER THAN 0 cGy BUT
              LESS THAN OR EQUAL TO 75 cGy.
   =RES-2=  THE UNIT HAS BEEN EXPOSED TO GREATER THAN 75 cGy BUT
              LESS THAN OR EQUAL TO 125 cGy.
   =RES-3=  THE UNIT HAS BEEN EXPOSED TO GREATER THAN 125 cGy.
  ===============================================================


_Table 3-2. Radiation Exposure Status Categories During Stability
Operations and Support Operations_

    =================================
     =RES-O=         <0.05 cGy
     =RES-1A=        0.05 TO 0.5 cGy
     =RES-1B=        0.5 TO 5 cGy
     =RES-1C=        5 TO 10 cGy
     =RES-1D=        10 TO 25 cGy
     =RES-1E=        25 TO 75 cGy
    =================================


3-13. Medical Triage

Medical triage is the classification of patients according to the
type and seriousness of illness or injury; this achieves the most
orderly, timely, and efficient use of HSS resources. However, the
triage process and classification of nuclear patients differs from
conventional injuries. See FM 4-02.283 for nuclear patient triage
and treatment procedures.


3-14. Biological Environment

_a._ A biological attack (such as the enemy use of bomblets,
rockets, spray or aerosol dispersal, release of arthropod vectors,
and terrorist or insurgent contamination of food and water) may be
difficult to recognize. Frequently, it does not have an immediate
effect on exposed personnel. All HSS personnel must monitor for BW
indicators such as--

    · Increases in disease incidence or fatality rates.

    · Sudden presentation of an exotic disease.

    · Other sequential epidemiological events.

_b._ Passive defensive measures (such as immunizations, good
personal hygiene, physical conditioning, using arthropod
repellents, wearing protective mask, and practicing good
sanitation) will mitigate the effects of many biological agent
intrusions.

_c._ The HSS commanders and leaders must enforce contamination
control to prevent illness or injury to HSS personnel and to
preserve the facility. Incoming vehicles, personnel, and patients
must be surveyed for contamination. Ventilation systems in MTFs
(without CPS) must be turned off if BW exposure is imminent.

_d._ Decontamination of most BW contaminated patients and equipment
can be accomplished with soap and water. Soap and water will not
kill all biological agents; however, it will remove the agent from
the skin or equipment surface. See Appendix G for specific patient
decontamination procedures.

_e._ Treatment of BW agent patients may require observing and
evaluating the individual to determine necessary medications,
isolation, or management. See FM 8-284 for specific treatment
procedures for BW agent patients.

_f._ Medical surveillance is essential. Most BW agent patients
initially present common symptoms such as low-grade fever, chills,
headache, malaise, and coughs. More patients than normal may be
the first indication of biological attack. Daily medical treatment
summaries, especially DNBI, need to be prepared and analyzed.
Trends of increased numbers of patients presenting with unusual or
the same symptoms are valuable indicators of enemy employment of
BW agents. Daily analysis of medical summaries can provide early
warnings of BW agent use, thus enabling commanders to initiate
preventive measures earlier and reduce the total numbers of troops
lost due to the illness. See FM 4-02.17 for information of medical
surveillance procedures. See FM 8-284 for preventive, protective,
and treatment procedures.


3-15. Chemical Environment

_a._ Consider that all patients generated in a CW agent environment
are contaminated. The vapor hazards associated with contaminated
patients may require HSS personnel to remain at MOPP Level 4 for
long periods. The MTF must be set up in clean areas or employ
CPS. If there is liquid agent contamination, or a continued vapor
hazard, the MTF should be moved and be decontaminated, mission
permitting.

_b._ Initial triage, EMT, and decontamination are accomplished on
the "dirty" side of the hot line. Life-sustaining care is rendered,
as required, without regard to contamination. Normally, the senior
health care sergeant performs initial triage and EMT at the BAS.
Secondary triage, ATM, and patient disposition are accomplished on
the clean side of the hot line. When treatment must be provided
in a contaminated environment outside the CPS, the level of care
may be greatly reduced because medical personnel and patients
are in MOPP Level 3 or 4. However, lifesaving procedures must be
accomplished. See FM 8-285 for specific treatment of CW agent
patients.

_c._ Decontamination of most chemically contaminated patients
and equipment requires the use of materials that will remove and
neutralize the agent. See FM 3-5 for equipment decontamination
procedures and Appendix G for specific patient decontamination
procedures.


3-16. Operations in Extreme Environments

Enemy employment of NBC weapons or TIMs in the extremes of climate
or terrain warrants additional consideration. Included are the
peculiarities of urban terrain, mountains, snow and extreme cold,
jungle, and desert operations in an NBC environment with the
resultant NBC-related effects upon medical treatment and MEDEVAC.
For a more detailed discussion on NBC aspects of urban terrain,
mountain, snow and extreme cold, jungle, and desert operations, see
FMs 3-06.11, 31-71, 90-3, 90-5, and 90-10.

_a._ In mountain operations, passes and gorges may tend to channel
the nuclear blast and the movement of chemical and biological
agents. Ridges and steep slopes may offer some shielding from
thermal radiation effects. Close terrain may limit concentrations
of troops and fewer targets may exist; therefore, a lower patient
load may be anticipated. However, the terrain will complicate
patient evacuation and may require patients to be decontaminated,
treated, and held for longer periods than would be required for
other operational areas.

_b._ The effects of extreme cold weather combined with NBC-produced
injuries have not been extensively studied. However, with traumatic
injuries, cold hastens the progress of shock, providing a less
favorable prognosis. Thermal effects will tend to be reinforced by
reflection of thermal radiation from snow and ice-covered areas.
Care must be exercised when moving chemically contaminated patients
into a warm shelter. A CW agent on the patient's clothing may
not be apparent. As the clothing warms to room temperature, the
CW agent will vaporize (off-gas), contaminating the shelter and
exposing occupants to potentially hazardous levels of the agent. A
three-tent system is suggested for processing patients in extreme
cold operations. The first tent (unheated) is used to strip off
potentially contaminated clothing. The second (heated) is used to
perform decontamination, perform EMT and detect off gassing. The
third (heated) is used to provide the follow on care and patient
holding.

_c._ In rain forests and other jungle environments, the overhead
canopy will, to some extent, shield personnel from thermal
radiation. However, the canopy may ignite and create forest fires
and result in burn injuries. By reducing sunlight, the canopy may
increase the persistency effect of CW agents near ground level.
The canopy also provides a favorable environment for BW agent
dispersion and survival.

_d._ In desert operations, troops may be widely dispersed,
presenting less profitable targets. However, the lack of cover and
concealment exposes troops to increased hazards. Smooth sand is a
good reflector of nuclear thermal and blast effects; generating
increased numbers of injuries. High temperatures will increase the
discomfort and debilitating effects on personnel wearing MOPP,
especially heat injuries.


3-17. Medical Evacuation in a Nuclear, Biological, and Chemical
Environment

_a._ An NBC environment forces the unit leadership to consider to
what extent he will commit MEDEVAC assets to the contaminated area.
If the battalion or task force is operating in a contaminated
area, most or all of the organic medical platoon MEDEVAC assets
will operate there. However, efforts should be made to keep
some ambulances free of contamination. For conventional MEDEVAC
operations see FM 8-10-6 and FM 8-10-26.

_b._ We have three basic modes of evacuating patients (personnel
[litter bearers], ground vehicles, and aircraft). Using litter
bearers to carry the patients involves a great deal of stress.
Cumbersome MOPP gear, added to climate, increased workload, and the
fatigue of battle, will greatly reduce personnel effectiveness.
If personnel must enter a radiologically contaminated area, an
OEG must be established (see Table 3-1). Radiation exposure
records are maintained by the NBC NCO and made available to the
commander, staff, and medical leader. The exposure is entered into
the individual's medical record. Based on the OEG, the commander
and leaders will decide which MEDEVAC assets will be sent into
the contaminated area. Again, every effort is made to limit the
number of MEDEVAC assets that are contaminated. Medical evacuation
considerations should include the following:

    (1) A number of ambulances will become contaminated in the
    course of battle. Optimize the use of resources; use those
    already contaminated (medical or nonmedical) before employing
    uncontaminated resources.

    (2) Once a vehicle or aircraft has entered a contaminated area, it
    is highly unlikely that it can be spared long enough to undergo
    thorough decontamination. However, operational decontamination
    should be performed to the greatest extent possible. This will
    depend upon the contaminant, the tempo of the battle, and the
    resources available to the MEDEVAC unit. Normally, contaminated
    vehicles (air and ground) will be confined to dirty environments.
    See FM 3-5 for details on decontamination procedures.

    (3) Use ground ambulances instead of air ambulances in contaminated
    areas; they are more plentiful, are easier to decontaminate, and
    are easier to replace. However, this does not preclude the use of
    aircraft. If an air ambulance is deployed into a contaminated area,
    use it for repeated MEDEVAC missions rather than sending other
    clean aircraft into the area.

    (4) The relative positions of the contaminated area, forward line
    of own troops (FLOT), and threat air defense systems will determine
    where helicopters may be used in the MEDEVAC process. One or more
    helicopters may be restricted to contaminated areas; use ground
    vehicles to cross the line separating clean and contaminated
    areas. The ground ambulance proceeds to an MTF with a patient
    decontamination station (PDS); the patient is decontaminated and
    treated. If further MEDEVAC is required, a clean ground or air
    ambulance is used. The routes used by ground vehicles to cross
    between contaminated and clean areas are considered dirty routes
    and should not be crossed by clean vehicles, if mission permits.
    Consider the effects of wind and time upon the contaminants; some
    agents will remain for extended periods of time.

    (5) Keep the helicopter rotor wash in mind when evacuating
    patients, especially in a contaminated environment. The intense
    rotor wash will disturb the contaminants and further aggravate
    the condition. The aircraft must be allowed to land and reduce to
    flat pitch before patients are brought near. This will reduce the
    effects of the rotor wash. Additionally, a helicopter must not land
    too close to a decontamination station (especially upwind) because
    any trace of contaminants in the rotor wash will compromise the
    decontamination procedure.

_c._ Immediate decontamination of rotor wing aircraft and ground
vehicles is accomplished to minimize crew exposure. Units include
decontamination procedures in their standing operating procedures
(SOP). A sample aircraft decontamination station that may be
tailored to a unit's needs is provided in FM 3-5.

_d._ Evacuation of patients must continue, even in an NBC
environment. The HSS leader must recognize the constraints NBC
places on operations; then plan and train to overcome these
deficiencies.

_e._ To minimize the spread of contamination inside the MEDEVAC
aircraft, plastic sheeting should be placed under the litter to
catch any contaminant that drips off the patient or litter. The
plastic sheeting can be removed with the patient, removing any
contamination with it. When plastic sheeting is not available,
placing a blanket under the litter will reduce the amount of agent
that makes contact with the inside of the aircraft.

    NOTE

    The key to mission success is detailed preplanning. A HSS plan
    must be prepared for each support mission. Ensure that the HSS
    plan is in concert with the tactical plan. Use the plan as a
    starting point and improve on it while providing HSS.

_f._ Medical evacuation by United States Air Force (USAF) aircraft
will be severely limited until runway repairs and decontamination
has occurred. Aerial flights from contaminated areas into
uncontaminated airspace and destinations may be impossible for
extended periods of time; some nations will not allow patients
from contaminated areas to travel through or over their country.
Therefore, patient holding on-site (or in theater) for an extended
period of time must be anticipated.

_g._ Patient protection during evacuation must be maintained.
Patients that have been decontaminated at the PDS at an MTF will
have had their MOPP ensemble removed. The forward deployed MTFs
will not have replacement MOPP ensembles for the patients. These
patients must be placed in a patient protective wrap (PPW) before
they are removed from the clean treatment area for evacuation (see
the PPW instruction sheet/PPW label for use of the PPW). The PPW
provides the same level of protection as the MOPP ensemble. The
patient does not have to wear a protective mask when inside the
PPW. The patient is placed inside the PPW that is on a litter. 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 PPW. The PPW will provide protection for the patient for
up to 6 hours and is a one-time use item. The blower is reusable,
remove it and the attachment devices from the used PPW and return
it to the patient movement items inventory. See FM 4-02.1 for a
discussion on patient movement items.

    +----------------------------------------------------------+
    |                       =WARNING=                          |
    |                                                          |
    | DO NOT place contaminated patients in the PPW. It is for |
    | use with uncontaminated/decontaminated patients only.    |
    +----------------------------------------------------------+




CHAPTER 4

=LEVELS III AND IV HOSPITALIZATION=

4-1. General

_a._ Many factors must be considered when planning for Levels III
and IV hospital support on the integrated battlefield. The hospital
staff must be able to defend against threats by individuals or
small groups (two or three) of infiltrators and survive NBC
strikes or TIM incidents while continuing their mission. This
threat may include the introduction of NBC or TIM in the hospital
area, the water or food supplies; and the destruction of equipment
and/or supplies. On the larger scale of surviving NBC strikes and
continuing to support the mission, operating in a contaminated
environment will present many problems for hospital personnel. 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 MTF; constrain mobility and evacuation;
and contaminate the logistical supply base. While providing
hospital support, consider the following assumptions:

    (1) Their location, close to other support assets, makes them
    vulnerable to NBC strikes and release/dispersion of TIMs.

      · Command, control, communications, computers, and intelligence
      (C4I) infrastructure, logistical nodes, and base clusters are
      high value targets.

      · Most NBC weapons are designed for wide-area coverage.
      Chemical and biological agents may present a hazard some
      distance downwind from the area of attack; also, residual
      radiation may extend for hundreds of kilometers (km) from
      ground zero.

      · The large signature (size, heat, infrared) of a hospital
      makes it easy to find and target (the assumption is that the
      hospital is very near the intended targets).

      · 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 releases.

      · There are ever-increasing numbers of countries and
      individuals with the ability to manufacture and deliver NBC
      weapons/agents. This activity increases their use potential at
      all levels of conflict.

        NOTE

        When using existing civilian hospitals, the materials for an
        RDD may be at these hospitals. Exploding the material in place
        is very practical for a small team of terrorists.

    (2) Large numbers of casualties are produced in a short period
    of time. Many of these casualties may have injuries that are
    unfamiliar to hospital personnel. These injuries may include--

      · Radiation casualties.

      · Biological casualties.

      · Chemical casualties.

      · Toxic industrial biological casualties (release of material
      from biological research facilities).

      · Toxic industrial chemical casualties.

      · Toxic industrial radiological casualties.

      · Chemical agent antidote overdose casualties.

      · Combined conventional and NBC injuries.

      · Stress casualties mimicking all the above.

    (3) In addition to the wounding effects of NBC weapons on troops,
    their use will have other effects upon the patient care delivery
    system.

      · Follow-on treatment may have to be delayed due to the need
      for patient and faculty decontamination.

      · The arrival of contaminated patients at the hospital will
      require hospital personnel to perform triage; administer EMT
      procedures in the patient decontamination area; supervise
      augmentation personnel performing patient decontamination;
      and constantly monitor the hospital for contamination. The
      combat support hospital [CSH] requires at least 20 nonmedical
      personnel from units within the geographic area/base cluster
      of the hospital to perform patient decontamination under
      medical supervision. See Appendix G for patient decontamination
      procedures.

      · Patients may have been triaged and decontaminated at a Level
      I or Level II MTF. However, all patients must be triaged and
      checked for contamination as they arrive at the hospital
      ambulance drop off point. Triage ensures patients receive
      life- or limb-saving care in a timely manner. If patients are
      arriving from a suspected NBC contaminated area, they must
      be decontaminated before admission into the clean treatment
      area of the hospital. The patient decontamination area is
      established on the downwind side of the hospital. When the
      hospital does not have collective protection, the patient
      decontamination point must be at least 50 yards downwind of
      the hospital entry point. When the hospital is located inside
      a base cluster, the patient decontamination area may have to
      be established some distance from the hospital to prevent
      contamination of other units in the area. Should this be the
      case, the patients may have to be transported by ambulance or
      other vehicle from the clean side (hot line) of the patient
      decontamination area to the receiving point of the hospital.

      · Conditions may mandate the use of nonmedical vehicles to
      transport casualties to the MTF. The use of these vehicles
      limits or prohibits en route medical care, but may be the only
      way to clear the battlefield and ensure timely care of patients
      at the hospital.

    (4) Mission-oriented protective posture reduces the efficiency of
    all personnel.

    (5) Without CPS systems, hospitals may operate for a limited
    time in a nonpersistent agent environment, but are incapable of
    operating in a persistent agent environment.

      · Chemical/biological filters for fixed site hospital
      ventilation systems will be a critical item of supply.
      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 established. All
      windows, doors, and other points that may have air leaks will
      have to be sealed (use tape and plastic sheeting) to enable the
      facility to have a positive overpressure to keep CB agents out.

      · Liquid chemical agents can penetrate the TEMPER in about 6
      hours or general purpose (GP) tentage in a shorter period of
      time. These agents will penetrate the wrappings on medical
      supplies and equipment; especially, sterilized equipment and
      supplies, paper-wrapped cotton sponges, and open or lightly
      closed medications/solutions. They can also contaminate
      water/food supplies. Therefore, equipment and supplies must be
      stored in protected areas or under protective coverings.

      · Without a CPS system, treatment procedures involving open
      wounds or the respiratory tract in the presence of a CB agent
      hazard is limited. Exposing open wounds and the respiratory
      tract to the agent increases the effects of these agents on the
      patient.

      · Without hardened protection, the hospital, staff, and
      patients are susceptible to the effects (blast, thermal,
      radiation, and missiling) of nuclear weapons.

      · Hospital electrical and electronic medical equipment is
      vulnerable to the effects of the EMP produced by nuclear
      weapons. The EMP is not harmful to humans, animals, or plants,
      but is very damaging to electronic equipment.

      · Hospital equipment is very difficult to decontaminate. Aging
      (allowing the agent to off-gas) may be the only means of
      decontamination.

      · Hospitals are not kept in reserve. All personnel and
      equipment losses due to NBC contamination or radiation will
      have to be replaced.

_b._ There are currently two force modernization initiative
hospital systems in the force structure. The Medical Force 2000
(MF2K) system consists of the CSH, the field hospital (FH), and the
general hospital (GH). The Medical Reengineering Initiative (MRI)
consists of only one hospital system--the CSH. The MF2K CSH is a
corps asset, whereas, the FH and GH are the echelon above corps
hospital systems. The MRI CSH will be located in the corps and at
echelons above corps. The MRI CSH will replace the FH and GH at
echelons above corps. See FM 4-02.10, FM 8-10-14, and FM 8-10-15
for detailed information on these hospital systems.

4-2. Protection

_a._ Protection of hospital assets requires intensive use of
intelligence information and careful planning. The limited
mobility of hospitals makes their site selection vital to minimize
collateral damage from attacks on other units.

    · Hospitals must be located as close to the supported units as
    possible to provide responsive care in support of the tactical
    commander's plan. However, their limited mobility must be
    considered when selecting their locations.

    · Protective factors (distance from other support units and
    interposed terrain features) must be balanced against the
    operational factors (accessibility and time required for
    patient transport).

    · Depending on the weapon systems used, local topography, and
    meteorological conditions, relatively large portions of the
    tactical area may remain uncontaminated.

_b._ Many defensive measures will either impede or preclude
performance of the hospital mission. Successful hospital defense
against an NBC threat is dependent upon accurate, timely receipt of
information via the nuclear, biological, and chemical warning and
reporting system (NBCWRS). 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 3 and
4. The detailed information (provided in the NBC 5 and 6 reports
respectively) on the areas affected and the types of agents used
allows the hospital staff to--

    · Project the number and types of patients to be expected.

    · Establish a patient decontamination area.

    · Request patient decontamination assistance.

    (1) _Protective procedures._

      (_a_) Because most hospital sections operate in sheltered areas
      (tentage or hard-walled shelter), some protection is provided
      against vapor, liquid, and particulate (fallout) hazards. Sealing
      all openings can increase the temporary protection from such
      hazards; all entries and exits must be curtailed while operating
      in this mode. Liquid agents will eventually seep through the tent
      fabric and create a vapor hazard inside the shelter. Locating
      equipment, such as trucks, under trees or other cover provides
      similar effects. Setting up hospitals in existing structures
      (concrete or steel buildings) provides greater protection from
      hazards and eliminates many decontamination problems. However,
      without means to seal openings, chemical agent vapors can enter the
      structure. The addition of CB filtration systems with air locks,
      that provide overpressure, can provide maximum protection for
      occupants. Entry and exit procedures must be established to prevent
      contamination being introduced by personnel and patients entering.
      See Appendix F for entry/exit procedures when CB filters and air
      locks are in use.

      (_b_) Concealment and good operations security (OPSEC) will help
      prevent identification of a unit.

      (_c_) Dispersion is a defensive measure employed by tactical
      commanders; however, hospital operations limit the value of this
      technique. One technique that may be used is locating sections of
      the hospital, such as the motor pool, personnel billets, laundry,
      and logistical storage, a greater distance from the hospital
      complex than normal. This will increase dispersion without severely
      compromising the hospital mission.

      (_d_) The MOPP ensemble does not protect against all radiation
      effects of nuclear weapons. However, it provides some protection
      against alpha and beta radiation burns. By covering all body
      surfaces, especially hairy areas, MOPP greatly expedites the
      decontamination process.

    (2) _Nuclear._

      (_a_) Most protective measures for hospitals against nuclear attack
      require engineer and/or intensive logistic support. This support
      includes placing sandbag walls around tents; digging trenches for
      patient occupation; or constructing earthen berms (see Appendix
      H). Occupying existing structures, depending upon their strength
      and potential flammability, may be the best protection against
      the effects of a nuclear strike. The remainder of this section
      presents factors to consider when selecting the protective posture
      for the hospital against a nuclear attack. Leaving equipment packed
      and loaded until actually needed for operations will help protect
      materiel in an NBC environment. In any event the unit must have
      established an OEG, implemented radiation monitoring, and have
      contingency plans if these radiation levels are approached or
      exceeded.

      (_b_) Personnel and patient protection requirements will depend
      upon the threat (blast, thermal, immediate radiation, or fallout
      effects). The MOPP ensemble will not protect against internal
      radiation, but will provide some protection from external
      radiological contamination.

        · If the threat is nuclear fallout, the hospital structure
        provides protection; the fallout can be brushed or washed
        off. This allows protection while permitting patient care
        to continue virtually uninterrupted. A need to relocate the
        hospital will depend upon the degree of contamination; the
        amount of decontamination possible; and the projected stay
        before a normal move in support of operations.

        · Hospital tentage alone offers little protection against blast
        and missiling effects. If the patients are to remain in the
        tents, they are placed on the floor. Place all equipment on
        the ground or as low as possible and secure all loose objects.
        In GP tents, sandbags can be piled around the base of the tent
        poles to add stability. The tent poles and patient beds should
        keep the canvas off the ground enough (if the tent collapses)
        to continue minimal patient care and evacuation; however, be
        aware of possible tent pole breakage.

        · Hospital units are very susceptible to the thermal effect
        of a nuclear detonation. Tents will not provide protection
        against the thermal pulse. If the thermal effect (fire) is an
        impending threat, patients and personnel in tentage must move
        to trenches, bunkers, or other nonflammable areas.

        · Protection factors that can reduce the overall radiation
        exposure rate for hospital personnel and patients are--

          · Time. Reducing the exposure time to the radiation reduces
          the overall exposure proportionally (cut the time of
          exposure in half and the overall exposure is cut in half).
          EXAMPLE: An exposure time of 60 minutes to a dose rate
          of 100 centigray (cGy) is cut in half (30 minutes) to an
          exposure rate of 50 cGy.

          · Distance. Increasing the distance from the radiation
          source reduces the exposure in an inverse square
          relationship (double the distance factor by 2 decreases the
          exposure factor by 4).

          · Shielding. Placing material between personnel and patient
          and the radiation source decreases the dose (the reduction
          factor is dependent on the type of radiation and the
          density of the shielding material). Placement of sandbags
          (two feet wide) around the hospital tents and shelters
          provides adequate shielding for protection from gamma and
          x-ray radiation; the thicker the sandbag stacks the greater
          the protection factor. Tent material is a good shield for
          alpha particles and adequate shielding from beta particles.
          See Appendix H for field expedient shielding techniques.

    (3) _Biological._ The most likely use of a biological agent (such
    as anthrax) is releasing the agent as an aerosol. While such agents
    may produce large numbers of casualties, initially patients may
    be seen at the MTF in small numbers, but the number of patients
    will rapidly increase within a few hours to days. When a trend
    is identified, the enemy use of a biological agent is suspected.
    General protective measures are the same as for any infectious
    disease; specific protective measures are used once the vector or
    method of transmission has been identified. Designating a single
    hospital to care for these patients (from a patient care or disease
    transmission standpoint) may not be necessary. However, if the
    agent is communicable, consolidating them all at one facility
    maximizes the use of limited assets and aids in limiting the
    spread of the disease. Protective measures against biological
    attack are the same as those for chemical agents when bombs,
    sprays, or gases are used; see (4) below. The difficulty in rapidly
    identifying biological agents may force the use of protective
    measures for longer periods of time. Faced with this situation, a
    careful evaluation of the mask-only posture is necessary before
    implementing any level of MOPP. See FM 8-284 for additional
    information on prevention, protection, and treatment of biological
    casualties.

    (4) _Chemical._

      (_a_) _Individual protection._ When CPS systems are not available,
      using the correct MOPP level is essential in hospital mission
      performance. The level of MOPP assumed depends upon the level of
      threat. An alternative approach for the hospital commander is the
      use of the mask-only posture. This posture is acceptable when
      the hazard is from vapor only (except mustard). See FM 3-4 for a
      description of each MOPP level and mask-only procedures.

        · _Hospital warning system._ The hospital must have a warning
        system that alerts all personnel of impending or present
        hazards. This system must include visual and auditory signals;
        the signals must operate inside and outside the hospital
        complex. There are numerous problems associated with warning
        personnel; they include--

          · The wide area covered by the hospital operations.

          · Some personnel will be asleep at all times of the day or
          night (two or three shifts).

          · The considerable noise from mechanical support equipment;
          such as the power generation and environmental control
          equipment.

          · Tentage and equipment interrupts line of sight.

        · _Hospital personnel response._ When NBC alarms are activated,
        all personnel (including off duty personnel) report to their
        duty stations as soon as they are in the designated MOPP level.
        This allows for 100 percent personnel accounting and provides
        additional personnel to secure patients and materiel.

        · _Unprotected hospital areas._ Areas of the hospital without
        CPS are at their best posture with all openings secured and
        the ventilation systems turned off. For nonpersistent agents
        (vapor hazards), personnel and patients stay at the designated
        MOPP level until the all clear signal is given; then normal
        operations are resumed.

          NOTE

          Patients with injuries that prevent their assuming a protective
          posture must be placed in a PPW or immediately evacuated to a
          clean MTF.

      _(b) Environmental protection._ As noted previously, hospital
      complexes without CPS offer some protection against liquid or
      fallout contamination, but little protection against vapor hazards.

        · When MOPP Level 1 must be assumed, close and secure all tent
        flaps, vents, and doors to prevent the entrance of liquids or
        particles. All hospital personnel outside of shelters assume
        MOPP Level 4. Cover or move all equipment and supplies into
        shelters (tents, hard-walled shipping containers), if possible.
        Placement under thick foliage trees is better than left out in
        the open. The best policy is to keep all equipment and supplies
        not immediately needed covered or in closed containers.

        · When MOPP Level 3 or mask-only posture is assumed, shut down
        the hospital's ventilation system to prevent drawing vapors
        or fallout contamination into the hospital. This measure also
        provides some protection of the internal environment during the
        time required for the vapor to penetrate the tentage.

      _(c) Patient protection._

        · Patient protection depends upon prior planning and timely
        warning of the chemical threat. Each patient's protective mask
        must be available and serviceable. If the patient came from
        a contaminated area, the mask must be decontaminated and the
        filters changed. The mask decontamination and filter change
        may have to be performed by hospital personnel. If ambulatory
        patients' medical conditions permit (minimal care ward), they
        may be able to perform this task. The hospital supply staff
        must ensure that mask filters are available at the supporting
        logistics support facility and can be requisitioned to meet
        this requirement. Check all masks for serviceability as soon as
        the mission permits, but always before they are needed. Do not
        wait until the warning has been received to begin checking the
        mask. Each area must have an established plan for operations
        (to include assisting patients assuming MOPP or other
        protective posture) in the NBC environment. Appendix F provides
        additional information on patient protection.

          +--------------------------------------------------------+
          |                     CAUTION                            |
          |                                                        |
          | Remember, personnel must assume MOPP Level 4 before    |
          | beginning any decontamination process or risk becoming |
          | a casualty themselves.                                 |
          +--------------------------------------------------------+

        · Hospital staff always mask themselves first, then assist
        patients in masking. On minimal care wards, most patients
        can put on their masks. For those who cannot, other patients
        can assist them after putting on their own masks. On the
        intermediate care wards, some patients will be able to put on
        their masks, but many will require assistance. Intensive care
        and emergency room staff will have to assist their patients in
        masking.

        · Many patients with head and neck wounds or who are on
        life-support devices will be unable to wear their individual
        protective masks; these patients must be placed in a PPW. While
        the PPW has two ports for intravenous or blood infusion lines,
        the staff may have to adapt for other devices (Foley catheters,
        traction devices, and cardiac monitor) by using tape and other
        means to seal the gaps created in the seal around the edge of
        the PPW. Patients requiring assisted ventilation are at extreme
        risk, unless their air supply is protected. The sequence of
        protecting everyone is mask yourself first; assist those
        patients who can wear their protective masks; and then place
        patients in the PPW.

      _(d) Materiel protection._ Protection of materiel, especially
      expendable supplies, requires covers and barriers. All materiel not
      required for immediate use is kept in shipping containers, medical
      chests, or under cover (tentage, plastic sheeting, and tarpaulin)
      for protection against particulate or liquid hazard. Protection
      against vapor hazard may require multiple barriers through which
      the vapor must penetrate. For example, intravenous solutions are in
      their individual plastic bags, in the cardboard shipping box, on a
      covered pallet, in a hard-walled shelter; such as a military-owned
      demountable container (MILVAN). This presents four barriers against
      the vapor hazard. These principles should be used to the maximum
      extent practical.


4-3. Decontamination

_a._ Decontamination of nuclear-contaminated personnel, equipment,
and the operational site is as follows:

    (1) Monitoring equipment is used to detect contamination; the
    contamination is then removed by brushing or scraping with brooms,
    brushes, or tree branches. Flushing hard surface contaminated areas
    with water is also effective in removing nuclear contamination.
    However, there remains a problem of containing and removing the
    contaminated water. The best method of containment is to trench
    the area into a sump for collection of the contamination. This
    will reduce the area of contamination; however, the level of
    concentrated radiation may be such that there is an increased
    hazard to personnel. The collection area must be clearly marked
    using the standard nuclear hazard signs.

    (2) Nuclear contamination of the site may require relocating the
    hospital. Scraping 1 or 2 inches of topsoil from the area, or
    covering the area with 1 or 2 inches of uncontaminated dirt will
    not be practical. A need to relocate the hospital will depend
    upon the degree of contamination; the amount of decontamination
    possible and the projected stay before a normal move in support
    of operations. If the hospital is immersed in a high level of
    radioactivity, the best option may be to abandon it for 48 to
    72 hours. 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 area. The
    command OEG must be followed if reoccupying or moving the facility.

_b._ Suspect biological agents should be removed from equipment as
quickly as possible, In the absence of agent-specific guidance,
clean exposed surfaces using a 5 percent hypochlorite solution or
copious quantities of soap and water (preferably hot). Liberally
apply the hot, soapy water and scrub all surfaces with a brush.
Then rinse the surfaces with hot water. As previously discussed,
the soapy water used is contaminated and must be controlled
and removed to a safe area. Supertropical bleach (STB) and
decontaminating solution Number 2 (DS2, US Army) are effective
against most known biological agents because of their caustic
nature. If anthrax (or other spore formers) is suspected, repeat
the entire decontamination process again to remove the spores.
Other standard biological decontamination agents are described in
FM 3-5.

    +------------------------------------------------------------------+
    |                            CAUTION                               |
    |                                                                  |
    | 1. Keep liquid decontaminants out of equipment with electronic   |
    | or electrical circuits. Unplug electrical devices before         |
    | attempting to decontaminate them; prevent electric shock. Some   |
    | electronic devices maintain an electric charge, even after being |
    | unplugged, use extreme care to prevent shock.                    |
    |                                                                  |
    | 2. Soap and water only mechanically remove BW agents. The        |
    | soap and water solution must be contained to prevent spreading   |
    | the agent to other personnel, thus causing more casualties.      |
    +------------------------------------------------------------------+

_c._ Decontamination of chemical contamination is as follows:

    (1) Personnel use their soldier skills and their M295 Individual
    Equipment Decontamination Kit to decontaminate their personal
    equipment. The M13, decontamination apparatus, portable, is used to
    decontaminate vehicles, trailers, and International Organization
    for Standardization (ISO) shelters. This apparatus uses DS2
    (a highly caustic, flammable solution that cannot be used to
    decontaminate tentage). The DS2 must be washed off after sufficient
    time has passed for decontamination (see FM 3-5 for details).
    Water used for NBC decontamination purposes becomes contaminated;
    therefore, it must be contained in sumps. Dig shallow trenches to
    channel the water into sumps. This will be difficult in hospital
    areas because relatively flat sites are needed for hospital
    complexing, but must be accomplished to reduce the contamination
    levels in the hospital area.

    (2) When hospital tentage becomes contaminated, decontamination
    operations must be considered immediately. Spot decontamination
    may be effective for small areas; however, gross contamination of
    TEMPER and GP tentage is best decontaminated by aging. Without
    CPS and with persistent agent contamination that absorbs into
    the tentage and presents a continuing vapor hazard, the hospital
    stops receiving patients and evacuates all patients as quickly as
    possible. When large portions of the hospital are contaminated,
    personnel decontaminate all equipment possible and relocate to
    a new site, leaving the contaminated equipment to age or to be
    decontaminated by a specialized unit. When small portions of the
    hospital are contaminated, the contaminated portions are removed
    to another location for decontamination; hospital operations are
    continued, but at a lower operational level. For detailed equipment
    decontamination procedures, see FM 3-5.

      NOTE

      Liquid decontamination material must not be used on electrical
      or electronic components of equipment. Liquid decontaminants
      can damage the equipment; thus making it inoperable and not
      available for patient care or transport. The use of liquids
      to decontaminate electronic equipment could also potentially
      result in injury or electrocution of personnel.

    (3) Each US Army hospital is issued =five= chemical agent patient
    treatment MES and =three= chemical agent patient decontamination
    MES, Chemical Agents Patient Decontamination, for use in
    decontaminating patients. Each hospital must decontaminate and
    treat its own personnel who become casualties; chemical casualties
    from units in its general area; or contaminated patients received
    from lower level MTFs. See Appendix G for patient decontamination
    procedures and for establishment of a patient decontamination and
    treatment station.


4-4. Emergency Services

_a._ Providing emergency services will be complicated by several
factors:

    · Varying levels of treatment received prior to arrival at the
    hospital.

    · Caring for combined conventional wounds and NBC agent effects.

    · Managing heat-related complications associated with MOPP/PPW
    use.

    · Controlling psychological effects caused by biological and
    chemical agents, the impact of NBC weapons, or the isolation of
    MOPP gear or PPWs.

    · Having EMT personnel working at the arrival point,
    decontamination site, and in the hospital EMT area.

    · Conducting triage and providing patient care while in MOPP
    gear.

    · Supervising supported units decontamination augmentation
    personnel. These personnel will most likely be of any military
    occupational specially (MOS), except medical. They will use
    hospital equipment and supplies to decontaminate patients.

_b._ Contaminated patients must be triaged in the decontamination
area that is established at the hospital. Contaminated patients
=WILL NOT= be brought into the clean EMT area until decontaminated.
All patients are screened for contamination. Based on the findings,
the patient is routed to the contaminated triage station, or to
the clean triage station. Contaminated patients are triaged,
then routed to the decontamination area, or to the contaminated
treatment area. Patient admission to the clean treatment area may
be delayed; however, life- or limb-saving care is provided in the
contaminated treatment area before decontamination.


4-5. General Medical Services

The provision of general medical services in the hospital will be
continued with minimal interruptions in the NBC environment. The
noninvasive nature of these services allows their continuation at
most MOPP levels. However, some general medical services will be
constrained by MOPP Levels 3 and 4 and the mask-only posture. These
constraints may include, but not be limited to--

    · Communication limitations.

    · Loss of the oral route for administering medications to
    patients.

    · Limited ability to accurately evaluate the eyes, nose, and
    mouth of patients wearing a protective mask.

    · Reduced ability to perform examination/assessment of patients
    in PPW or MOPP Levels 3 and 4.

    · Inability to provide oxygen therapy or ventilator support
    to a patient in a vapor hazard environment, unless a CB
    filter-supported respirator is available.

    · Logistical constraints based upon the fact that key areas
    such as dietetics, supply, and laundry are not in the
    CPS. These services may be reduced or delayed in the NBC
    environment. See Appendix F for Information on patient feeding
    under NBC conditions.


4-6. Surgical Services

_a._ Surgical services will be severely limited in the NBC
environment. At any level above MOPP Level 0, without a CPS system
surgical services are halted except for life- or limb-saving
expedient procedures. Surgery cannot be safely performed outside a
CPS due to a variety of factors including--

    · Lack of protected ventilation for patients during and after
    surgery.

    · Inability to maintain a sterile field while using MOPP gear.

    · Direct access for agents through open wounds to the
    circulatory and respiratory systems.

    · Decreased dexterity and vision resulting from MOPP gear use.

    · Inability to quickly place the patient in a PPW should the
    need arise.

_b._ Due to the relatively high number of trauma cases, hospital
services may be severely constrained by NBC contamination. The
hospital location and the possible need for relocation are two
major planning considerations for the command staff.

_c._ 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 environment. Hospitals without CPS stop
receiving patients when a persistent hazard is identified; patients
on hand are protected and transferred to a clean MTF.


4-7. 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
patients. The patients may be in their MOPP gear, in a PPW, or
wearing only their protective mask; any of which will interfere
with care. The nursing staff will wear the same level of protection
as the patients.

_a._ Direct assessment of a patient's vital signs is extremely
limited at MOPP Levels 3 or 4; however, a carotid artery pulse can
be taken by palpating the neck area. The patient's respiratory rate
and level of consciousness may be assessed visually. Palpitation
of the blood pressure through a PPW may be possible if it is
relatively strong, or at least in the normal range. The patient's
temperature cannot be monitored; this is an area of concern due to
the possibility of heat stress.

_b._ Only gross neurological signs can be assessed through the PPW
or when the patient is in MOPP Levels 3 or 4. However, even this
assessment is complicated by the presence of miosis and by the
health care provider's mask. Urinary output and cardiac monitoring
is continued uninterrupted for patients wearing a mask only and for
patients in the PPW.

_c._ Oral hygiene and bathing are postponed until a safe
environment is available (MOPP Level 2 or less). All toileting will
occur within the hospital complex using ISO contained latrines,
chemical toilets, bedpans, urinals, buckets, or containers with
plastic liners. 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
facility.

_d._ At MOPP Levels 3 and 4, feeding must be postponed. A
nutritional assessment is needed to determine how long each patient
can tolerate a fasting state when MOPP Level 3 or Level 4 remains
in effect for over 24 hours.

_e._ Intravenous (IV) medications are mixed in a clean area and
then transported in a protective wrap (multilayers of plastic,
medical chest, or layered cardboard) to the user. However, IV
solutions, blood, and injections can be given to patients on an
unprotected ward. Normally, oral medications are only given at MOPP
Level 2 or lower.

_f._ Treatment procedures that have the potential of contaminating
the patient's pulmonary or circulatory systems are conducted only
at MOPP Level 2 or below. However, EMT procedures may have to
be performed in the contaminated treatment area, or the patient
decontamination area.

_g._ Continuous oxygen therapy requires a collective protection
environment or a CB filter supported respirator.

_h._ Delivery of nursing care at MOPP Level 3 or Level 4 is limited
due to the sensory restrictions of MOPP gear. Time is taken to
reassure the patients on a personal basis, as much as possible,
and by routinely monitoring the ward environment. Communications
are difficult and identities are masked. Maintain the identity of
personnel by using handwritten name tags for staff and patients
(including patients in PPW).

_i._ As with all procedures, the time required for record-keeping
rises markedly at MOPP Level 3 or Level 4. Contaminated paperwork
cannot be evacuated with the patient. Transcribe essential
information onto uncontaminated documents for evacuation with the
patient. A record of patient exposure time to a contaminated area
is prepared to assess the cumulative risk to the patient.


4-8. Conventional Operations

For conventional operations of hospitals in a field environment see
FM 4-02.10, FM 8-10-14, and FM 8-10-15.




CHAPTER 5

OTHER HEALTH SERVICE SUPPORT


Section I. PREVENTIVE MEDICINE SERVICES


5-1. General

On the integrated battlefield, PVNTMED services will be in greater
demand than at any other time, especially under BW conditions.
Preventive medicine personnel will be called upon to assist the
commander in determining the health hazards associated with nuclear
fallout; the safety of drinking water in an NBC environment;
as well as determining when to use prophylaxis, pretreatments,
immunizations, and other PVNTMED measures (PMM) associated with
NBC warfare. Preventive medicine personnel must be aware of the
medical threat in the AO. They must continually update their
medical surveillance activities to identify disease trends (endemic
and epidemic), potential disease vectors, and the susceptibility
of troops to these diseases. Under NBC conditions, diseases may
manifest that exist in the area, but were not being transmitted to
personnel. However, due to the reduced health status of personnel
from exposures to or from stress-related NBC conditions, the
troops begin to suffer their effects. The appearance of diseases
or arthropods not known to exist in the AO are indicators that BW
agents have been used. For details on PVNTMED operations, see FM
4-02.17.


5-2. Disease Incidence Following the Use of Nuclear, Biological,
and Chemical Weapons

_a._ _Determining Factors._ Factors of prime importance in
determining the nature and severity of the disease effects are--

    · Immunization status of personnel.

    · Population density.

    · Degree of industrialization in the operational area.

    · Availability of food supplies.

    · Availability of water.

    · Climate.

Finally, the manner and situation in which nuclear weapons are used
are of importance. 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 stability. At
Hiroshima and Nagasaki, Japan (excellent examples of the first
type of situation), the survivors who could get away were able
to obtain food, shelter, and care from surrounding intact areas.
With prolonged combat operations, such intact areas would not be
available, resulting in no food, shelter, or care for survivors.
There will be a breakdown in social order and there will be a lack
of effective medical support; including PVNTMED functions and
facilities.

_b._ _Disease Incidence._ Without PVNTMED capabilities, increased
incidence and morbidity from diseases will follow. Some diseases
will predominate in incidence, depending upon the geographical
areas involved and the endemic diseases present.

    (1) In urban areas in temperate climates, several diseases are
    epidemic threats. These epidemic threats may include--

      · Dysentery (due to a variety of pathogens).

      · Rickettsial diseases, particularly typhus and scrub typhus.

      · Hepatitis.

      · Tuberculosis.

      · Sexually transmitted diseases.

      · Malaria and cholera (in many parts of the world).

    (2) There are several reasons for the increased risk of disease
    including, but not limited to--

      · Crowding of surviving populations with limited sanitary
      facilities, such as was seen in Europe at the end of World War
      II.

      · A lack of prophylaxis and immunizations with resultant
      increases in the susceptible faction of a given population.

      · A lack of pest management.

      · The effect of irradiation on susceptibility to infection.
      With the high levels of fallout covering wide areas, a large
      number of people will sustain sublethal whole-body doses of
      irradiation. The interaction of irradiation with infections
      is not clear; but it may be the result of latent infections
      manifesting and decreased resistance to infection. The result
      is an increased incidence of disease.

      · The ecological imbalance and host-parasite relationship
      following the use of nuclear weapons. Each class and order of
      animals has marked differences in sensitivity to irradiation.
      Arthropods, for example, are much more resistant than are
      vertebrates. The normal balance between arthropods and
      birds that prey upon them in a given area may be severely
      upset, producing a marked overgrowth of the arthropods. If
      the arthropods include vectors of disease there would be a
      serious increase in disease hazards. If there is an increase
      in arthropods that destroy vegetation there would be a serious
      destruction of food crops.

      · 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 personnel.


5-3. Preventive Medicine Section

The PVNTMED sections of the brigade, divisional, and nondivisional
medical companies perform analysis on water sources and supplies
to determine the presence or absence of NBC/TIM contamination; see
Appendix I for additional information. Based upon their findings,
the water is released for consumption, or is restricted from use
until it is treated (usually by water production personnel using
the reverse osmosis water purification unit [ROWPU]). They also
collect water samples for suspect biological agent contamination
for supporting medical laboratory analysis (see Appendix B). They
conduct medical surveillance activities, to include occupational
and environmental health threat surveillance. They conduct
limited entomological surveys to determine the existence of
disease-vectoring arthropods in the AO. They inspect food service
facilities to determine the extent, if any, of NBC contamination.
They evaluate the unit's--

    · Immunization status.

    · Use of prophylaxis for specific diseases (such as
    antimalarial tablets) (see FM 4-02.33), for nuclear radiation
    exposure (such as granisetron for nausea and vomiting) (see
    FM 4-02.283), and for BW agents (such as Ciprofloxacin for
    postexposure chemoprophylaxis for Anthrax) (see FM 8-284).

    · Use of nerve agent pyridostigmine pretreatment tablets (see
    FM 8-285), if warranted.

    · Application of personal hygiene and field sanitation
    procedures (FM 21-10/MCRP 4-11.1D).

Based upon their findings, they provide recommendations for
corrective actions to the commanders. They assist in training
US Army unit field sanitation teams (FM 4-25.12); they are not
members of the unit field sanitation team. They conduct medical
surveillance activities for their command (FM 4-02.17).


5-4. Preventive Medicine Detachment

The PVNTMED detachment provides PVNTMED services on an area support
basis to units within their assigned AO. These services include,
but are not limited to--

    · Conducting water surveillance, including NBC contamination.
    Collecting water samples suspected of NBC/TIM contamination for
    analysis by supporting medical laboratory (see Appendix B).

    · Performing food service sanitary inspections.

    · Conducting medical surveillance and providing epidemiological
    consultation.

    · Conducting pest (arthropod and rodent) surveys and
    surveillance.

    · Conducting arthropod control operations. The aerial spraying
    missions are dependent upon availability of helicopter support.

    · Conducting occupational and industrial hygiene surveys.

    · Advising commanders on the application of PMM.

    · Training the supported units' field sanitation teams.


Section II. VETERINARY SERVICES


5-5. General

The US Army Veterinary Service is the Executive Agent for
veterinary services to all Services within the DOD. They ensure
that food and bottled water supplies are safe and provide
veterinary medical and surgical care for government-owned animals
throughout the AO. On the integrated battlefield, their role is
particularly important; the potential for food supplies becoming
contaminated with NBC agents is high. For detailed information on
provision of veterinary services see FM 8-10-18.


5-6. Food Protection

Food may become contaminated from enemy employment of NBC
weapons/agents or from terroristic contamination of food
procurement facilities and food supplies. The NBC agents may
be introduced during production or in the storage area of the
procurement facility; while the product is in transit; at the
military storage facility; or at the unit food service facility.
Regardless of where the agent is used, the effect is the same;
personnel will become ill or die if they consume the contaminated
food. To ensure food safety, veterinary personnel inspect and
monitor food from its procurement until it is issued to the
consumer. Throughout the AO, all Services (Army, Navy, Marine,
and Air Force) logistics and food service personnel must take
precautions to protect subsistence from contamination.


5-7. Food Decontamination

Veterinary personnel are involved in the detection and monitoring
of NBC contaminated rations; before use, they must inspect all
food suspected of being contaminated with NBC agents. Appendix J
provides guidance on food decontamination procedures. Veterinary
personnel provide advice on the decontamination of food to unit
personnel owning the food, or personnel performing the food
decontamination. Depending on the type of contamination and
packaging, the food may be--

    · Consumed without being decontaminated.

    · Decontaminated and then consumed.

    · Destroyed.

Some items may be held to allow time for natural decay of nuclear
or chemical contamination before consumption. The commander,
with advice from veterinary personnel, makes the decision on the
disposition of the food. However, veterinary personnel make the
final determination of food safety.


5-8. Animal Care

Veterinary personnel are concerned with the protection of
government-owned animals and animals being procured for
consumption. Animals must be protected from NBC contamination,
whenever possible. Animals should be moved into enclosures to
protect them as much as possible from contamination. Protective
equipment is not available for military working dogs; however,
protection of the animal's feet and body must be considered. When
military working dogs must cross a contaminated area, protect
their feet by using butyl rubber material to improvise booties.
Since CPS systems are not available, animal treatment facilities
must be established in contamination free areas. Veterinary
treatment personnel must remain in MOPP Level 4 when caring for NBC
animal casualties until the animals have been decontaminated. The
treatment of military working dog NBC casualties is outlined in FM
8-10-18.


Section III. LABORATORY SERVICES


5-9. General

Laboratory services must continue their support role even under
NBC conditions. For the provision of clinical and diagnostic
support, the facility must be located in a contamination-free
area or be inside collective protection. Designated laboratories
within the theater will analyze NBC samples/specimens (including
in theater field confirmation identification of biological agents
by evaluating specimens from symptomatic patients and animals
and environmental samples collected from the AO). See Appendix
B for procedures in collecting biological samples/specimens,
handling/packaging, maintaining chain of custody, transporting
samples/specimens, and analysis.


5-10. Level II

Laboratory support at this level is extremely limited; it consists
of laboratory procedures in direct support of MTF and FST
activities. Laboratory personnel prepare collected suspect NBC
specimens for submission to the supporting laboratory for analysis;
the specimens are forwarded to supporting medical laboratories
(Appendix B).


5-11. Level III

Laboratory support in a CSH is intended for providing clinical
laboratory support and is primarily in support of acute surgical
cases, blood services, and statim (STAT) services required for
intensive care operations. Only extremely limited microbiology
services (parasitological exams and gram stains) are provided. In
a mature theater, the microbiology services may be augmented to
include limited cultures and sensitivity testing. Patients with
documented or suspected exposure to NBC weapons/agents will be
medically evaluated, specimens will be collected, packaged, and
have chain of custody established. The specimens will be forwarded
through technical channels to the supporting medical laboratory
(such as the theater Army medical laboratory [TAML]) for analysis.
See Appendix B for specimen collection, packaging, chain of
custody, and processing requirements.


5-12. Level IV

_a._ _Clinical Laboratories._ The clinical laboratories in the
combat support, field, and general hospitals have the ability to
perform a general, but limited, array of analytical procedures in
hematology, urinalysis, chemistry, microbiology, serology, and
blood bank. Patient specimens of suspected biological or chemical
agent exposures are forwarded through technical channels to the
supporting medical laboratory. See Appendix B for sample/specimen
collection, packaging, chain of custody, processing, and
transporting requirements.

_b._ _Field Laboratories._

    (1) _Theater Army Medical Laboratory._ The TAML is the specialized
    echelons above corps (EAC) laboratory that provides clinical and
    nonclinical medical laboratory support. When equipped and staffed,
    the TAML provides in-theater field confirmation identification
    of NBC samples or specimens. Using sophisticated equipment and
    methods, the TAML has the capability to detect and identify NBC
    agents in a variety of specimens/samples (such as human, air,
    soil, water, animals, vegetation, and food). Direct support from
    continental United States (CONUS)-based laboratories aids the TAML
    with identification of NBC agents. Command decision on use of
    protective/preventive measures and patient care may be based on the
    TAML findings. Proper collection, packaging, and rapid shipment
    of specimens by MTFs and samples from other sources will ensure
    effective, timely, and accurate laboratory analyses.

    (2) _Area Medical Laboratory._ The Area Medical Laboratory (AML)
    is the specialized laboratory within the theater that provides
    nonclinical medical laboratory support. The AML can be deployed in
    the corps or to EAC for support missions. When fielded, the AML
    will replace the TAML in the force structure. The AML provides
    in-theater field confirmation identification of NBC samples or
    specimens. Using sophisticated equipment and methods, the AML has
    the capability to detect and identify NBC agents in a variety
    of specimens/samples (such as human, air, soil, water, animals,
    vegetation, and food). Direct support from CONUS-based laboratories
    aids the AML with identification of NBC agents. Command decision
    on use of protective/preventive measures and patient care may be
    based on the AML findings. Proper collection, packaging, and rapid
    shipment of specimens by MTFs and samples from other sources will
    ensure effective, timely, and accurate laboratory analyses.


5-13. Level V (Continental United States)

Designated Level V medical laboratories perform analyses to
provide definitive identification of suspect biological agents for
the President and Secretary of Defense purposes. The definitive
identification of suspect biological agents also aids commanders in
the AO in maintaining the health of their command.


5-14. Field Samples

Chemical corps personnel collect environmental, air, soil, and
vegetation samples. Preventive medicine personnel collect samples
from drinking water sources and supplies. Veterinary personnel
collect samples from food supplies and medical specimens from
animals. All other units collect soil, vegetation, and small
animal samples for laboratory analysis. Samples are subjected to
initial screening with rapid test kits and in-theater confirmatory
identification at the supporting medical laboratory. The President-
and Secretary of Defense-required definitive identification
is performed at the designated Level V medical laboratory.
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 environment. See Appendix B for
specific procedures for sample collection, packaging, transporting,
maintaining chain of custody, and analysis.


Section IV. DENTAL SERVICES


5-15. General

Dental service support is provided in the AO at Levels II, III,
and IV. Because of their location close to main supply routes
and other support assets, dental units are vulnerable to an NBC
strike. Nuclear, biological, and chemical operations have an impact
at all levels; thus, dental units must be prepared to survive on
the integrated battlefield. Defense against NBC weapons must be
included in the dental unit's TSOP. Individual and collective tasks
must be intensely trained on a regular basis; survival depends on
the ability of personnel to use basic survival skills against an
NBC attack. For details on provision of dental services, see FM
4-02.19.


5-16. Mission in a Nuclear, Biological, or Chemical Environment

The overall mission of dental units to provide dental services is
greatly affected in the aftermath of an NBC attack. First, the
unit must survive the attack and rapidly recover from its effects.
Secondly, in the event of mass casualties, the dental patient care
effort must be redirected from dental treatment to the alternate
wartime role of augmenting the adjacent MTF. Dental units do
not possess CPS; therefore, providing dental services in an NBC
environment will be limited to the treatment of maxillofacial
emergencies requiring immediate attention. This care will be
provided at an MTF with a CPS.


5-17. Dental Treatment Operations

As a general rule, in the aftermath of an NBC attack, dental
treatment operations cease until deliberate decontamination of the
unit and its equipment has been accomplished. Only maxillofacial
injuries of an immediate life-threatening nature should be
considered for treatment. After an attack, the resources of the
dental treatment facility (DTF) are redirected toward support
of any mass casualty situation that may have been generated at
an adjacent MTF, or toward decontamination and relocation to a
noncontaminated area.


5-18. Patient Treatment Considerations

The only category of dental treatment appropriate in an NBC
environment is emergency; and then, only those emergencies of an
extreme nature which demand immediate attention. The most likely
condition requiring such attention would be maxillofacial trauma
and would most likely be treated at an MTF rather than a DTF.
Although the likelihood of a requirement to treat dental patients
in an NBC environment is extremely low, DTFs must have a plan in
the event that such patients do present.

_a._ _Patient Decontamination._ Decontamination of patients, dental
patients included, is an absolute requirement before admission into
a clean MTF. Contaminated patients are triaged and decontaminated
before treatment (except for life- or limb-saving care). Both
triage and decontamination should be accomplished as far forward
as possible. Specific details on patient decontamination are
in Appendix G. It is important to note that normally patient
decontamination is not performed by medical or dental personnel.
Initial decontamination at the basic skill level is accomplished
at the casualty's unit. Detailed patient decontamination is
accomplished by the patient decontamination teams (made up of
nonmedical personnel from the supported units) that are supervised
by medical personnel at the MTF.

_b._ _Patient Decontamination at Dental Treatment Facilities._
Neither dental units nor their DTFs are equipped for patient
decontamination. Any contaminated patients arriving at a DTF
requiring urgent attention must be directed or evacuated to the
nearest MTF with a patient decontamination capability.


5-19. Patient Protection

Dental treatment facilities must also consider the need to protect
patients in their care in the event of an NBC attack, or when the
threat of an attack is high. Special consideration must be made for
maxillofacial patients whose condition prevents them from wearing
their protective mask.

_a._ _Immediate Response._ In the event of an attack or when the
alarm sounds, dental treatment providers immediately cease work and
mask. The patients should do likewise. Only after putting on their
own masks, do the dental treatment providers assist the patient,
if necessary, by removing materials that impede the patient's
masking. Only those materials that impede masking or may compromise
the airway (such as rubber dam frames or impressions) are removed,
the rest are left in place until the all clear is sounded.
Special attention must be given to patients who may have been
medicated into a less than fully conscious state, or are otherwise
incapacitated.

_b._ _Mission-Oriented Protective Posture Considerations._ The
MOPP level should be taken into account when determining the
category and extent of dental treatment to be provided. Patients,
including those seated in the dental chair, should be at the MOPP
level prescribed for the DTF by its parent headquarters. Dental
treatment at MOPP Levels 3 and 4 is, of course, impossible because
of the requirement to wear the protective mask; however, treatment
is still possible at MOPP Levels 0, 1, and 2. Treatment at MOPP
Level 2 should be limited only to emergency care requiring urgent
attention. At MOPP Level 1, most types of dental emergencies can
be accommodated; however, only minimal essential treatment should
be undertaken in order to reduce risk of the patient being caught
in a compromised state. At MOPP Level 0, the provision of dental
treatment generally is not limited. However, the degree of the
NBC threat forecast for the area should be considered before
undertaking extensive treatment.

_c._ _Maxillofacial Injuries._ Patients with maxillofacial injuries
that prevent proper fit and seal of the individual protective
mask must be placed in a PPW. Though patients with these types of
injuries are most likely to be found only in MTF channels, DTFs
should nevertheless be prepared in the event a patient presents
to the DTF. Since the DTF does not have any PPWs; these patients
should be immediately evacuated to the adjacent MTF for treatment.


Section V. COMBAT OPERATIONAL STRESS CONTROL


5-20. General

When operating under the threat of or under actual NBC conditions,
soldiers will be at a high risk of suffering combat operational
stress-related conditions. The invisible, pervasive nature of these
weapons creates a higher degree of uncertainty and ambiguity,
presenting fertile opportunities for false alarms, mass panic,
and other maladaptive stress reactions. Therefore, commanders and
leaders must take actions to prevent and reduce the numbers of
combat operational stress cases in this environment. The symptoms
and physical signs caused by excessive stress are similar to some
signs of true NBC agent injury. In World War I, inexperienced units
initially evacuated two stress cases for every one true chemical
casualty. Some minor chemical casualties also had major stress
symptoms. Therefore, far forward triage is essential to prevent
over evacuation and loss of the individual to the unit. For details
on provision of COSC see FM 8-51 and FM 22-51.


5-21. Leadership Actions

_a._ _Keep Personnel Informed of the Situation._ Keep information
flowing, dispel myths, and control rumors by--

    · Discussing the situation and its possible long-term
    implications honestly.

    · Maintaining the perspective that the best chance for mission
    accomplishment is assured when the unit and the Army stays
    mission focused.

_b._ _Train Soldiers to Survive._ Use training procedures that--

    · Tell the lessons of history on NBC weapons employment. Show
    that the enemy's use of NBC weapons/agents will not give him
    enough advantage to justify the risk to his forces.

    · Increase the chance of surviving and winning should the enemy
    use NBC weapons/agents.

    · Emphasize the buddy system as a means of keeping watch
    for each other. Personnel must always seek buddy aid before
    taking additional antidotes. This will reduce the numbers of
    individuals using their antidotes when not needed; and prevent
    the increased heat stress caused by the effects of atropine on
    the body's cooling capabilities.

_c._ _Put Nuclear, Biological, and Chemical Defense in Realistic
Perspective._ 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 MOPP.
    The decision to initiate a MOPP level should be like deciding
    how much cover is needed to protect a unit from conventional
    weapons.

    · Choosing the lowest MOPP level that protects the unit, yet
    permits accomplishment of the mission. Do not try to be 100
    percent safe from chemical attack if it means that there is--

    · Only a small chance of mission accomplishment.

    · A high probability of being killed by the enemy.

    · A high personnel loss due to heat injury.

_d._ _Train in the Protective Mask._ Train in the protective mask
often. It takes repeated wear and time to acclimate and get over
the claustrophobic feeling of wearing the mask. The training can be
conducted during a variety of activities.

    · Have personnel wear the mask often in garrison or during
    lulls in other activities, even at desk jobs. If on average,
    one person in five wears the mask, on a rotational basis, at
    any given time, everyone will quickly become accustomed to
    wearing it.

    · Periodic prolonged wear (8 hours or more) helps soldiers gain
    confidence and realize that they can tolerate the discomfort.

    · Have personnel wear the mask while performing combat-related
    (mission essential) tasks.

_e._ _Train in Mission-Oriented Protective Posture Level 4._
Training in MOPP Level 4 (or simulated MOPP 4, which is to
overdress while wearing the protective mask, overboots, and gloves)
will increase personnel confidence in their ability to wear the
ensemble.

_f._ _Ensure Sleep Plans are Safely Practiced._ Have everyone
practice wearing the mask while sleeping. Ensure personnel only
sleep in safe places; do not allow personnel to sleep under or near
vehicles or other motorized machinery. Require ground guides for
all vehicles in the unit bivouac area. Ensure that each individual
get at least 4 hours of uninterrupted sleep during every 24-hour
period, mission permitting (See FM 21-10).


5-22. Individual Responsibilities

_a._ _Follow Orders._ By following orders, individuals can
increase their ability to cope with and prevent combat operational
stress-related conditions. Coping with the stresses of an NBC
environment requires extra individual action. Concentrate on the
positive aspects of survival, not the negatives of illness or
death.

_b._ _Train._ Use every opportunity to wear the protective mask or
the entire MOPP ensemble during training, when permitted. You build
self-confidence and endurance by frequently training with your
protective mask, or at MOPP Level 4. Perform refresher training in
basic NBC survival skills.

_c._ _Use Buddy System._ Use the buddy system to increase your
ability to survive. Service members looking out for each other give
a sense of security that relieves stress. Looking out for each
other improves every individual's ability to perform his duties.


5-23. Mental Health Personnel Responsibilities

_a._ _Staffing for Combat Operational Stress Control._ Combat
operational stress control is provided by the following activities
or units:

    · Brigade mental health section.

    · Division mental health section.

    · Area support medical battalion mental health section.

    · Neuropsychiatric ward and consultation service of each CSH,
    field hospital, and general hospital.

    · Medical detachment, COSC.

    · Medical company, COSC.

_b._ _Conduct Preventive Activities._ In an NBC environment,
prevention is the most economical means of controlling combat
operational stress reactions. Mental health personnel must begin
consultation services before NBC weapons/agents have been employed.

_c._ _Control Stress Reactions._ Individuals with combat
operational stress reactions require prompt intervention. The
evaluation of over-stressed personnel is difficult but not
impossible when both the soldier and the evaluator are in MOPP.
The primary method of mental health evaluation is the interview
and mental status examination. For details on controlling stress
reactions, see FM 8-51.


Section VI. HEALTH SERVICE LOGISTICS


5-24. General

As in all combat situations, the protection of medical supplies
and equipment on the integrated battlefield is a must. Without
medical supplies and equipment, HSS will be greatly diminished.
Thus, the flow of supplies must continue to forward units as
they are requested, including during NBC operations. For detailed
information on providing health service logistics see FM 4-02.1 and
FM 8-10-9.


5-25. Protecting Supplies in Storage

Protecting supplies can be accomplished by placing them under
tents, using plastic wraps, or providing storage warehouses with
CB filtered-conditioned (heated or cooled) air systems. Wrapping
supplies in two layers of plastic material provides protection from
most agents for a short period of time; the thicker the plastic
material, the longer the protection. Effectiveness of protective
procedures can be checked by placing M9 tape on supplies and
between layers of the covering. Protection from the thermal and
blast effects of nuclear detonations requires much more elaborate
measures. Placing the supplies in trenches, inside earthen berms,
behind stonewalls, or in other field expedient facilities will
enhance the protective posture of supplies from the nuclear
effects. Even when taking these protective measures, a quantity
of supplies will become contaminated and must be replaced. Plans
should be in place for replacement of lost items.


5-26. Protecting Supplies During Shipment

During shipment, supplies are protected by placement inside
MILVANs, in covered enclosed vehicles, or by wrapping them in
several layers of plastic, in tarpaulins, or in other protective
material. To monitor exposure of supplies to chemical agents
during shipment, place M9 detector paper between the wrappings.
If exposure is limited to the outer layer, simple removal of this
layer may be all that is required to eliminate the contamination.
Decontamination is much easier when the supplies and equipment have
been protected by multilayers of over-wraps.


5-27. Organizational Maintenance

Maintenance on vehicles, equipment, and medical equipment will
become much more complex under NBC conditions. Most chemical agents
are soluble in organic solvents such as gasoline, motor oils, and
lubricants. The agent may be removed from the equipment by these
solvents, but exposure to the contaminated solvents will produce
the same effects as exposure to the agent on the equipment. The
agents may seep down around the threads of bolts, in cracks and
crevices of the equipment, and inside the cabinets or enclosures
of equipment. These potential contamination sources produce an
increased hazard to maintenance personnel. Decontamination of
some items, especially medical equipment, may be a problem for
maintenance personnel. The use of standard decontamination agents
will cause damage beyond repair to most medical equipment and
electronic equipment. In some instances, removal of chemical
agents will require aging (off-gassing) of the agent. Turning the
equipment on and running it, or just exposing the equipment to
warm air will speed the off-gassing process. Maintenance personnel
must perform all procedures in MOPP Level 4 until decontamination
is completed. Radiation will penetrate the metal structures of
vehicles and other equipment; radioactive material will be absorbed
into the lubricants and fuels. Decontamination of this type of
contamination is very difficult, if not impossible. Personnel
must use radiation detection equipment to determine the extent of
contamination and decontaminate the items as much as possible.
Dusting or washing with water can remove any fallout on the surface
of vehicles and nonelectrical/electronic components of equipment.
Removal of radioactivity absorbed into metals or mixed in
lubricants and fuels is beyond the capabilities of unit personnel.
See FM 3-5 for decontamination procedures.


Section VII. HOMELAND SECURITY RESPONSE


5-28. Chemical, Biological, Radiological, Nuclear, and High-Yield
Explosive Response

Although, homeland security is not a specific military mission,
commanders must plan for and be prepared to support a lead federal
agency (such as the Federal Bureau of Investigation or Federal
Emergency Management Agency) in response to CBRNE event. When the
CBRNE event occurs on a military installation, the Weapons of Mass
Destruction--Incident Support Team (WMD-IST) is the lead federal
agency in charge of responding and establishes an incident command
center (ICC). The installation medical authority (IMA) provides
the HSS initial response to the event site. Request for assistance
from deployable HSS organizations and staffs are initiated by
the IMA through military channels. The incident commander will
submit a request for HSS assistance to a CBRNE event off the
military installation through the appropriate federal channels. The
President will direct any DOD response in support of a lead federal
agency to a CBRNE event. The Presidential direction to assist
will be passed down through military channels to the appropriate
HSS organization for response. The HSS response may be in the
form of special medical augmentation teams (SMART) support from
US Army Medical Command resources or HSS (table of organization
and equipment [TOE]) units may be directed to respond. Normally,
responding TOE units will provide HSS to nonmedical military
responders. However, the HSS mission may be to provide support to
the lead federal agency or civilian public health organizations,
emergency medical services (ambulance crews), or hospitals. The HSS
response will include, 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 casualty.

    · Providing en route care for casualties from the incident site
    to an MTF or designated location for further care. Normally,
    TOE MEDEVAC assets are not used, but HSS personnel provide the
    en route care on locally provided transport vehicles.

    · Providing guidance to local responders in the management of
    CBRNE casualties. The guidance may be on the correct use of
    antidotes, chemoprophylaxis, prevention of contamination spread
    in the MTF, patient decontamination at the MTF, and other
    related medical management procedures.

    · Identifying suspect chemical, biological, or radiological
    materials used in the event.

    · Providing guidance on application of standard precautions
    for CBRNE, especially preventive measures to prevent spread of
    contagious agents.

    · Managing, triaging, and treating mass casualties.


5-29. Capabilities of Response Elements

For detailed Information on capabilities of SMARTs see FM 4-02 and
FM 8-42. For detailed information on capabilities and functions of
TOE HSS units see FM 4-02- and 8-series publications.




APPENDIX A

MEDICAL EFFECTS OF NUCLEAR, BIOLOGICAL, AND CHEMICAL WEAPONS AND
TOXIC INDUSTRIAL MATERIAL


A-1. General

Biological and chemical weapons/agents may be employed by
assassins, terrorists, rebels, and insurgents, as well as
well-formed battle organizations, across the continuum of
operations. In addition, nuclear weapons will remain a threat
on the future battlefield. Another weapon that may be used is
the RDD. 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 weapons. The RDD can
disperse radioactive material over an area of the battlefield;
the area covered is dependent upon the amount of radioactive and
explosive material used. In order to detonate a nuclear weapon, an
adversary must first obtain access to the appropriate weapons-grade
material. However, an RDD can be produced and used by anyone with
access to industrial or medical radioisotopes and explosives.
Biological agents are easy to disperse on the battlefield without
immediate detection; however, their effects on exposed troops can
change the course of the battle. Some nations consider chemical
weapons as a component of their munitions for the battlefield.
As more nations enter the arena of developing biological and
chemical weapons, their potential effects on our troops will
increase. The enemy's use of TIMs as weapons or collateral damage
to TIM storage faculties can severely affect the unit personnel's
ability to continue the mission. The signs and symptoms of some
TIM exposure can be the same as those presented from exposure to
NBC weapons. Considerations of both the physical and biological
effects of these weapons are required for HSS operations. Field
Manual 4-02.283 provides additional information on nuclear and
radiological effects; FM 8-284 provides additional information on
biological agent effects; FM 8-285 provides additional information
on CW effects; FM 8-500 provides detailed information on hazardous
material (TIM) effects.


A-2. Physical Effects of Nuclear Weapons

_a._ The principal physical effects of nuclear weapons are blast,
thermal radiation (heat), and nuclear radiation. These effects
are dependent upon the yield (or size) of the weapon expressed
in kilotons (KT), the physical design of the weapon (such as
conventional and enhanced), and the method of employment. The
distribution of energy (Figure A-1) from the detonation of a
moderate-sized (3 to 10 KT) weapon is as follows:

    (1) Fifty percent as blast.

    (2) Thirty-five percent as thermal radiation; made up of a wide
    spectrum of electromagnetic radiation, including infrared,
    visible, and ultraviolet light and some soft x-ray radiation.

    (3) Fourteen percent as nuclear radiation, 4 percent as initial
    ionizing radiation composed of neutrons and gamma rays emitted
    within the first minute after detonation, and 10 percent as
    residual nuclear radiation (fallout).

    (4) One percent as EMP.

_b._ Larger weapons are more destructive than smaller weapons,
but the destructive effect is not linear. Table A-1 presents a
comparison of three aspects of nuclear weapons effects with yield.

[Illustration: _Figure A-1. Distribution of energy._]

_c._ The altitude at which the weapon is detonated determines the
blast, thermal, and nuclear radiation effects. Nuclear blasts are
classified as air, surface, or subsurface bursts.

    (1) An airburst is a detonation in air at an altitude below
    30,000 meters, but high enough that the fireball does not touch
    the land or water surface. The altitude is varied to obtain
    the desired tactical effects. Initial radiation will be a
    significant hazard, but there is essentially no local fallout.
    However, the ground immediately below the airburst may have a
    small area of neutron-induced radioactivity. This may pose a
    hazard to troops passing through the area.

    (2) A surface burst is a detonation in which the fireball
    actually touches and vaporizes the land or water surface. In
    this case, the area affected by blast, thermal radiation, and
    initial nuclear radiation will be smaller than for an airburst
    of comparable yield. However, in the region around ground
    zero, the destruction will be much greater and a crater is
    often produced. Additionally, all the material that was within
    the fireball becomes fallout and will be a hazard downwind. A
    surface burst is the most likely type of terrorist detonation.

    (3) A subsurface burst is an explosion in which the detonation
    is below the surface of land or water. Cratering usually
    results. If the burst does not penetrate the surface, the
    only hazard is from the ground or water shock. If the burst
    penetrates the surface, blast, thermal, and initial nuclear
    radiation will be present, though less than for a surface burst
    of comparable yield. Local fallout will be heavy over a small
    area.

    (4) A high altitude burst occurs above 30,000 meters. Radiation
    and physical effects do not reach the ground and there is no
    local fallout. This is the only detonation where the effects
    of the EMP are significant. Nonhardened electronic equipment
    including many medical devices may become inoperative. The EMP
    damage is a moot point with other types of detonations, as its
    range is primarily limited to the area of intense physical
    destruction.


_Table A-1. Comparison of Weapons Effects (Radii of Effects
in Kilometers--Airburst)_

    ==============================================================
                             1 KT  20 KT 100 KT  1 MT  10 MT
    --------------------------------------------------------------
    NUCLEAR
    RADIATION                0.71    1.3    1.6   2.3    3.7
    (1,000 cGy)
    --------------------------------------------------------------
    BLAST (50% INCIDENCE
    OF TRANSLATION WITH
    SUBSEQUENT IMPACT        0.28    1.0    1.4   3.8   11.7
    WITH A NON-YIELDING
    SURFACE)
    --------------------------------------------------------------
    THERMAL (50% INCIDENCE
    OF 2ND-DEGREE BURNS TO   0.77    1.8    3.2   4.8   14.5
    BARE SKIN, 10 KM
    VISIBILITY)
    ==============================================================


A-3. Physiological Effects of Nuclear Weapons

The physiological effects of nuclear weapons are the result of
exposure to the blast; thermal radiation; ionizing radiation
(initial or residual) effects; or a combination of these. For
smaller weapons (less than 10 KT), ionizing radiation is the
primary creator of casualties requiring medical care, while for
larger weapons (greater than 10 KT), thermal radiation is the
primary creator of casualties.

_a._ The rapid compression and decompression of blast waves on the
human body results in transmission of pressure waves through the
tissues. Resulting damage is primarily at junctions between tissues
of different densities (bone and muscle), or at the interface
between tissue and airspace. Lung tissue and the gastrointestinal
system (both contain air) are particularly susceptible to injury.
The tissue disruptions can lead to severe hemorrhage or to an air
embolism; either can be rapidly fatal. 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 effects. A typical
range of probability of lethality, with variations in overpressure
for a 1 KT weapon, is shown in Table A-2.


_Table A-2. Range of Lethality of Peak Overpressure_

    ==============================================================
       LETHALITY        PEAK OVERPRESSURE        DISTANCE FROM
    (APPROXIMATE %)       (ATMOSPHERES)       GROUND ZERO; METERS
    --------------------------------------------------------------
           1                 2.3-2.9                  150
          50                 2.9-4.1                  123
         100                   4.1+                   110
    ==============================================================


    (1) The significance of the data is that the human body is
    relatively resistant to static overpressure compared to rigid
    structures such as buildings. For example, an unreinforced
    cinder block panel will shatter at 0.1 to 0.2 atmospheres.

    (2) Overpressure lower than those in Table A-2 can cause
    nonlethal injuries such as lung damage and eardrum rupture.
    Lung damage is a relatively serious injury, usually requiring
    hospitalization, even if not fatal; whereas eardrum rupture is
    a minor injury, often requiring no treatment at all.


      (_a_) The threshold level of overpressure for an unreinforced
      unreflected blast wave that can cause lung-damage is about 1.0
      atmosphere.

      (_b_) The threshold level for eardrum rupture is around 0.2
      atmospheres; the overpressure associated with a 50 percent
      probability of eardrum rupture is about 1.1 atmospheres.

    (3) Casualties requiring medical treatment from direct blast
    effects are produced by overpressure between 1.0 and 3.5
    atmospheres. However, other effects (such as indirect blast
    injuries and thermal injuries) are so predominate that patients
    with only direct blast injuries make up a small part of the
    patient workload.

_b._ The drag forces (indirect blast) of the blast winds are
proportional to the velocities and duration of the winds. The
winds are relatively short in duration, but can reach velocities
of several hundred km per hour. Injury can result from missiles
impacting on the body or from the physical displacement of the body
against objects and structures.

    (1) The distance from the point of detonation at which severe
    indirect injury occurs is greater than that for equally serious
    direct blast injuries. A high probability of serious indirect
    injury can occur when the peak overpressure is about 0.2
    atmospheres. This range will increase with the increased size
    of the weapon; for a 1 KT weapon, the range is 0.22 km, whereas
    for a 20 KT weapon, the range is 0.76 km. At greater ranges
    injuries will occur and casualties will be generated, but not
    consistently.

    (2) 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 missiles. Thus,
    multiple, varied missile injuries will be common, increasing
    their overall severity and significance. Table A-3 lists ranges
    at which significant missile injuries can be expected.


_Table A-3. Ranges for Probabilities of Serious Injury from Small
Missiles_

    =================================================================
                              RANGES (km)
    -----------------------------------------------------------------
    YIELD  1% PROBABILITY OF  50% PROBABILITY OF   99% PROBABILITY OF
    (KT)    SERIOUS INJURY      SERIOUS INJURY       SERIOUS INJURY
    -----------------------------------------------------------------
        1        0.28                0.22                 0.17
       10        0.73                0.57                 0.44
       20        0.98                0.76                 0.58
       50        1.4                 1.1                  0.84
      100        1.9                 1.5                  1.1
      200        2.5                 1.9                  1.5
      500        3.6                 2.7                  2.1
    1,000        4.8                 3.6                  2.7
    -----------------------------------------------------------------
    1  INCIDENCE OF INJURY BASED ON SKIN AND TISSUE PERFORATION.
    2  MISSILES USED WERE 10 GRAM (gm) IN WEIGHT.
    =================================================================

    (3) The velocity to which missiles are accelerated is the major
    factor in causing injury. The probability of a penetration
    injury increases with increasing velocity, particularly for
    small, sharp missiles such as glass fragments. Small, light
    objects are accelerated to speeds approaching the maximum
    (wind) velocity. Table A-4 shows data for probability of
    penetration related to size and velocity of glass fragments.


_Table A-4. Probability of Glass Fragments Penetrating the
Abdominal Cavity_

    =======================================================
     MASS OF GLASS       1%           50%           99%
     FRAGMENTS (gm)    IMPACT VELOCITY (METERS PER SECOND)
    -------------------------------------------------------
          0.1           78            136           243
          0.6           53             91           161
          1.0           46             82           143
         10.0           38             60           118
    =======================================================

    (4) Heavy, blunt missiles may not penetrate, but can result
    in significant injury, particularly fractures. The threshold
    velocity for skull fractures from a 4.5 milligram (mg) missile
    is about 4.6 meters per second (m/sec).

    (5) The drag forces of the blast winds are strong enough to
    displace large objects (such as vehicles), or cause large
    structures to collapse (such as buildings) resulting in serious
    crushing injuries. Man himself can become a missile resulting
    in injuries (called translational injuries). The velocity at
    which the body is displaced will determine the probability and
    the severity of injury. Assuming a displacement of 3.0 meters,
    the impact velocity associated with various degrees of injury
    is shown in Table A-5. The velocities in Table A-5 can be
    correlated against yield. The ranges at which such velocities
    can occur and the probability of injury are given in Table A-6.


_Table A-5. Translational Injuries_

    ================================================
     A. BLUNT INJURIES AND FRACTURES
        PROBABILITY OF INJURY      VELOCITY (m/sec)
    ------------------------------------------------
                1%                     2.6
               50%                     6.6
               99%                    16.5
    ------------------------------------------------
     B. FATAL INJURIES
        PROBABILITY OF FATALITY    VELOCITY (m/sec)
    ------------------------------------------------
                1%                     6.6
               50%                    17.0
               99%                    39.7
    ================================================


_Table A-6. Ranges for Selected Impact Velocities of a 70-Kilogram
Human Body Displaced by Blast Wind Drag Forces for Different Yield
Weapons_

    ==============================================
       WEAPON YIELD       VELOCITIES (m/sec)
           (KT)        2.6        6.6       17.0
    ----------------------------------------------
                              RANGES (km)
    ----------------------------------------------
             1        0.38        0.27       0.19
            10        1.0         0.75       0.53
            20        1.3         0.99       0.71
            50        1.9         1.4        1.0
           100        2.5         1.9        1.4
           200        3.2         2.5        1.9
           500        4.6         3.6        2.7
         1,000        5.9         4.8        3.6
    ===============================================


A-4. 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 (flash burns); or by the indirect action of fires
in the environment (flame burns). Indirect flame burns can easily
outnumber all other types of injury.

_a._ Thermal radiation travels outward from the fireball in a
straight line; therefore, the amount of energy available to
cause flash burns decreases rapidly with distance. Close to the
fireball all objects will be incinerated. The range for 100
percent lethality will vary with yield, height of burst, weather,
environment, and immediacy of treatment. The critical factors
determining the degree of burn injury are the flux (calories per
square centimeter/second [cal/cm^2/sec]) and the duration of the
thermal pulse. 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 (Table A-7).
Most burn patients will come from the zones where partial thickness
burns occur. In areas where radiation, blast, and thermal intensity
are highest, burn victims surviving long enough to reach medical
care will be rare.

    NOTE

    The battle dress uniform (BDU), MOPP gear, or any other
    clothing will provide additional protection against flash
    burns. The airspace between the clothing significantly impedes
    heat transfer and may prevent or reduce the severity of burns,
    depending on the magnitude of the thermal flux.


_Table A-7. Factors for Determining the Probability of Partial
Thickness Burns_

    ==================================================================
    YIELD OF WEAPON              1 KT   10 KT  100 KT   1 MT    10 MT
    ------------------------------------------------------------------
    RANGE (km) FOR PRODUCTION
    OF PARTIAL THICKNESS BURNS   0.78    2.1     4.8     9.1     14.5
    ON EXPOSED SKIN
    ------------------------------------------------------------------
    DURATION OF THERMAL
    PULSE IN SECONDS             0.12    0.32    0.9     2.4      6.4
    ------------------------------------------------------------------
    Cal/cm^2/sec REQUIRED TO
    PRODUCE PARTIAL THICKNESS    4.0     4.5     5.3     6.3      7.0
    BURNS ON EXPOSED SKIN
    ==================================================================

_b._ Indirect (flame) burns result from exposure to fires caused by
the thermal effects in the environment, particularly from ignition
of clothing. The larger-yield weapons are more likely to cause
firestorms over extensive areas. There are too many variables
in the environment to predict either incidence or severity of
casualties. Expect the burns to be far less uniform (in degree)
and not limited to exposed surfaces. For example, the respiratory
system may be exposed to the effects of hot gases produced by
extensive fires. Respiratory system burns cause high morbidity and
high mortality rates.

_c._ The initial pulse of radiation in the optical and thermal
bands can cause injuries in the forms of flash blindness and
retinal scarring. The initial brilliant flash of light produced
by the nuclear detonation causes flash blindness. This flash
swamps the retina, bleaching out the visual pigments and producing
temporary blindness. During daylight hours, this temporary effect
may last for about 2 minutes. At night, with the pupil dilated for
dark adaptation, flash blindness will affect personnel at greater
ranges and for greater durations. Partial recovery can be expected
in 3 to 10 minutes, though it may require 15 to 35 minutes for
full night adaptation recovery. Retinal scarring is the permanent
damage from a retinal burn. It will occur only when the fireball
is actually in the individual's field of view and should be a
relatively uncommon injury. The location of the scar will determine
the degree of interference with vision. Because night vision
apparatus electronically amplifies an image, it cannot transmit the
flash intensity and will not cause eye injury.


A-5. Physiological Effects of Ionizing Radiation

A nuclear burst results in four types of ionizing radiation:
neutrons, gamma rays, beta, and alpha radiation. The initial burst
is characterized by neutrons and gamma rays while the residual
radiation is primarily alpha, beta, and gamma rays. The effect
of radiation on a living organism varies greatly by the type of
radiation to which the organism is exposed. See Table A-8 for
characteristics of nuclear radiation.

_a._ Alpha particles are extremely massive, charged particles (four
times the mass of a neutron); they are a fallout hazard. Because of
their size, alpha particles cannot travel far and are fully stopped
by the dead layers of the skin or by the uniform. Alpha particles
are a negligible external hazard, but if inhaled or ingested, can
cause significant internal damage.

[Illustration: _Figure A-2. Threshold distance for minimal
chorioretinal burn and flash blindness versus yield (airburst) at
night._]


_Table A-8. Characteristics of Nuclear Radiation_

     [Part 1]
  +----------+-----------------+------------------+-------------------+
  | NAME AND |   WHAT IS IT    |      SOURCE      |     ENERGY AND    |
  |  SYMBOL  |                 |                  |       SPEED       |
  +----------+-----------------+------------------+-------------------+
  |          |                 |                  | ENERGY VARIES:    |
  |    α     | HELIUM          | DECAY OF URANIUM | SPEED VARIES      |
  |   ALPHA  | NUCLEUS         | AND PLUTONIUM    | FROM 1/20 TO 1/10 |
  | PARTICLE |                 |                  | SPEED OF LIGHT    |
  |          |                 |                  |                   |
  +----------+-----------------+------------------+-------------------+
  |    β     | HIGH-SPEED      | DECAY OF FISSION |                   |
  |   BETA   | SPEED           | PRODUCTS AND     | VARIES            |
  | PARTICLE | ELECTRON        | NEUTRON INDUCED  |                   |
  |          |                 | ELEMENTS         |                   |
  +----------+-----------------+------------------+-------------------+
  |    γ     | ELECTROMAGNETIC | DECAY OF FISSION | ENERGY VARIES:    |
  |  GAMMA   | ENERGY          | PRODUCTS AND     | TRAVELS AT THE    |
  |   RAY    |                 | NEUTRON INDUCED  | SPEED OF LIGHT    |
  |          |                 | ELEMENTS         |                   |
  |          |                 |                  |                   |
  +----------+-----------------+------------------+-------------------+
  |          | UNCHARGED       | FISSION AND      |                   |
  |    η     | PARTICLE        | FUSION REACTIONS | VARIES            |
  | NEUTRON  |                 |                  |                   |
  |          |                 |                  |                   |
  |          |                 |                  |                   |
  +----------+-----------------+------------------+-------------------+

     [Part 2]
  +----------+------------+--------------+---------------+-------------+
  | NAME AND | RANGE IN   |   RANGE IN   |    SHIELDING  |  BIOLOGICAL |
  |  SYMBOL  |    AIR     |    TISSUE    |    REQUIRED   |    HAZARD   |
  +----------+------------+--------------+---------------+-------------+
  |          |            |              |               | NONE, UNLESS|
  |    α     |  ~ 5 cm    | CANNOT       | NONE          | INGESTED OR |
  |   ALPHA  |            | PENETRATE    |               | INHALED IN  |
  | PARTICLE |            | THE EPIDERMIS|               | SUFFICIENT  |
  |          |            |              |               | QUANTITIES  |
  +----------+------------+--------------+---------------+-------------+
  |    β     |            | SEVERAL      | STOPPED BY    |             |
  |   BETA   | 5 METERS   | LAYERS       | A FEW cm OF Al| SUPERFICIAL |
  | PARTICLE |            | OF SKIN      | OR MODERATE   | SKIN INJURY |
  |          |            |              | CLOTHING      |             |
  +----------+------------+--------------+---------------+-------------+
  |    γ     | UP TO 500  | VERY         | DENSE         | WHOLE BODY  |
  |  GAMMA   | METERS, BUT| PENETRATING, | MATERIAL, SUCH| INJURY, MANY|
  |   RAY    | IS ENERGY  | BUT IS ENERGY| AS CONCRETE,  | CASUALTIES  |
  |          | DEPENDENT  | DEPENDENT    | STEEL PLATE,  | POSSIBLE    |
  |          |            |              | EARTH         |             |
  +----------+------------+--------------+---------------+-------------+
  |          | LESS THAN  | VERY         | HYDROGENOUS   | WHOLE BODY  |
  |    η     | GAMMA, BUT | PENETRATING, | MATERIALS,    | INJURY, MANY|
  | NEUTRON  | IS ENERGY  | BUT IS ENERGY| SUCH AS       | CASUALTIES  |
  |          | DEPENDENT  | DEPENDENT    | WATER OR      | POSSIBLE    |
  |          |            |              | DAMP EARTH    |             |
  +----------+------------+--------------+---------------+-------------+

_b._ Beta particles are very light, charged particles that are
found primarily in fallout radiation. These particles can travel a
short distance in tissue; if large quantities are involved, they
can produce damage to the basal stratum of the skin. The lesion
produced is similar to a thermal burn (called a beta burn).

_c._ Gamma rays, emitted during the nuclear detonation and in
fallout, are uncharged radiation similar to X rays. They are highly
energetic and pass through matter easily. Because of its high
penetrability, radiation can be distributed throughout the body,
resulting in whole body exposure.

_d._ Neutrons, like gamma rays, are uncharged, are only emitted
during the nuclear detonation, and are not a fallout hazard.
However, neutrons have significant mass and interact with the
nuclei of atoms, severely disrupting atomic structures. Compared to
gamma rays, they can cause 20 times more damage to tissue.

_e._ When radiation interacts with atoms, energy is deposited
resulting in ionization (electron excitation). This ionization
may involve certain critical molecules or structures in a cell,
producing its characteristic damage. Two modes of action in the
cell are direct and indirect action. The radiation may directly
hit a particularly sensitive atom or molecule in the cell. The
damage from this is irreparable; the cell either dies or is caused
to malfunction. The radiation can also damage a cell indirectly by
interacting with water molecules in the body. The energy deposited
in the water leads to the creation of toxic molecules; the damage
is transferred to and affects sensitive molecules through this
toxicity.

_f._ The most radiosensitive organ systems in the body are the
male reproductive, the hematopoietic, and the gastrointestinal
systems. The relative sensitivity of an organ to direct radiation
injury depends upon its component tissue sensitivities. Cellular
effects of radiation, whether due to direct or indirect damage,
are basically the same for the different kinds and doses of
radiation. The simplest effect is cell death. With this effect,
the cell is no longer present to reproduce and perform its primary
function. Changes in cellular function can occur at lower radiation
doses than those that cause cell death. Changes can include
delays in phases of the mitotic cycle, disrupted cell growth,
permeability changes, and changes in motility. In general, actively
dividing cells are most sensitive to radiation. Additionally,
radiosensitivity tends to vary inversely with the degree of
differentiation of the cell.

_g._ Predicting radiation effects is difficult because often it
is unknown which organs were exposed. Thus, most predictions
are based on whole body irradiation. Partial body and specific
organ irradiation will occur due to shielding by equipment, from
fallout particles, or from internal deposition. Depending upon the
organ system, the irradiation can be severe. The severe radiation
sickness resulting from external, whole body irradiation and
its consequent organ effects is a primary medical concern. The
median lethal dose (LD) of radiation that will kill 50 percent
of the exposed persons within a period of 60 days (designated
as LD50/60) is estimated to be approximately 4.5 gray (Gy) if
appropriate medical care is not provided to the casualties.
Medical intervention should raise this figure to approximately 10
Gy. This larger figure includes most of the casualties who would
be actually capable of reaching medical care following a nuclear
detonation, and nearly all those who could be exposed to a RDD.
For acute effects of single high dose rate exposures of whole-body
irradiation to healthy adults see Table A-9.

_h._ 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
received. Complete recovery may appear to occur; however, the
immune system may repair incompletely with consequent greater
susceptibility to future insult from a variety of agents. It is
possible for late somatic effects to have a higher probability of
occurring because of the radiation damage. Efficacy of both prior
and future immunization in this group is not adequately understood.

_i._ Interactions between radiological injury and chemical or
biological agents appear to be synergistic. Insult by these
agents in radiologically injured personnel, even in individually
subclinical dosages, may result in significant clinical illness.


A-6. Handling and Managing Radiologically Contaminated Patients

_a._ _Radiologically Contaminated Patients._ Personnel from
contaminated areas may have fallout on their skin and clothing.
Although the individual will not be radioactive, he may
suffer radiation injury from the contamination. Removal of
the contamination should be accomplished as soon as possible;
definitely before admission into a clean treatment area. The
distinction must be made between a radiation-injured soldier and
one who is radiologically contaminated. Although personnel may
have received substantial radiation exposure, this exposure alone
does not result in the individual being contaminated. Contaminated
personnel do not pose a short-term hazard to the medical staff,
rather the contamination is a hazard to the individuals' health.
However, without patient decontamination, medical personnel may
receive sufficient exposure to create beta burns, especially with
extended exposure.

_b._ _Handling Radiologically Contaminated Patients._ To properly
handle radiologically contaminated personnel, medical personnel
must first detect the contamination. Detectors that may be used are
the AN/PDR27 and AN/VDR2 to monitor patients for contamination.
Generally, a reading on the meter twice the current background
reading indicates that the patient is contaminated. Monitoring
is conducted when potentially contaminated personnel arrive at
the MTF. This monitoring is conducted at the MTF's receiving
point before admitting the patient. Contaminated patients must
be decontaminated before admission. Removal of radiological
contamination is less important than immediate lifesaving treatment
and providing the best possible medical care. Lifesaving care
before decontamination is provided outside the MTF.

_c._ _Decontamination._ Removing all outer clothing and a brief
washing or brushing of exposed skin will reduce 95 percent of
contamination; vigorous bathing or showering is unnecessary. See
Appendix G for patient decontamination procedures.

_d._ _Internal Contamination._ Internalization of radioactive
isotopes will primarily occur via inhalation, ingestion, and
contaminated wounds. Extensive internal decontamination should
only be undertaken when individual dose estimates indicate that
the individual will benefit from the procedures. Soldiers who
wear their protective mask will be adequately protected from
inhalation and ingestion of radioactive particulate matter.
Internal contamination is considered a delayed problem and does not
influence triage categories, as does irradiation injury.

_e._ _Treatment._ Treatment procedures for radiation injuries are
described in FM 4-02.283, FM 8-9, and the NATO Handbook, _Emergency
War Surgery_. Appropriate medical intervention and bone marrow
resuscitation will prevent most deaths secondary to irradiation and
infection.


_Table A-9. Acute Clinical Effects of Single High Dose Rate
Exposures of Whole-body Irradiation of Healthy Adults_

     [Part 1]
  -----------------------++-----------+------------+
                         || 0-100 cGy |100-1000 cGy|
      DOSE (RANGE)       || (SUB-     | (SUBLETHAL |
                         || CLINICAL  |  RANGE)    |
                         || RANGE)    |------------+
                         ||           |100-200 cGy |
  ----------+------------++-----------+------------+
            |INCIDENCE   ||           |            |
            |OF NAUSEA   ||    NONE   |   5-50%    |
            |& VOMITING  ||           |            |
            +------------++-----------+------------+
            |TIME OF     ||    ----   |  APPROX    |
  INITIAL   |ONSET       ||           |  3-6 HRS   |
  PHASE     +------------++-----------+------------+
            |DURATION    ||    ----   | LESS THAN  |
            |            ||           |   24 HRS   |
            +------------++-----------+------------+
            |            ||           |            |
            |COMBAT      ||           |            |
            |EFFECT-     ||    100%   |   100%     |
            | IVENESS    ||           |            |
            |            ||           |            |
  ----------+------------++-----------+------------+
  LATENT    |DURATION    ||    ----   | MORE THAN  |
  PHASE     |            ||           |  2 WEEKS   |
  ----------+------------++-----------+------------+
            |SIGNS &     ||           | MODERATE   |
            |SYMPTOMS    ||    NONE   |LEUKOPENIA  |
            +------------++-----------+------------+
            |TIME OF     ||           |            |
            |ONSET POST  ||    ----   |2 WEEKS OR  |
  SECONDARY |EXPOSURE    ||           |   MORE     |
  PHASE     +------------++-----------+------------+
            |CRITICAL    ||           |            |
            |PERIOD POST ||    ----   |    NONE    |
            |EXPOSURE    ||           |            |
            +------------++-----------+------------+
            |ORGAN       ||           |            |
            |SYSTEM      ||    NONE   |            |
            |RESPONSIBLE ||           |            |
  ----------+------------++-----------+------------+
  HOSPITAL- |PERCENTAGE  ||    NONE   |LESS THAN 5%|
   IZATION  +------------++-----------+------------+
            |DURATION    ||    ----   | 45-60 DAYS |
  ----------+------------++------------------------+
  INCIDENCE OF DEATH     ||    NONE   |    NONE    |
  -----------------------++-----------+------------+
  AVERAGE TIME OF DEATH  ||    ----   |   ----     |
  -----------------------++-----------+------------+
                         ||           | REASSURANCE|
  THERAPY                ||    NONE   | HEMATOLOGIC|
                         ||           |SURVEILLANCE|
  -----------------------++-----------+------------+

     [Part 2]
  -----------------------++--------------------+--------------------------+
                         ||      100-1000 cGy (SUBLETHAL RANGE)           |
      DOSE (RANGE)       ||                                               |
                         ||--------------------+--------------------------+
                         ||    200-600 cGy     |       600-1000 cGy       |
  ----------+------------++--------------------+--------------------------+
            |INCIDENCE   ||                    |                          |
            |OF NAUSEA   ||      50-100%       |         75-100%          |
            |& VOMITING  ||                    |                          |
            +------------++--------------------+--------------------------+
            |TIME OF     ||   APPROX 2-4 HRS   |      APPROX 1-2 HRS      |
  INITIAL   |ONSET       ||                    |                          |
  PHASE     +------------++--------------------+--------------------------+
            |DURATION    ||  LESS THAN 24 HRS  |     LESS THAN 48 HRS     |
            |            ||                    |                          |
            +------------++--------------------+--------------------------+
            |            ||CAN PERFORM ROUTINE |CAN PERFORM ONLY SIMPLE   |
            |COMBAT      ||TASKS. SUSTAINED    |ROUTINE TASKS. SIGNIFICANT|
            |EFFECT-     ||COMBAT OR COMPARABL |INCAPACITATION IN UPPER   |
            | IVENESS    ||ACTIVITIES HAMPERED |PART OF RANGE. LASTS MORE |
            |            ||FOR 6-20 HRS.       |THAN 24 HRS.              |
  ----------+------------++--------------------+--------------------------+
  LATENT    |DURATION    ||  APPROX 7-15 DAYS  |  NONE TO APPROX 7 DAYS   |
  PHASE     |            ||                    |                          |
  ----------+------------++--------------------+--------------------------+
            |SIGNS &     ||  SEVERE LEUKOPENIA; PURPURA, HEMORRHAGE;      |
            |SYMPTOMS    ||  INFECTION; EPILATION ABOUT 300 cGy.          |
            +------------++--------------------+--------------------------+
            |TIME OF     ||                                               |
            |ONSET POST  ||            SEVERAL DAYS TO 2 WEEKS            |
  SECONDARY |EXPOSURE    ||                                               |
  PHASE     +------------++-----------------------------------------------+
            |CRITICAL    ||                                               |
            |PERIOD POST ||                   4-6 WEEKS                   |
            |EXPOSURE    ||                                               |
            +------------++-----------------------------------------------+
            |ORGAN       ||                                               |
            |SYSTEM      ||                HEMATOPOIETIC TISSUE           |
            |RESPONSIBLE ||                                               |
  ----------+------------++--------------------+--------------------------+
  HOSPITAL- |PERCENTAGE  ||          90%       |           100%           |
   IZATION  +------------++--------------------+--------------------------+
            |DURATION    ||       60-90 DAYS   |       90-120 DAYS        |
  ----------+------------++--------------------+--------------------------+
  INCIDENCE OF DEATH     ||          0-80%     |         90-100%          |
  -----------------------++--------------------+--------------------------+
  AVERAGE TIME OF DEATH  ||            3 WEEKS TO 2 MONTHS                |
  -----------------------++-----------------------------------------------+
                         ||                                               |
  THERAPY                ||          BLOOD TRANSFUSION, ANTIBIOTICS       |
                         ||                                               |
  -----------------------++-----------------------------------------------+

     [Part 3]
  -----------------------++------------------------+----------------------+
                         ||         OVER 1000 cGy (LETHAL RANGE)          |
      DOSE (RANGE)       ||                                               |
                         ||------------------------+----------------------+
                         ||      1000-3000 cGy     |    OVER 3000 cGy     |
  ----------+------------++------------------------+----------------------+
            |INCIDENCE   ||                                               |
            |OF NAUSEA   ||                      100%                     |
            |& VOMITING  ||                                               |
            +------------++-----------------------------------------------+
            |TIME OF     ||                 LESS THAN 1 HR                |
  INITIAL   |ONSET       ||                                               |
  PHASE     +------------++------------------------+----------------------+
            |DURATION    ||    LESS THAN 48 HRS    |    APPROX 48 HRS     |
            |            ||                        |                      |
            +------------++-----------------------------------------------+
            |            ||PROGRESSIVE INCAPACI-   |PROGRESSIVE INCAPACI- |
            |COMBAT      ||TATION FOLLOWING AN     |TATION FOLLOWING AN   |
            |EFFECT-     ||EARLY CAPABILITY FOR    |EARLY CAPABILITY FOR  |
            | IVENESS    ||INTERMITTENT HEROIC     |INTERMITTENT HEROIC   |
            |            ||RESPONSE.               |RESPONSE.             |
  ----------+------------++------------------------+----------------------+
  LATENT    |DURATION    ||  NONE TO APPROX 2 DAYS |         NONE         |
  PHASE     |            ||                        |                      |
  ----------+------------++------------------------+----------------------+
            |SIGNS &     ||DIARRHEA; FEVER; DISTUR-|CONVULSIONS; TREMOR   |
            |SYMPTOMS    ||BANCE OF ELECTROLYTE    |ATAXIA; LETHARGY.     |
            |            ||BALANCE.                |                      |
            +------------++------------------------+----------------------+
            |TIME OF     ||                        |                      |
            |ONSET POST  ||        2-3 DAYS        |                      |
  SECONDARY |EXPOSURE    ||                        |                      |
  PHASE     +------------++------------------------+----------------------+
            |CRITICAL    ||                        |                      |
            |PERIOD POST ||       5-14 DAYS        |          1-48 HR     |
            |EXPOSURE    ||                        |                      |
            +------------++------------------------+----------------------+
            |ORGAN       ||                        |                      |
            |SYSTEM      || GASTROINTESTINAL TRACT |CENTRAL NERVOUS SYSTEM|
            |RESPONSIBLE ||                        |                      |
  ----------+------------++------------------------+----------------------+
  HOSPITAL- |PERCENTAGE  ||          100%          |          100%        |
   IZATION  +------------++------------------------+----------------------+
            |DURATION    ||        2 WEEKS         |         2 DAYS       |
  ----------+------------++------------------------+----------------------+
  INCIDENCE OF DEATH     ||                     90-100%                   |
  -----------------------++------------------------+----------------------+
  AVERAGE TIME OF DEATH  ||       1-2 WEEKS        |         2 DAYS       |
  -----------------------++------------------------+----------------------+
                         ||    MAINTENANCE OF      |                      |
  THERAPY                ||   ELECTROLYTE BALANCE  |       SEDATIVES      |
                         ||                        |                      |
  -----------------------++------------------------+----------------------+


A-7. Radiological Patients in Stability Operations and Support
Operations

In stability operations and support operations, 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 status.
Treatment and evacuation guidelines will be in accordance with
command guidance. Individual physical dosimetry is the most
expedient measurement technique for this exposure (see Table A-10).
These radiation injuries and effects may also be seen in war;
especially, from hostile forces employment of RDDs.


_Table A-10. Stability Operations and Support Operations: 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
  ------------------------------------------------------------------------
  0      <0.05 cGy   NORMAL RISK.   US BASELINE 20%   RECORD IN EXPOSURE
                                    LIFETIME RISK OF  RECORD IF NORMALLY
                                    FATAL CANCER.     MONITORED PERSONNEL.
  ------------------------------------------------------------------------
  1A  0.05 TO        UP TO 0.04%    NONE (0.001 Sv US RECORD AS HISTORY IN
           0.5 cGy   INCREASED      ANNUAL GEN. POP.  MEDICAL RECORD--
                     RISK LIFETIME  EXPOSURE LIMIT.)  TACTICAL OPERATION
                     FATAL CANCER.                    EXPOSURE.
  ------------------------------------------------------------------------
  1B  0.5 TO 5 cGy   US RADIATION   REASSURANCE       RECORD IN MEDICAL
                     OCCUPATIONAL   (0.05 Sv US       RECORD--
                     RISK.          ANNUAL            TACTICAL OPERATION
                     0.04%-0.4%     OCCUPATIONAL      EXPOSURE.
                     INCREASED RISK  LIMIT.)
                     LIFETIME CANCER.
  ------------------------------------------------------------------------
  1C   5 TO 10 cGy   0.4%-0.8%      COUNSEL REGARDING  RECORD IN MEDICAL
                     INCREASED RISK  INCREASED LONG-   RECORD--
                     LIFETIME FATAL  TERM RISK.        TACTICAL OPERATION
                     CANCER.         NO LIVE VIRUS     EXPOSURE.
                                     VACCINES X
                                     3 MONTHS.
  ------------------------------------------------------------------------
  1D  10 TO 25 cGy   0.8%-2%        POTENTIAL FOR INC-  RECORD IN MEDICAL
                     INCREASED RISK  REASED MORBIDITY   RECORD--
                     LIFETIME FATAL  OF OTHER INJURIES  TACTICAL OPERATION
                     CANCER.         OR INCIDENTAL      EXPOSURE. CONSIDER
                                     DISEASE.  <2%      ROUTINE EVACUATION
                                     INCREASED LIFETIME  FROM THEATER IAW
                                     RISK OF FATAL      COMMANDER'S OPER-
                                     CANCER.            ATIONAL GUIDANCE.
  ------------------------------------------------------------------------
  1E  25 TO 75 cGy   2%-5.6%       INCREASED MORBIDITY  RECORD IN MEDICAL
                     INCREASED RISK  OF OTHER INJURIES  RECORD--
                     LIFETIME FATAL  OR INCIDENTAL      TACTICAL OPERATION
                     CANCER.         DISEASE.  <6%      EXPOSURE. CONSIDER
                                     INCREASED LIFETIME  EXPEDITED EVACU-
                                     RISK OF FATAL      ATION FROM THEATER
                                     CANCER.            IAW COMMANDER'S
                                                        OPERATIONAL
                                                        GUIDANCE.
  ========================================================================


A-8. Effects of Biological Weapons

Biological warfare is the intentional use, by an enemy, of live
agents or toxins to cause death and disease among personnel,
animals, and plants, or to deteriorate materiel.

_a._ _Live Agents._

    (1) Live agents are living organisms like viruses, bacteria,
    and fungi. They can be delivered directly (artillery or
    aircraft spray), or through a vector such as a flea or tick.
    Advances in modern weaponizing of biological agents have become
    easier.

    (2) For some agents, only a few organisms are needed to cause
    infection. Live agents are small and light; they can be spread
    great distances by the wind and contaminate unfiltered or
    nonairtight places.

    (3) Aerosolized particles of 1 to 5 micron (μ) size carrying
    live agents are small and light. They require time after
    they are ingested to multiply enough to overcome the body's
    defenses. This incubation period may vary from hours to days or
    weeks depending on the type of organism. Thus, to be effective,
    a live agent attack would need to be launched well in advance
    of a tactical assault.

    (4) These agents are sensitive to environmental conditions (for
    example humidity and sunlight). Many bacterial agents will not
    survive outside the host organism (human and animals).

    (5) Live agents are not detectable by any of the five physical
    senses; usually the first indication of a biological attack
    is the ill personnel. The diseases caused by live agents may
    be difficult to control when the aerosol attack is directed
    against a large population. Some diseases may be transmitted
    from person-to-person after the initial attack; examples
    include plague, smallpox, and some viral hemorrhagic fevers.

    (6) Because of their incubation period and life cycle, likely
    areas for live agent use are in the combat service support
    (CSS) area; but attacks in forward areas cannot be ruled out.

_b._ _Spore Forming Biological Agents._ Spore formers such as
anthrax can survive for an extended time, even under very adverse
environmental conditions (dry, extremes of temperatures, and
flooding). Once inhaled, ingested, or injected into the human body,
the spores germinate and produce the illness.

_c._ _Toxins._

    (1) Toxins are by-products (poisons) produced by plants,
    animals, or microorganisms. It is the poisons that harm man,
    not the organisms that make the toxins. In the past, the
    only way to deliver toxins on a large scale was by using the
    organism. With today's technology large quantities of many
    toxins can be produced; thus, they can be delivered without the
    accompanying organism.

    (2) Toxins have several desirable traits. They are poisonous
    compounds that do not grow, reproduce, or die after they have
    been dispersed; they are more easily controlled than live
    organisms. Field monitors capable of providing prompt warning
    of a toxin attack are not available; therefore, personnel must
    learn to quickly recognize signs of attack, such as observing
    unexplained symptoms of victims. Toxins produce effects similar
    to those caused by chemical agents; however, the victims
    will not respond to the first-aid measures that work against
    chemical agents. Unlike live agents, mycotoxins (T2) can
    penetrate intact skin; other toxins cannot. Because the effects
    on the body are direct, the symptoms of an attack may appear
    very rapidly. The potency of most toxins is such that very
    small doses will cause injuries and/or death. Thus, 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 area. Slight exposure at the edges of an attack area
    may produce severe symptoms or death from exposure to toxins
    because of their extreme toxicity. Lethal or injury downwind
    hazard zones for toxins may be far greater than those of CW
    agents.


A-9. Behavior of Biological Weapons

Biological agents can be disseminated in a spectrum of physical
states. They may be living microorganisms or spore forms of the
organism. See Table A-11 for stability of various biological
agents. They may be spread by--

    · Arthropods.

    · Contact with infected animals.

    · Contamination of food and water.

    · Aerosol, liquid, or solid dispersion.

The only requirement is that they must be stable enough to survive
transport and dissemination. The toxicity of biological agents
is not the same for everyone; each individual does not react
exactly the same way to the same amount of an agent. Some are more
resistive than others because of race, sex, age, or other factors.
The dose is the quantity of a biological agent received by the
subject. The penetration of agents by various routes need not be
accompanied by irritation or damage to the absorbent surface. There
are often unique signs and identifying symptoms depending on entry
route (inhalation, ingestion, or dermal).

_a._ Biological agents dispersed by spray often enter the body
through the respiratory tract (inhalation injury). 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 lungs.

_b._ Liquid droplets and (less commonly) solids may be absorbed
from the surface of the skin, digestive tract, and mucous
membranes. Agents penetrating the skin may form temporary
reservoirs under the skin.

_c._ Contaminated food and water can produce casualties when
ingested.


_Table A-11. Types and Characteristics of Some Biological Agents_

  =========================================================================
                                                     ENTRANCE
  TYPE OF AGENT     STABILITY  INCUBATION TIME  AEROSOL     NONAEROSOL
  -------------------------------------------------------------------------
  ANTHRAX            HIGH      HOURS TO 7 DAYS  INHALATION  SKIN, MOUTH
  -------------------------------------------------------------------------
  BOTULINUM TOXIN    HIGH      24 TO 36 HOURS   INHALATION  MOUTH, WOUND
  -------------------------------------------------------------------------
  BRUCELLOSIS        HIGH IN   1 TO 4 WEEKS     INHALATION  MOUTH, SKIN,
                     WET ENV-                               EYES
                     IRONMENT
  -------------------------------------------------------------------------
  CHOLERA            MODERATE  HOURS TO 5 DAYS              MOUTH
  -------------------------------------------------------------------------
  PLAGUE(PNEUMONIC)  LOW       2 TO 4 DAYS      INHALATION
  -------------------------------------------------------------------------
  PLAGUE (BUBONIC)   MODERATE  2 TO 10 DAYS                 BITE OF VECTOR
  -------------------------------------------------------------------------
  RICIN              HIGH      <36 HOURS        INHALATION  MOUTH
  -------------------------------------------------------------------------
  SMALLPOX           HIGH      7 TO 17 DAYS     INHALATION  LESION CONTACT
  -------------------------------------------------------------------------
  STAPHYLOCOCCAL     HIGH      1 TO 6 HOURS     INHALATION  MOUTH
  ENTEROTOXIN B
  -------------------------------------------------------------------------
  TRICHOTHECENE      HIGH      MINUTES TO HOURS  INHALATION  MOUTH, SKIN
  MYCOTOXIN
  -------------------------------------------------------------------------
  TULAREMIA          LOW       2 TO 10 DAYS     INHALATION  MOUTH, SKIN,
                                                            BITE OF VECTOR
  -------------------------------------------------------------------------
  VENEZUELAN EQUINE  MODERATE  1 TO 6 DAYS      INHALATION  BITE OF VECTORS
  ENCEPHALITIS
  -------------------------------------------------------------------------
  VIRAL HEMORRHAGIC  LOW       DAYS TO MONTHS   INHALATION  BITE OF VECTORS
  FEVERS
  =========================================================================


A-10. Management of Biological Warfare Patients

_a._ _Management._ Management of patients suffering from the
effects of BW agents may include the need for isolation. 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 patients. Specimens must be
collected and submitted to the designated supporting laboratory for
identification. For details on hospital infection control aspects
of managing BW casualties, see FM 8-284.

_b._ _Mass Casualty._ A BW agent attack can produce a mass casualty
situation at all levels of HSS. A major problem with a BW mass
casualty situation is that HSS personnel are more susceptible to
becoming a casualty to BW agents. Also, the ill patient may be the
first indicator that a BW agent has been dispersed.

_c._ _Decontamination._ Decontamination is an individual and unit
responsibility. However, some individuals may arrive at the MTF
that have not been decontaminated or that become contaminated en
route to the MTF. 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 agent. See
Appendix G for details on patient decontamination.

_d._ _Treatment._ Specific treatment is dependent upon the BW agent
used. Patients are treated for symptomatic presentation unless the
BW agent identity is known. Field Manuals 8-9 and 8-284 provide
detailed information on medical management and treatment.


A-11. Effects of Chemical Weapons

_a._ A chemical agent is a chemical that is used to kill, seriously
injure, or incapacitate man because of its physiological effects.
They can be disseminated by artillery, aircraft, rocket, or by
nonconventional means used by terrorists. When first employed in
combat during World War I, the chemical weapon (chlorine) was so
effective that the attacking Germans were not prepared to exploit
the success.

_b._ Chemical agents are very effective weapons against poorly
trained and equipped forces; however, they are less effective
against well-trained forces.


A-12. Behavior of Chemical Weapons

Chemical agents can be disseminated as a gas, vapor, or aerosol
under ambient conditions. They have a range of odors varying
from none to highly pungent characteristics. Their stability
is dependent upon the environmental conditions in the area of
employment. See Table A-11 for persistency of various chemical
agents.

_a._ The toxicity of a chemical agent is not the same for everyone;
each individual does not react exactly the same way to the same
amount of an agent. Some are more resistant than others because
of physiological factors. The dose is the quantity of a chemical
received by the individual for percutaneous or oral doses and
as a time-weighted concentration, milligrams-minute (m3), for
inhalation. It is usually expressed as milligrams of agent per
kilogram of subject body weight (mg/kg). The LD50 is the dose that
kills 50 percent of the exposed population. The incapacitation dose
50 (ID50) is the incapacitation dose for 50 percent of the exposed
subjects. The penetration of agents by various routes need not be
accompanied by irritation or delayed superficial damage to the
absorbent surface, but there are often unique signs and symptoms
identifiable by the route of entry.

    (1) Gaseous, vapor, and aerosol chemical agents often enter the
    body through the respiratory tract (inhalation injury). 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 lungs.
    Aerosol particles larger than 5 μ tend to be retained in the
    upper respiratory tract; particles in the 1 to 5 μ range are
    retained in the deep volume of the lungs; while those below
    1 μ tend to be breathed in and out again; although a few are
    retained in the deep volume of the lungs.

    (2) Vapors and droplets of liquids can be absorbed from the
    surface of the skin and mucous membranes. Toxic compounds that
    are harmful to the skin can produce their effects in liquid or
    solid state. Agents penetrating the skin may form temporary
    reservoirs under the skin; the vapors of some volatile liquids
    can penetrate the skin and cause intoxication. Additionally,
    wounds and abrasions may present areas that are more permeable
    than intact skin.

_b._ Chemical agents may be divided into two main categories
(persistent and nonpersistent) that describe how long they are
capable of producing casualties. Table A-12 lists the common
chemical agents, their effects and time of effectiveness. Table
A-13 lists the types and characteristics of common chemical agents.

    (1) Persistent agents continue to present a hazard for
    considerable periods (days) after delivery by remaining as a
    contact hazard, or by slowly vaporizing to produce a hazard by
    inhalation.

    (2) Nonpersistent agents disperse rapidly after release and
    present an immediate, short duration (hours) hazard. They are
    released as airborne particles, aerosols, and gases.


_Table A-12. Common Chemical Warfare Agents_

  =========================================================================
  COMMON NAME          EFFECT                    TIME TO EFFECT
  -------------------------------------------------------------------------
  TABUN (GA)                                 INHALATION: SECONDS TO MINUTES
  SARIN (GB)        LETHAL NERVE AGENTS      TOPICAL: MINUTES
  SOMAN (GD)                                 INGESTION: MINUTES TO HOURS
  V-AGENTS
  -------------------------------------------------------------------------
  HYDROGEN CYANIDE  LETHAL BLOOD AGENT       MINUTES
  -------------------------------------------------------------------------
  MUSTARD           BLISTER AGENTS           1 TO 12 MINUTES
  LEWISITE                                   MINUTES
  -------------------------------------------------------------------------
  LSD AND BZ        INCAPACITATING AGENTS    15 TO 60 MINUTES
  -------------------------------------------------------------------------
  PHOSGENE          LUNG-DAMAGING (CHOKING)  MINUTES
  CHLORINE                                   SECONDS TO MINUTES
  =========================================================================


_Table A-13. Types and Characteristics of Chemical Agents_

    [Part 1]
  ================================================================
  TYPE OF                     PERSISTENCE              RATE OF
   AGENT     SYMBOL       SUMMER         WINTER        ACTION
  ----------------------------------------------------------------
             GA, GB, GD   10 MIN-24 HR   2 HR-3 DAYS   VERY QUICK
  =NERVE=  -------------------------------------------------------
             VX           2 DAYS-1 WK    2 DAYS-WEEKS  QUICK
  ----------------------------------------------------------------
  =CHOKING=  CG, DP       1-10 MIN       10 MIN-1 HR   IMMEDIATE
  ----------------------------------------------------------------
             HD, HN       3 DAYS-1 WK    WEEKS         SLOW
            ------------------------------------------------------
  =BLISTER=  L, HL        1-3 DAYS       WEEKS         QUICK
            ------------------------------------------------------
             CX           DAYS           DAYS          VERY QUICK
  ----------------------------------------------------------------
  =BLOOD=    AC, CK       1-10 MIN       10 MIN-1 HR   VERY QUICK

  ================================================================

    [Part 2]
  ================================================================
  TYPE OF                                ENTRANCE
   AGENT     SYMBOL          VAPOR/AEROSOL      LIQUID
  ----------------------------------------------------------------
             GA, GB, GD     EYES, LUNGS         EYES, SKIN, MOUTH
  =NERVE=  -------------------------------------------------------
             VX             EYES, LUNGS         EYES, SKIN, MOUTH
  ----------------------------------------------------------------
  =CHOKING=  CG, DP         LUNGS               EYES
  ----------------------------------------------------------------
             HD, HN         EYES, SKIN, LUNGS   EYES, SKIN
            ------------------------------------------------------
  =BLISTER=  L, HL          EYES, SKIN, LUNGS   EYES, SKIN, MOUTH
            ------------------------------------------------------
             CX             EYES, LUNGS, SKIN   EYES, SKIN, MOUTH
  ----------------------------------------------------------------
  =BLOOD=    AC, CK         EYES, LUNGS         EYES, MOUTH,
                                                INJURED SKIN
  ================================================================


A-13. Characteristics of Chemical Agents

The effectiveness of a chemical agent is a measure of how much
agent is required to produce the desired effect. Thus, an agent
that is toxic at a lower dose than another similar agent is more
effective. Besides dose required for a given effect, persistency
may be used to measure effectiveness. Persistency depends on the
agent's physical characteristics, the amount of agent delivered,
its physical state, weapons system used, the terrain, and weather
in the target area. The desired effects will determine the
physical, chemical, and toxicological properties of the chemical
agent employed.

_a._ Nerve agents are primarily organophosphorus esters similar to
insecticides. Those of military importance are combined under this
term. Although some have been given names, they are usually known
by their code letters: GA; GB; GD; and VX. They are all liquids,
varying in volatility that is in a range between gasoline and heavy
lubricating oil. Their freezing points are -40 degrees Celsius or
lower.

    (1) Liquid nerve agents are pale yellow to colorless and are
    almost odorless. They are moderately soluble in water and
    highly soluble in lipids (oil). They are rapidly destroyed by
    strong alkalies and chlorinating compounds. Normal clothing
    is readily penetrated by liquid or vapor agents. Butyl rubber
    and synthetic material are more resistant than natural fibers.
    Agents can penetrate into nonabsorbent material such as web
    belts and can continue to present a hazard by desorption
    (off-gassing) of the vapor. Although local sweating and
    twitching may occur, usually there is no local irritant change
    after cutaneous exposure. Toxicity depends upon the route of
    entry and physical characteristics.

    (2) Nerve agents strongly inhibit the cholinesterase enzymes.
    When acetylcholine is released by the nerve junction, it
    is hydrolyzed by the enzyme. Acetylcholine is the chemical
    mediator for transmission of the nerve impulses in numerous
    synapses of the central nervous system (CNS) and the autonomic
    nervous system and at the endings of the cholinergic nerves
    (for example: affecting the smooth muscles of the iris,
    ciliary, bronchial tree, and gastrointestinal tract). The
    inhibition of cholinesterase by nerve agents is almost
    irreversible, so the effects are prolonged. Until the
    cholinesterase level is restored to normal, there is an
    increased susceptibility to nerve agent exposure. During this
    time, the effects of repeated exposure are cumulative and the
    patient may feel "subpar" (for example: tired, fatigue easily,
    poor appetite, impaired concentration) until recovery is
    complete.

    (3) Nerve agent poisoning is easily identified by the
    characteristic signs and symptoms as follows:

      (_a_) =MILD= symptoms (self-aid). Casualties with MILD symptoms may
      experience most or all of the following:

        · Unexplained runny nose.

        · Unexplained sudden headache.

        · Sudden drooling.

        · Difficulty in seeing (dimness of vision) (miosis).

        · Tightness in the chest or difficulty in breathing.

        · Localized sweating and muscular twitching in the contaminated
        area.

        · Stomach cramps.

        · Nausea.

      (_b_) Casualties with =MODERATE= symptoms (buddy aid) will
      experience an increase in the severity of most or all of the MILD
      symptoms. Especially prominent will be an increase in fatigue,
      weakness, and muscle fasciculations. The progress of symptoms from
      MILD to MODERATE indicates either inadequate atropine treatment or
      continuing exposure to agent.

      (_c_) =SEVERE= symptoms (buddy aid). Casualties with SEVERE
      symptoms may experience most or all of the MILD symptoms, plus most
      or all of the following:

        · Strange or confused behavior.

        · Wheezing, dyspnea (severe difficulty in breathing), and
        coughing.

        · Severely pinpointed pupils.

        · Red eyes with tearing.

        · Vomiting.

        · Severe muscular twitching and general weakness.

        · Involuntary urination and defecation.

        · Convulsions.

        · Unconsciousness.

        · Respiratory failure.

_b._ There are three major families of blister agents (vesicants);
HD and HN, L, and CX. Most vesicants (except CX) are relatively
persistent. Mustards can modify the structure of nucleic acids,
cellular membranes, and proteins by combining with certain
functional groups (particularly the sulfhydryl-containing enzymes)
for which they have an affinity.

    (1) The cutaneous syndrome is divided into four phases: latent,
    erythema, vesication, and necrosis. Vesicants can penetrate the
    skin by contact with either liquid or vapor. The latent period
    is characteristic of the agent. For mustards it is usually
    several hours, for L it is short, and for CX it is negligible.
    The latent period is also affected by the dose, temperature,
    and humidity. The symptoms of the erythema phase are red,
    painful itching followed by painful necrosis that heals slowly.

    (2) In the eyes, vesicants produce intense pain and
    photophobia. Blistering of the eyelids and mucous membranes can
    result in temporary blindness. Even after recovery, scars on
    the cornea can reduce visual acuity.

    (3) In the respiratory tract, these agents attack the mucous
    membranes irritating them. They can paralyze vocal chords and
    can lead to chemical pneumonitis, or possibly death.

    (4) Although blister agents can affect other organs and produce
    deleterious effects, the skin, eyes, and respiratory tract are
    the principle organs effected.

_c._ Chemical agents that attack lung tissue (choking agents) and
cause pulmonary edema are classed as lung damaging agents. Choking
agents consist of CG and DP, CL, and PS. Phosgene is typical of the
lung-damaging agents; it is used as the example here.

    (1) Phosgene is a colorless gas that has an odor resembling new
    mown hay. Although effects are primarily confined to the lungs,
    phosgene may also cause mild irritation of the eyes and upper
    respiratory tract. Phosgene causes a shift in the membrane
    potential of the alveoli allowing the passage of fluid into
    the alveoli, resulting in massive pulmonary edema and severely
    impairing the exchange of oxygen (O_{2}) and carbon dioxide
    (CO_{2}) between the capillary blood and the alveolar air.

    (2) Initially hypoxemia occurs and is followed shortly by
    hyperventilation when the frothy edema fluid fills the
    bronchioli and CO_{2} expiration stops.

    (3) Signs and symptoms during and immediately following
    exposure are coughing, tightness of chest, nausea, occasionally
    vomiting, headache, and lacrimation (tearing).

_d._ Blood agents consist of AC and CK; both are readily absorbed
by the mucous membranes and the intact skin. The odor of AC
resembles bitter almonds, but many people cannot detect it.
Detecting the odor of CK is difficult because of its irritating
and lacrimatory effects. It is also poorly absorbed by the metallic
salt-impregnated charcoal filters in the protective mask. These
agents inhibit certain enzymes (particularly cytochrome oxidase)
that are important for oxidation-reduction in the cells; therefore,
cell respiration is inhibited and oxygen carried by the hemoglobin
is not consumed causing the venous blood to remain bright red.
Initial symptoms are characterized by violent convulsions,
increased deep respiratory movements, followed by cessation of
respiration within one minute, slowing of heart rate to death. High
concentrations exert their effects rapidly; however, if the patient
is still alive after the cloud has passed, he will probably recover
spontaneously.

_e._ Incapacitating agents are chemicals that produce a temporary
disabling condition that persists for hours to days after exposure
to the agent has ceased (unlike that produced by riot control
agents). While not required, medical treatment produces a more
rapid recovery. Characteristics of these agents are that they--

    · Are highly potent and logistically feasible.

    · Produce their effects mainly by altering or disrupting the
    higher regulatory activity of the CNS.

    · Produce effects that last for hours or days rather than
    momentary or fleeting.

    · Do not seriously endanger life, except in exceedingly high
    doses.

    · Produce no permanent injury.

The two types likely to be encountered are CNS depressants and CNS
stimulants.

    (1) Central nervous system depressants are compounds that have
    a predominant effect of depressing or blocking the activity
    of the CNS; often by interfering with the transmission of
    information across synapses. An example of this type of agent
    is BZ. The action of acetylcholine, both peripherally and
    centrally, appears to be blocked by BZ. Low doses disrupt
    higher integrative functions of memory, problem solving,
    attention, and comprehension. High doses produce toxic delirium
    that destroys the ability to perform any military task. Within
    the CNS, BZ seems to produce its effects in the same way as
    atropine. Small doses cause sleepiness and decreased alertness
    with elevated heart rate, dry skin and eyelids, drowsiness,
    increased pupil size, and elevated skin temperatures.
    Progressive intoxication is marked by an inability to respond
    effectively to the environment (4 to 12 hours), followed by
    increasing activity and random/unpredictable behavior (12 to 96
    hours). Because the patient cannot sweat, heat stress becomes a
    problem.

    (2) Central nervous system stimulants are agents that cause
    excessive nervous activity, often by boosting or facilitating
    transmission of impulses across synapses. The effect is
    to "flood" the cortex and other higher regulatory centers
    with too much information, making concentration difficult
    and causing indecisiveness and an inability to act. These
    include LSD, psilocybin, and mescaline. Intoxication shows
    sympathetic stimulation (rapid heart rate, sweaty palms,
    pupillar enlargement, and cold extremities) and mental
    excitation (nervousness, trembling, anxiety, and inability to
    relax or sleep); feelings of tension, exhilaration, heightened
    awareness, paranoid ideas, and profound states of terror may
    also occur.


A-14. Management of Chemical Agent Patients

_a._ _Management._ Movement of chemical agent casualties can spread
the contamination to clean areas. All casualties are decontaminated
as far forward as the situation permits. All patients must be
decontaminated before they are admitted into a clean MTF. The
admission of one contaminated patient into an MTF will contaminate
the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ A mass casualty situation is presented
when chemical agents are employed. Additional HSS personnel and
equipment must be provided in a short period of time if the level
of care is to be maintained. Treatment at far forward MTFs is
limited to life- or limb-saving care. Patients that can survive
evacuation to the next level of care are not treated at the forward
facility. This provides time for treating those patients that
cannot survive the evacuation time.

_c._ _Decontamination._ Decontamination is an individual and unit
responsibility. However, some individuals may arrive at the MTF
that have not been decontaminated or that become contaminated en
route to the MTF. 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 chemical. See Appendix G
for detailed information on patient decontamination procedures.

_d._ _Treatment._ Field Manuals 8-9 and 8-285 provide treatment
procedures for chemical agent patients.


A-15. Management of Toxic Industrial Material Patients

_a._ _Management._ Movement of TIM casualties can spread the
contamination to clean areas. All casualties are decontaminated
as close to the incident site as possible. All patients must be
decontaminated before they are admitted into a clean MTF. The
admission of one contaminated patient into an MTF may contaminate
the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ 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
site. Treatment at the incident site is limited to life- or
limb-saving care. Patients that can survive are evacuated to the
nearest MTF with a patient decontamination capability.

_c._ _Decontamination._ Decontamination is an individual and
first responder responsibility. However, some individuals that
self evacuated or were evacuated due to the mass casualty
situation arrive at the MTF that have not been decontaminated.
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 TIM. See FM
8-500 for detailed information on decontamination procedures for
TIM contaminated casualties.

_d._ _Treatment._ Field Manual 8-500 provides treatment procedures
for some TIM casualties. Treatment for many TIM casualties is agent
specific and receiving MTFs must be prepared for these events.

EXAMPLE: 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 casualty.




APPENDIX B

SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT


Section I. INTRODUCTION


B-1. General

_a._ Critical elements for accuracy in analysis of NBC samples
and physiological specimens are correct collecting, packaging,
handling, and transporting techniques. 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 testing. Health service support personnel collect
and submit specimens for suspect NBC hazards/agents involving
humans and animals. Chemical corps and other nonmedical units
collect and submit environmental (air, plant, and soil) samples for
suspect NBC hazards/agents. Preventive medicine personnel collect
and submit water and ice samples for suspect NBC hazards/agents.
Veterinary personnel collect and submit food samples, such as
fruits and vegetables, and specimens from animals for suspect
NBC hazards/agents. Specimens collected from patients that are
suspect of being exposed to a biological agent are forwarded to the
supporting medical laboratory (such as the TAML, AML or US Navy
Forward Deployed PVNTMED Unit) for analysis.

_b._ Essentially all military operations from war to stability
operations and support operations may generate medical laboratory
testing requirements. Each scenario, geographical region,
population base, and suspect agent will impact on the type
and amount of samples/specimens required and the collection
process. During all operations, express permission is required
before collecting specimens from civilians because of religious
or sociological beliefs in many cultures. To obtain such
specimens without permission could result in unnecessary mission
complications.

    NOTES

    1. The term "sample" refers to nonhuman and nonanimal origin.
    The term "specimen" refers to human and animal origin.

    2. Always consider that chemical agents may have been employed.
    Check for chemical agents before collecting a biological
    sample/specimen. Chemical agents can damage or destroy
    biological agents. Also, chemical agents not identified in
    the sample/specimen can pose a hazard to receiving laboratory
    personnel. Mark all samples that are potentially contaminated
    with chemical agents as such.

    3. Precautions should be taken to protect the sample/specimen
    collector from potential BW agents; at a minimum, respiratory
    protection and rubber gloves must be worn. Additional care
    must be taken when collecting samples/specimens to prevent
    cross-contamination. Gloves must be changed or decontaminated
    between sample/specimen collections.

    4. Samples will not be delivered to the clinical laboratory of
    an MTF for analysis. They must be delivered to the designated
    supporting medical laboratory for processing. This will prevent
    accidentally spreading a biological agent in the MTF.

_c._ Coordination for follow-on testing is absolutely critical to
the sample/specimen collection process.

_d._ Coordination with the receiving laboratory should be made to
establish sample requirements, preferred collection techniques,
methods of preservation, and transportation conditions, when the
tactical situation and/or mission permits.

_e._ The number of medical specimens that need to be collected
varies with the type of analysis performed and the impact
of the values determined. The number and types of "control"
samples/specimens required to validate test information is
determined by the supporting medical laboratory personnel. Random
sampling, matched with control populations, or other techniques
will be employed as the requirements are identified.


B-2. Sample/Specimen Background Information

_a._ A complete history of the circumstances about each
sample's/specimen's acquisition must be provided to the agency
conducting the analysis.

_b._ Critical information includes, but is not limited to--

    · Meteorological conditions. Describe what the meteorological
    conditions were at the time of the alleged attack and at the
    time of the sampling.

    · Attack to collection time. State the length of time after
    alleged attack when sample/specimen was taken.

    · Circumstances of acquisition. Describe how the
    sample/specimen was obtained and the source of the
    sample/specimen.

    · Physical description. Describe the physical state of the
    sample/specimen (solid, liquid, powder, apparent viscosity),
    color, approximate size, identity of the sample/specimen
    (that is, dirt, leaves, blood, tissue), and dose rate (if
    radiologically contaminated).

    · Circumstances of the agent deposition. Describe the
    type of delivery system, a description of how the weapon
    functioned, how the agent acted on release, sounds heard during
    dissemination, a description of any craters or shrapnel found
    associated with the burst, and colors of smoke, flames, or
    mists that may be associated with the attack.

    · Agent effects on vegetation. Describe the general area
    (jungle, mountain, grassland) and changes in the vegetation
    after the agent deposition (that is, color change, wilting,
    drying, dead) in the main attack and fringe areas.

    · Agent effects on humans. How the agent affected personnel
    in the main attack area versus fringe areas; the duration of
    agent effects; peculiar odors that may have been noticed in the
    area before, during, or after an attack; measures taken that
    alleviated or worsened the effects; and the approximate number
    of victims and survivors (include age and gender).

    · Agent effects on animals. Describe how they are affected.

    · Grid coordinates or other descriptive information on sample
    collection location.


B-3. Sample/Specimen Collection and Preservation

_a._ _Ante mortem Specimens._ Physiological specimens from living
human or animal patients can include just about any conceivable
body source or excreted by-product. It must be noted that specimen
types are seldom interchangeable; the exact type and amount of
specimen required for a specific assay must be known before a
collection procedure is initiated (see Table B-1).

    · Patients seen in an MTF may be the first and in some cases
    the only source for sampling for suspect biological agent
    release. The primary medical care provider will determine
    the level of treatment for these patients and the specimens
    required for laboratory diagnosis. The MTF laboratory is
    not equipped to handle biological agents and, therefore,
    specimens generated will be forwarded to the supporting medical
    laboratory for analysis. Patient disposition will be based
    on evacuation policies, exposure, suspect agent, clinical
    symptoms, and required treatment/isolation.

    · Blood specimens represent the most common analytical sample.
    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 collector. In general,
    phlebotomy requires the use of a 20 to 22-gauge needle to
    minimize mechanical hemolysis during aspiration using a syringe
    or Vacutainer^{TM} tube collection system. Blood collected with
    a syringe and needle should be transferred to an appropriate
    Vacutainer^{TM} tube immediately after collection. The type
    of tube, type of anticoagulant or preservative, and amount of
    blood collected will vary with the specific assay requested.
    Unless some special sample preparation step is required, the
    blood is best left in the original rubber-stopper tube for
    transport.

    · Urine specimens are best collected using a clean-catch
    (midstream, if possible) technique in a sterile urine cup. The
    volume of sample required will vary depending on the specific
    assay requested; however, 25 to 50 ml is sufficient for most
    tests.

    · Tissue specimens can originate from any body source
    accessible by scraping, swabbing, or minor excision. Tissue
    specimens are collected only by medical trained personnel.
    Specific techniques for collecting these specimens are not
    provided in this appendix.

    · Sputum specimens are best collected using a sterile cup. The
    volume of specimen will normally be very small. However, a
    sufficient quantity must be collected to provide for in-theater
    testing and to provide for CONUS laboratory testing.

    · Nasal swabs should be collected using sterile cotton-tipped
    swabs. The swabs with specimen from each person should
    be placed in a separate sterile container to prevent
    cross-contamination.

        NOTE

        In cases where the supporting laboratory cannot be contacted,
        as a minimum the following specimens should be collected:
        Urine--25 to 50 ml in a sterile container. Blood--two
        7 to 10 ml tubes without anticoagulant (red-stopper
        Vacutainer^{TM}); two 7 to 10 ml tubes with potassium or
        sodium ethylenediaminetetraacetate (EDTA) (lavender-stopper
        Vacutainer^{TM}).

    · All specimens (regardless of physiological source) must be
    labeled to positively identify the individual or animal from
    whom it was collected; at a minimum, the individual's full
    name, unique personal identification number (social security
    number, when possible), military unit and location, and date
    and time of collection should be written on the label of the
    specimen container.

    · All specimens are collected using aseptic techniques. All
    specimens are packaged, handled, and transported in a manner
    that ensures they arrive at the final destination laboratory
    in a testable condition. Personal protection guidelines must
    be adhered to when collecting or processing specimens; at a
    minimum, this includes gloves and a mask. In the laboratory,
    a gown or other protective items may also need to be used. In
    the field, under suspect NBC conditions, collectors should be
    in MOPP Level 4 or inside NBC-protected vehicles. Common sense
    and the clinical and/or tactical situation will determine the
    extent of personal protection necessary.

    · Preservation of specimens, either chemically or mechanically
    (cooling), will be necessary to minimize the amount of analyte
    degradation that occurs after removing the specimen from its
    physiological microenvironment. The optimal preservation
    technique will vary with different laboratory tests and must
    be confirmed for each requested assay. While freezing may
    preserve some serum constituents, freeze-thawing cycles may
    denature others. Freezing may also completely destroy certain
    microorganisms. This caution also applies to tissue specimens
    since "fixing" tissue with a standard 10 percent formalin
    solution will preserve tissue for special staining techniques;
    however, it renders the specimens completely useless for
    microbiological culture. Always verify specimen preservation
    requirements for storage and transport with the supporting
    medical laboratory before processing the specimen. Ideally,
    confirmation of the correct handling conditions should be
    coordinated before collection.

    · The importance of coordinating sample/specimen collection
    with the supporting laboratory facility cannot be overstated.
    Contact the receiving laboratory for instructions when
    doubt exists about the appropriate source, collection
    technique, storage and preservation conditions (such as,
    aerobic or anaerobic environment), and transportation
    requirements for samples/specimens. Extremely small volumes of
    samples/specimens, properly collected and handled, can yield a
    tremendous amount of information to assist in making medical,
    tactical, and strategic decisions. Conversely, very large
    quantities of poorly collected and insufficiently preserved
    samples/specimens are essentially worthless for most analytical
    techniques.

    · Analysis beyond intratheater capabilities will be coordinated
    by the supporting laboratory, when deployed, or through medical
    channels in the absence of an in-theater supporting laboratory.

_b._ _Post mortem and Forensic Specimens._ The analysis
of specimens from deceased humans and animals can provide
valuable information about the disease, organisms, injuries, or
environmental conditions at the time of death. This information
can greatly enhance the treatment of others affected by the same,
or physiologically similar, process. Specimen collection for post
mortem or forensic examination is very important; the techniques
involved reflect a significant degree of training, experience, and
skill. Most specimens will be of the same type and size as for
ante mortem specimens, but types and amounts of specimens will be
determined by the collector.

    (1) The collection of specimens from remains should be
    conducted exclusively by a pathologist, or other personnel
    specifically trained in forensic collection techniques. An
    exception is when Special Operations Forces (SOF) personnel are
    operating under radio silence conditions; the most qualified
    medical person with the operation collects, preserves,
    and transports or coordinates transport of specimens for
    evaluation. The same chain of custody requirements applies
    to specimens collected by SOF personnel, as with all other
    specimens.

    (2) A large amount of support information can be gained by
    analyzing the site of injury and subsequent death. This "site
    scene" investigation requires a tremendous attention to detail
    and a trained observer. If forensic personnel cannot be
    contacted, or will be unduly delayed in arriving at the scene,
    then photographs of the victim and the immediate surroundings
    should be made. 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 retrospectively.
    In the event that photography is not feasible, detailed
    sketches of the scene should be made to assist the forensic
    investigation.

    (3) Techniques such as cardiac or bladder puncture, needle
    biopsy of organs, spinal tap, or exploratory laparotomy will
    not be performed by untrained personnel unless specifically
    requested and directed by forensic investigators.


_Table B-1. Specimen Collection for Suspect Biological Warfare
Agents_

  ========================================================================
  EARLY POSTEXPOSURE              CLINICAL
                                        CONVALESCENT/TERMINAL/POSTMORTEM
  ------------------------------------------------------------------------
      =ANTHRAX=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL AND THROAT SWABS, AND     SERUM (TT OR RT) FOR TOXIN ASSAYS.
  INDUCED RESPIRATORY SECRETIONS  BLOOD (E, C, H) FOR PCR.
  FOR CULTURE, FA, AND PCR.       BLOOD (BC OR C) FOR CULTURES.
                                        _3 TO 10 DAYS._
                                        SERUM (TT OR RT) FOR TOXIN ASSAYS.
                                        BLOOD (BC OR C) FOR CULTURE.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =PLAGUE=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL SWABS, SPUTUM, AND        BLOOD (BC AND C) FOR CULTURE AND
  INDUCED RESPIRATORY SECRETIONS  BLOODY SPUTUM (C) FOR FA. SERUM
  FOR CULTURE, FA,                (TT OR RT) FOR F-1 ANTIGEN ASSAYS.
  AND PCR.                        BLOOD (E, C, OR H) FOR PCR.
                                        _>6 DAYS._
                                        SERUM (TT OR RT) FOR IgM,
                                        LATER FOR IgG.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =TULAREMIA=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL SWABS, SPUTUM, AND        BLOOD (BC OR C) FOR CULTURE.
  INDUCED RESPIRATORY             BLOOD (E, C, OR H) FOR PCR.
  SECRETIONS FOR CULTURE, FA,     SPUTUM FOR FA AND PCR.
  AND PCR.                              _>6 DAYS._
                                        SERUM (TT OR RT) FOR IgM AND
                                        LATER IgG, AGGLUTINATION TITERS.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =MELIOIDOSIS/GLANDERS=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL SWABS, SPUTUM, AND        BLOOD (BC OR C) FOR CULTURE.
  INDUCED RESPIRATORY             BLOOD (E, C, OR H) FOR PCR.
  SECRETIONS FOR CULTURE AND      SPUTUM AND DRAINAGE FROM SKIN
  PCR.                            LESIONS FOR PCR AND CULTURE.
                                        _>6 DAYS._
                                        BLOOD (BC OR C) AND TISSUE FOR
                                        CULTURE.
                                        SERUM (TT OR RT) FOR
                                        IMMUNOASSAYS.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =BRUCELLOSIS=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL SWABS, SPUTUM, AND        BLOOD (BC OR C) FOR CULTURE.
  INDUCED RESPIRATORY             BLOOD (E, C, AND H) FOR PCR.
  SECRETIONS FOR CULTURE AND            _>6 DAYS._
  PCR.                                  BLOOD (BC OR C) AND TISSUE FOR
                                        CULTURE.
                                        SERUM (TT OR RT) FOR
                                        IMMUNOASSAYS.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =Q FEVER=
  _0 TO 24 HOURS._                _2 TO 5 DAYS._
  NASAL SWABS, SPUTUM, AND        BLOOD (BC OR C) FOR CULTURE IN EGGS
  INDUCED RESPIRATORY             OR MOUSE INOCULATION.
  SECRETIONS FOR CULTURE AND      BLOOD (E, C, AND H) FOR PCR.
  PCR.                                  _>6 DAYS._
                                        BLOOD (BC OR C) FOR CULTURE IN
                                        EGGS OR MOUSE INOCULATION.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =BOTULISM=
  _0 TO 24 HOURS._                _24 TO 72 HOURS._
  NASAL SWABS AND INDUCED         NASAL SWABS AND RESPIRATORY
  RESPIRATORY SECRETIONS FOR      SECRETIONS FOR PCR (CONTAMINATING
  PCR (CONTAMINATING              BACTERIAL DNA) AND TOXIN ASSAYS.
  BACTERIAL DNA) AND TOXIN              _>6 DAYS._
  ASSAYS.                               USUALLY NO IgM OR IgG.
  SERUM (TT OR RT) FOR TOXIN            PATHOLOGY SPECIMENS (LIVER AND
  ASSAYS.                               SPLEEN FOR TOXIN DETECTION).
  ------------------------------------------------------------------------
      =RICIN INTOXICATION=
  _0 TO 24 HOURS._                _36 TO 48 HOURS._
  NASAL SWABS AND INDUCED         SERUM (TT OR RT) FOR TOXIN
  RESPIRATORY SECRETIONS FOR      ASSAY.
  PCR (CONTAMINATING CASTOR       TISSUE FOR IMMUNOHISTOLOGICAL
  BEAN DNA) AND TOXIN ASSAYS.     STAINING.
  SERUM (TT OR RT) FOR TOXIN      PATHOLOGY SPECIMENS.
  ASSAYS.                               _>6 DAYS._
                                        SERUM (TT OR RT) FOR IgM AND IgG
                                        IN SURVIVORS.
  ------------------------------------------------------------------------
      =STAPH ENTEROTOXICOSIS=
  _0 TO 3 HOURS._                 _2 TO 6 HOURS._
  NASAL SWABS AND INDUCED         URINE FOR IMMUNOASSAYS.
  RESPIRATORY SECRETIONS FOR      NASAL SWABS AND INDUCED
  PCR (CONTAMINATING BACTERIAL    RESPIRATORY SECRETIONS FOR
  DNA) AND TOXIN ASSAYS.          PCR (CONTAMINATING BACTERIAL
  SERUM (TT OR RT) FOR TOXIN      DNA) AND TOXIN ASSAYS.
  ASSAYS.                         SERUM (TT OR RT) FOR TOXIN
                                  ASSAYS.
                                        _>6 DAYS._
                                        SERUM FOR IgM AND IgG.
  ------------------------------------------------------------------------
      =T-2 TOXICOSIS=
  _0 TO 24 HOURS POSTEXPOSURE_    _1 TO 5 DAYS._
  NASAL AND THROAT SWABS AND      SERUM (TT OR RT) AND TISSUE FOR
  INDUCED RESPIRATORY             TOXIN DETECTION.
  SECRETIONS FOR IMMUNOASSAYS,          _>6 DAYS POSTEXPOSURE._
  HPLC/MASS SPECTROMETRY.               URINE FOR DETECTION OF TOXIN
                                        METABOLITES.
  ------------------------------------------------------------------------
      =EQUINE ENCEPHALOMYELITIS=
  (VEE, EEE, AND WEE VIRUSES)     _24 TO 72 HOURS._
  _0 TO 24 HOURS._                SERUM (TT OR RT) AND THROAT FOR
  NASAL SWABS AND INDUCED         CULTURE.
  RESPIRATORY SECRETIONS FOR      SERUM (E, C, H, TT, OR RT) FOR
  RT-PCR AND VIRAL CULTURE.       RT-PCR. THROAT SWABS UP TO 5 DAYS
                                  FOR CULTURE THEN CSF.
                                  SERUM (TT OR RT) FOR ANTIGEN
                                  ELISA.
                                        _>6 DAYS._
                                        SERUM (TT OR RT) FOR IgM.
                                        PATHOLOGY SPECIMENS PLUS BRAIN.
  ------------------------------------------------------------------------
      =POX=
  (SMALLPOX AND MONKEYPOX)        _2 TO 5 DAYS._
  _0 TO 24 HOURS._                SERUM (TT OR RT) FOR VIRAL
  NASAL SWABS AND INDUCED         CULTURE
  RESPIRATORY SECRETIONS FOR            _>6 DAYS._
  PCR AND VIRAL CULTURE.                SERUM (TT OR RT) FOR VIRAL CULTURE
                                        DRAINAGE FROM SKIN LESIONS/
                                        SCRAPINGS FOR MICROSCOPY, EM,
                                        VIRAL CULTURE, AND PCR.
                                        PATHOLOGY SPECIMENS.
  ------------------------------------------------------------------------
      =EBOLA=
  _0 TO 24 HOURS._                _2 TO 5 DAYS._
  NASAL SWABS AND INDUCED         SERUM (TT OR RT) FOR VIRAL
  RESPIRATORY SECRETIONS FOR      CULTURE.
  RT-PCR AND VIRAL CULTURE.             _>6 DAYS._
                                        SERUM (TT OR RT) FOR VIRAL CULTURE
                                        PATHOLOGY SPECIMENS PLUS ADRENAL
                                        GLAND.
  ------------------------------------------------------------------------
  =LEGEND:=

  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-1     fraction-1
  FA      fluorescent antibody
  H       Heparin
  HPLC    high-pressure liquid chromatography
  IgG     immunoglobulin class G
  IgM     immunoglobulin class M
  PCR     polymerase chain reaction
  RT      Red Top, if TT is not available
  RT-PCR  reverse transcriptase/polymerase chain reaction
  TT      Tiger top
  VEE     Venezuelan equine encephalitis
  WEE     western equine encephalitis
  =========================================================================

_c._ _Water Sample Collection._

    (1) Water samples for identification or verification of
    biological agent contamination are collected by PVNTMED
    personnel. The supporting laboratory should provide guidance on
    sampling procedures and collecting kits for use in collecting
    the samples. In the absence of guidance, a technique for use of
    the Sep-Pak^{TM} is described in FM 3-19.

    (2) When sampling kits are not available, samples may be
    collected in other available sterile containers. The best
    containers for use are the 100-ml glass bottles used for
    collecting routine water samples. All water samples must be
    collected and placed in a cooler or refrigerator until the
    sample is transported to its destination. During transportation
    the samples must be maintained at a temperature between 1°C and
    4°C.

_d._ _Food Samples._ Veterinary personnel must collect suspect
biologically contaminated food samples for submission to the
supporting laboratory for in-theater verification of contamination.
All food samples must be collected and placed in sterile
containers. Place the samples in a cooler or refrigerator until the
sample is transported to its destination. During transportation the
samples must be maintained at a temperature between 1°C and 4°C.

_e._ _Animal Specimens._ Veterinary personnel collect specimens
from suspect biologically contaminated/diseased animals. The same
types and amounts of specimens are prepared and shipped in the same
manner as are human specimens.

_f._ _Environmental Samples._ Environmental samples are collected
as directed in the operators' manual or other publications for
operating collection systems. Example: The Biological Integrated
Detection System (BIDS) collects an environmental sample using a
single liquid sample collector. The collector is a high-volume
aerosol sampling and collection device. On demand it samples
ambient air through a two-stage virtual impactor that concentrates
aerosol particles in the 2 to 10 micrometer diameter-size range.
The concentrate particle stream is directed through a wet collector
containing a buffer solution and, over a 45-minute period, a 40 to
50 ml sample is collected. On order or when test results indicate
a suspected agent, the sample and associated documentation are
packaged and transported IAW FM 3-101-4.


B-4. Chain of Custody

_a._ A strict chain of custody must be maintained for every
sample/specimen collected. Use DD Form 1911 (Material
Courier Receipt), or other document (such as DA Form 4137
[Evidence/Property Custody Document]) as directed for each
sample/specimen collected. The chain of custody document must
accompany the sample/specimen during transport from the point
of collection to the final receiving laboratory. Each time the
sample/specimen is transferred to another individual, 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 custody. The document will provide the answer to the
following questions:

    · When was the sample/specimen collected?

    · Who has maintained custody of the sample/specimen?

    · What has been done with the sample/specimen at each change of
    custody?

_b._ The samples/specimens must be appropriately packaged, labeled,
and evacuated to the designated medical laboratory for confirmation
of a biological attack. The standard chain of custody for the
evacuation would be as follows:

    · Sampling unit.

    · Unit S2/security office or medical operations officer.

    · Technical escort unit or other command-designated escort
    personnel.

    · In-theater supporting medical laboratory.

    · Designated CONUS laboratory.


Section II. SAMPLING TECHNIQUES AND PROCEDURES


B-5. General

The collection of environmental, and background (control)
samples/medical specimens is an integral part of investigating
allegations pertaining to the first use of chemical or biological
agents. The types of samples/specimens taken and the collection
methods primarily depend upon the circumstances encountered by the
collector. During all chemical and biological sampling operations,
the commander establishes the required protective equipment to
fit the situation. This appendix includes a recommended list
of equipment for use during chemical and biological sampling
operations (Table B-2).


_Table B-2. Example NBC Collection and Shipping Equipment List_

  ======================================================================
  AMOUNT           DESCRIPTION                         STOCK NUMBER
  ----------------------------------------------------------------------
    20     LABELS, PAPER, PRESSURE SENSITIVE           7530-00-577-4376
     2     GLOVES, 8-8½, EDMONT WILSON^{TM}            8415-00-JO2-2902
     2     GLOVES, 9-9½, EDMONT WILSON^{TM}            8415-00-634-4639
     1     TAPE, ADHESIVE, PRESSURE SENSITIVE, 2 INCH  7510-00-159-4450
     1     PLIERS, #47, 5 INCHES                       6520-00-543-5330
     1     SCREWDRIVER, FLAT TIP, ¼ INCH               5120-00-596-865
     1     TONGS, TEFLON^{TM} TIPS                     AF 15-202-5
     2     MICROSPATULA, WITH TEFLON^{TM} ENDS         AF 21-401-50A
     1     SCISSORS, UNIVERSAL TYPE                    AF 08-951-30
     1     SCOOP, POLYPROPYLENE, 5X2X2                 ASP S1021-5
     2     SPOON/SPATULA WITH TEFLON^{TM}              AF 14-356-10
     1     KNIFE, POCKET                               5110-00-526-8740
     5     BOTTLES, SAMPLE, POLYETHYLENE, 6 OUNCE      CP J-6103-50
     1     PIPET, JUMBO, TRANSFER TYPE (500/PKG)       AF 13-711-7
    10     PIPET, GRADUAL, TRANSFER TYPE (500/PKG)     AF 13-711-9A
    10     BAG, INSULATED, TYPE I                      AF 01-814-8
    10     BAG, INSULATED, TYPE 2[*]                   AF 01-814-10
     1     BAG, WHIRL/PAK, 6 OUNCE (500/PKG)           AF 01-812-6B
     1     STRIP, pH TESTING, NONBLEEDING, PLASTIC     SW S-65271
     1     SEP-PAK^{TM} C18                            W51910 (50/BOX)
     2     SYRINGE, HYPODERMIC, 50 OR 60 ml            6515-00-168-6913
     2     STOPCOCK, THREE-WAY                         ASP S8965-2
     1     TUBING, LABORATORY, R3602 CLEAR             AF 14-169-3B
     1     PEN, MARKING, WATERPROOF                    AF13-381 (12/PKG)
     2     TUBES, TENAX^{TM}                           EC ST-023
     1     BLADE, SURGICAL, CS2L 150S                  6515-01-009-5297
     2     PACK, ICE                                   CP TR-6345-20
     6     PAD, NONADHESIVE, 3X4, 100s                 6510-00-111-0708
     4     PAD, COOLING, CHEMICAL, 4S                  6530-00-133-4299
     2     PIGLETTES                                   SPECIAL ORDER
     1     TAPE, ANTISEIZE                             8030-00-889-3535
     1     AIR SAMPLER, PERSONAL                       LSS G4980
     1     KIT, METRIC, POCKET BUBBLE                  GL4981
     2     METHANOL
     1     WATER, DISTILLED (5 BOTTLE/PKG)
     1     MATCHES, WATERPROOF
    20     RAZOR, SURGICAL PREP                        6515-00-926-2089
    10     WATCH, WRIST                                6645-00-066-4279
     2     PARAFILM WITH DISPENSER                     6640-01-185-3289
     2     FLOOR SWEEP (VERMICULITE)                   8720-01-026-9419
   100     SEALS, TAMPER-RESISTANT
     1     A GAS METER CAPABLE OF PROVIDING
             ON-STATION ANALYSIS/DETECTION CAPABILITY
             FOR MULTIPLE GASES TO INCLUDE INDUSTRIAL
             GASES.
     1     A COMBUSTIBLE GAS INDICATOR THAT INDICATES
             PERCENTAGE OF OXYGEN AND EXPLOSIVITY.
     1     A GAS METER THAT DETECTS VAPOR IN PARTS
             PER MILLION (PPM) AND INDICATES PRESENCE
             OF VAPOR AND ITS STRENGTH.
     1     SWABS, THROAT
     2     CAN, 6 POUND, METAL
    10     BAG, MYLAR
     1     CONTAINER, LEAD SHIELDING (FOR RADIATION
             SAMPLES)
     1     CONTAINER, SHIPPING, IATA
     1     CHEST, ICE
    10     BAG, PLASTIC, RECLOSABLE

  [*] WILL BE REPLACED BY MYLAR BAGS
  ======================================================================


B-6. Expended Material

The NBC recon units collect samples under various circumstances.
For example, a recon unit may collect samples in an area free of
hostile forces. The Special Forces NBC Reconnaissance team may
collect samples within the enemy area of operations or deep into
the enemy's rear area. Samples include toxic agent munitions,
chemical products, air, water, soil, and vegetation. In addition,
all expended material used to collect the samples should be turned
in to the laboratory with the samples. This material includes items
such as expended M256A1 kits, M8 and M9 paper. These items should
be recovered, packaged, and shipped with the suspected samples for
analysis. Different information may be derived from each type of
sample; Table B-3 compares different types of samples.


B-7. 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 data. The contaminated samples must be
compared to the baseline data (control samples). This is especially
true if unknown or nonstandard chemical and/or suspected biological
agents were employed. The analysis center uses the control samples
to compare with a contaminated one. The recon unit collects control
samples of soil, water, and vegetation from areas about 500 meters
upwind of an alleged attack area. Control samples generically are
the same as those collected in an alleged attack area. For example,
if leaves from an apple tree in an attack area were collected as
a suspected contaminated sample, the recon team should collect
leaves (as a control sample) from an apple tree outside of the
contaminated area. If water from a pond in the attack area is
collected, the recon unit should collect control samples of water
from a pond (not a moving stream) in a nearby clean area. The size
of an environmental control sample should be about the same as the
suspected contaminated sample collected from the attack area (see
Table B-4, page B-20).


_Table B-3. Comparison of Sample Types_

  ======================================================================
                               SAMPLE STABILITY                ANALYSIS
  SAMPLE TYPE       INFO VALUE   TO COLLECT   TIME REQUIRED  RELIABILITY
  ----------------------------------------------------------------------
  AIR                 GOOD          GOOD          20 MIN          HIGH
  WATER               GOOD          GOOD           5 MIN          HIGH
  SOIL                FAIR          FAIR           5 MIN        MODERATE
  VEGETATION          FAIR          POOR          10 MIN          LOW
  TISSUE              EXCELLENT     FAIR          30 MIN          HIGH
  BLOOD               GOOD          FAIR          10 MIN          HIGH
  URINE               GOOD          FAIR          10 MIN          HIGH
  MUNITION FRAGMENTS  FAIR          FAIR          10 MIN          FAIR
  PACKING MATERIALS   FAIR          FAIR          10 MIN          FAIR
  ======================================================================


B-8. Collection of Air and Vapor Samples

_a._ Air is a good sample matrix since it is a well-mixed medium.
Air from a sample site contains a static concentration of
contaminants. The concentration of contaminants depends upon the
flow rate of the contaminant into the environment, the wind speed,
and the physical state of the contaminant, the terrain contours,
and temperature as a variable. The sample should be taken within
102 meters of a contaminated surface and at the downwind edge of
a contaminated area. The method should consist of pumping a given
volume of air, by hand or electric pump, through sample tubes.

_b._ To avoid contamination, persons conducting air sampling should
not use cologne, perfume, insect repellent, medical creams, or
strong soaps before taking a sample. The fragrances from these
products are volatile organic compounds that may be absorbed on the
filter and skew analytical results. Smoke also severely interferes
with air sampling, therefore, avoid tobacco and vehicle exhaust
smoke.

_c._ The primary method for collecting air samples is with the PAS
1000 automatic air sampler in conjunction with a Tenax^{TM} tube
for a total of three to four minutes when possible. Upon completion
of sampling, place the Tenax^{TM} tube in a 2¼-inch piglette.
Seal the piglette around the cap with either pressure-sensitive
or Teflon^{TM} tape. Once sealed, place the piglette into a Mylar
or reclosable bag. Fold the bag around the piglette in a circular
motion, then apply another bag and fold again. Once the bag is
folded around the piglette, use any type tape to secure the bag
around the piglette. Place the piglette into a refrigerator or
cooler until the sample is transported to its destination.

_d._ When chemicals are permitted into the atmosphere from a
facility, the best places to obtain samples are close to the
emission source where the concentration of the chemical is not
diluted. The further from the original point of release, the
more diluted the sample becomes from mixing with air, water, or
environmental pollutants.

_e._ Natural and man-made terrain features such as hills, valleys,
and rows of buildings, sometimes aid the collector by channeling
emissions. When these features are associated with a particular
facility, their downwind side is a suitable place to collect a
sample because the emission remains more concentrated further from
the release point.

_f._ For collection in a possibly contaminated location, and if
the situation permits, initially use a detection kit such as
the M18A2/M256AI to determine if a possible vapor hazard exists
from known chemical agents. Also, use the kit when personnel
are required to examine possible toxic agent munitions. In any
case, collect air samples with the white-band tubes and save for
identification and analysis.

_g._ Small air samplers also enable the collector to obtain vapor
samples from alleged toxic agent munitions at a safe distance while
explosive ordnance disposal (EOD) operations are performed. If EOD
personnel are not on the scene, the air sampler can be activated,
and the collector can stand at a safe distance while the sampler is
operating.

_h._ Perform sampling operations as soon as possible when directed
by a higher headquarters or after suspected chemical or biological
contamination is encountered.


B-9. Collection of Water Samples

_a._ Water sampling is a matter of collecting enough water to get
acceptable information about the contaminants. The collector should
provide the analysis center with one C18 and one silica cartridge
when using the Sep-Pak^{TM} technique or 100 ml in a sterile bottle
when Sep-Pak^{TM} is not available.

_b._ General guidelines: If it is believed that the threat has used
standard chemical agents during an attack, use the M272 chemical
agent water test kit for initial screening and sampling.

_c._ When collecting water samples using the Sep-Pak^{TM} C18
cartridge, the following items are required:

    · One 60 cc syringe without needle.

    · One 3-way sterile, plastic, stopcock with protective covers.

    · One piece of plastic tubing (3/16" inner diameter × 6" long
    minimum).

    · Sterile water or methanol.

    · One clean container, such as a Teflon^{TM} cup or glass jar.

_d._ Prior to collecting each sample, prime the Sep-Pak^{TM} system
in the following manner:

    · =Step 1.= Attach Sep-Pak^{TM} directly to 60 cc syringe.

    · =Step 2.= Pour small amount of sterile water or methanol into
    container.

    · =Step 3.= Insert tip of Sep-Pak^{TM} into container.

    · =Step 4.= Withdraw at least 40 cc of solution.

    · =Step 5.= Detach Sep-Pak^{TM} from syringe and discard
    solution from syringe.

    · =Step 6.= Repeat steps 3 through 5 using the same syringe.

_e._ After priming the Sep-Pak^{TM}, assemble the components in the
following configuration:

    · Attach the 3-way stopcock to a 60 cc syringe.

    · Attach the Sep-Pak^{TM} to the opposite end of stopcock.

    · Attach the plastic tubing to the open end of the Sep-Pak^{TM}.

_f._ Use the following procedures to collect samples with
Sep-Pak^{TM}:

    · =Step 1.= Ensure that the lever on the stopcock is turned
    sideways with the off arrow pointed toward the large outlet
    port.

    · =Step 2.= Place the open end of the plastic tubing into the
    water near the bottom, without touching the bottom or sides of
    the body of water.

    · =Step 3.= Draw 60 cc of water into the syringe.

    · =Step 4.= Turn the stopcock lever to the off position by
    positioning the lever to point toward the stopcock.

    · =Step 5.= Push the plunger all the way in, discharging the
    water from the syringe through the outlet port.

    · =Step 6.= Repeat steps 1 through 5.

    · =Step 7.= Detach a plastic tubing from the Sep-Pak^{TM}, and
    discard it as contaminated waste.

    · =Step 8.= Detach Sep-Pak^{TM} from 3-way stopcock; place into
    sample container; seal with pressure-sensitive tape; and mark
    for Identification.

        NOTE

        You should take a minimum of four samples: three samples of the
        suspected contamination and one control sample from a nearby
        unaffected (none contaminated) area for reference.

    · =Step 9.= Dispose of the syringe and stopcock as contaminated
    waste.

    · =Step 10.= Insert the sample container in a cooler or
    refrigerator until the sample is transported to its destination.

_g._ For samples to be representative of the overall contaminated
area, the collection point should be carefully selected. Collect
samples from--

    · Drains and slow-moving streams, since contamination and
    dilution from other sources are minimized.

    · Stagnant pools of water if the pools of water are part of
    chemical waste areas, such as a landfill or chemical disposal
    area. Chemicals may percolate into stagnant pools or sumps
    close to the site.

        NOTE

        If an oil film, globules of organic materials, or an unnatural
        appearing powder-like material is visible on the water's
        surface, collect a surface sample of the material. If not,
        collect the sample from near the bottom of the water source
        (stream, lake, pond, water container). The upper layers of
        water may have lesser amounts of contaminants, due to higher
        temperatures that promote decomposition. Since most chemicals
        of interest are more dense than water, contaminants usually
        sink to the bottom of the water source.

_h._ Collect the sample without the Sep-Pak^{TM} by immersing
a capped or stoppered container to the desired depth, removing
the cap or stopper, letting the container fill, and then capping
the container. An alternate method for deeper water is to use a
plastic, pump-operated siphon to pump water from a specific depth.

_i._ 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 ongoing. In the absence of reliable reporting,
this may be indicated by increased activity, higher than normal
amounts of security, or increased flow from facility chimneys or
water discharge pipes. In field areas where a toxic agent has been
sprayed or disseminated over a land area, the best time to collect
water samples is just after the start of a rainstorm when runoff is
beginning. Natural surface drainage will concentrate any remnants
of toxic compounds in depressions, streams, or ditches.


B-10. Collection of Soil Samples

Soil is a suitable medium to collect as samples for toxic organic
compounds. A critical point, however, is that the precise site
of the agent deposition must be sampled for best results.
Contamination may be recognized by discoloration or apparent
deposition of material on the soil's surface. If discoloration or
deposits of material are evident, only collect the discolored soil
or deposited materials, if possible. Dead, malformed, and wilted
foliage is an indicator of contamination. Soil samples should be
collected from open areas, along the drip line tents, stationary
equipment, bottom of ditches and terrain depressions.

_a._ Collect the soil samples by using a knife, spoon, spatula,
or similar item to scrape a square of topsoil (2×5×1 centimeters)
from areas that appear to have been contaminated in to a collection
container. If chunks or clods of earth are collected, select those
that are no larger than 10×5×1 centimeters (see Table B-4). Also,
collect a control sample of soil of the same type and texture from
a nearby uncontaminated area.

_b._ Use a glass bottle, jar, or Teflon^{TM} jar as the container
when available. When these containers are not available, Mylar bags
may be used. When using a glass bottle, jar, or Teflon^{TM} jar,
seal the cap with either pressure-sensitive or Teflon^{TM} tape,
and mark for identification. When using Mylar bags, place each
sample in a separate bag, push excess air out, and seal by folding
the open end over two to three times and wrapping the bag with
tape. Insert the first bag into a second bag, seal, tape, and mark
for identification. If possible, place the samples in a piglette.

    +-----------------------------------------------------------+
    |                           CAUTION                         |
    |                                                           |
    | Avoid direct contact with the sample to prevent exposing  |
    | yourself to the suspect agent (MOPP 4 is required).       |
    +-----------------------------------------------------------+

_c._ Collect samples as soon as possible when directed, upon
detection of a suspect substance, or after the alleged incident.


B-11. Collection of Contaminated Vegetation

As with soil samples, vegetation is also a suitable medium to
collect as samples for toxic organic compounds.

_a._ Collect samples of vegetation that appear to be different
from normal. Select leaves that have wilted or appear to have been
chemically burned. Collect samples of vegetation that appear to
have liquid or solid substances deposited on their surfaces (this
may be noticed as a shiny or moist area).

_b._ Collect samples of vegetation at several locations within the
suspected contaminated area. Using a cutting tool or any sharp
object, cut several affected leaves and/or a handful of grass
whenever possible. Do not crush the sample. Place the sample into a
Mylar or reclosable bag. Squeeze excess air out of the bag and seal
it. Fold the open end of the Mylar bag over two to three times, and
wrap it with tape. The minimum size for a sample is three leaves or
three handsful of grass. One leaf is of little value, but is better
than nothing. Bark is acceptable but not preferred. Mark the bag
for identification. Take a control sample of similar material from
an unaffected (uncontaminated) area. Fold, seal, tape, and mark the
control sample in the same manner as the actual sample.

_c._ When it is possible to determine a probable center of attack
in an area, collect vegetation samples near the center of the area,
about 100 meters upwind of the area, and in several 100-meter
increments downwind of the area. If the collector can discern a
contamination pattern in the area, this should be reported.


B-12. Medical Specimens

_a._ Just as blood and urine specimens are taken from humans who
were allegedly exposed in an attack, also collect specimens from
individuals who claim not to be affected by a toxic agent and
are from the same group as exposed personnel. The purpose is the
same as collecting environmental control specimens; that is, to
determine if a toxic substance is present in the individuals'
natural environment or if it has been artificially introduced.

_b._ Selection of humans for control sampling is somewhat more
complicated than selection of environmental control samples. This
is because ethnic diets, racial differences, physiological makeup,
and actual living conditions of persons who are outwardly similar
may introduce potentially large deviations. Each of these factors
must be accurately considered before selecting subjects as controls.

_c._ Consideration of ethnic diets is important because of unique
foods or methods of food preparation that may exist. As an example,
individuals in settled areas may purchase beer that has been
carefully filtered and sterilized, while individuals in a nearby
unsettled area may ferment their own beer by burying home crafted
jugs in the ground and extracting the product little by little over
several months.

_d._ Racial differences can account for differences in mortality
and morbidity rates in specific populations. One example of this
could be the high rate of hemophilia in a population versus the
rarity of the disease in another.

_e._ Physiological makeup is critical because of the differences in
hormone balance and tissue composition in males, females, adults,
and juveniles. For this reason, medical control specimens should be
drawn from individuals of the same gender and approximate age as
specimens from exposed personnel, if possible.

_f._ Differences in the actual living conditions of people also
require a close look. The point here is that conditions in
remote, semicivilized camps are seldom the same as those in a
well-established camp that has access to modern amenities.

_g._ The bottom line in selecting subjects for medical control
sampling is that they be as similar in all aspects as possible.


B-13. Collection of Medical Specimens

_a._ Trained medical technicians or physicians should collect
medical specimens (human or animal); however, Special Forces NBC
Reconnaissance team personnel are trained to do this procedure.
Remember, the collector must have express permission (authority)
to collect medical specimens from the dead, because of religious
beliefs in many cultures. To obtain such specimens without
permission may result in unnecessary mission complications. Ensure
all personnel handling or collecting medical specimens have
received proper immunizations for their own protection. They must
be inoculated IAW The Surgeon General's guidance.

_b._ Medical specimens collected during an investigation include
blood, urine, sputum, nasal swabs, and tissue specimens from living
victims and blood and urine specimens from unexposed persons
(background control specimens).

_c._ Collect blood specimens using either a standard 10 cc
disposable syringe with a 1- to 1½-inch needle (20 to 22 gauge),
or by using a Vacutainer^{TM} system. When using a Vacutainer^{TM}
system, ensure that multiple specimen needles and "red top" vacuum
tubes are used. Ten cc of blood is sufficient for analytical
testing. Do not take more than 5 cc from small, malnourished
children. After blood is collected, it should be transferred to
a polypropylene-type container and sealed with parafilm before
transporting.

All body fluids should be collected without violating antiseptic
techniques. Also, prior to transporting specimens, collectors
need to check specimen containers for paper labels IAW guidelines
for labeling medical specimens. Collect blood specimens using the
following materials equipment:

    · Gloves.

    · 10 cc sterile, disposable syringe.

    · 1- to 1.5-inch sterile needle (20 to 22 gauge).

    · Vacutainer^{TM} device (adapter with needle).

    · Constricting band.

    · Disinfectant pads, Betadine, or alcohol.

    · Sterile 2×2-inch gauze pads.

    · Labels.

        NOTE

        Gloves should be worn whenever handling medical specimens. Do
        not freeze liquid blood and urine specimens (ideal cooling
        temperature is between 35° and 40°F [2° to 4°C].)

_d._ Collect urine specimens using either a standard urine cup or
by a urine catheter and urine cup. When collecting the specimen
directly into a urine cup, the person must urinate into the cup
until sufficient fluid is collected (40 cc of urine is preferable,
although 10 cc can support analytical testing). When the person is
unable to urinate, the catheterization technique is preferable.
The catheterization technique is best performed in a clinical
environment. As with other body fluids collected, urine must be
kept cold. Do not freeze.

        NOTE

        For correct procedures on catheterization refer to STP
        8-91W15-SM-TG.

_e._ Collect tissue specimens using sterile scissors and forceps or
as directed by the attending physician.

    (1) When casualties have unidentified skin lesions, photographs
    of the lesion(s) and overall photos of the extent of the
    lesion(s) should be taken, using color film before biopsy. A
    specimen of the lesion should be obtained. This is done by
    surgically removing a portion of the skin with a sterile pair
    of scissors and forceps.

    (2) Place tissue specimens in a Teflon^{TM} container filled
    ¼ inch from the bottom with a preservative, (formalin 10%)
    for preservation of the specimen until it reaches its proper
    destination. Seal the container and lid with parafilm. As with
    any other medical specimens, tissue specimens are refrigerated
    prior to shipment; but do not freeze tissue specimens.

_f._ Collect nasal swabs by using a cotton-tipped swab. Place the
swab with collected specimen in a Teflon^{TM} container filled ¼
inch from the bottom with a preservative for preservation of the
specimen until it reaches its destination. Seal the container and
lid with parafilm. Refrigerate the specimen for shipment, but do
not freeze.

_g._ Collect sputum by having the patient discharge the sputum into
a small, sterile screw-top jar or urine specimen cup. Seal the
container and refrigerate the specimen for shipment, but do not
freeze.


B-14. Post mortem Specimens

Post mortem specimens should be collected by individuals trained in
forensics. When forensics-trained individuals are not available,
the most qualified medical person should collect human specimens.
Specimens from animals should be collected by veterinary personnel.
In either case, the following specimens are collected:

    · =Blood.= Use a 50 to 60 cc sterile syringe with an 18-gauge,
    5-inch (large bore) needle to collect blood from the heart, and
    urine directly from the bladder. Use a spinal needle to collect
    cerebral spinal fluids. Three of each type of specimens must be
    collected.

    · =Lungs.= A biopsy needle is needed to properly collect lung
    tissue specimens. After collecting specimens from the lungs,
    place specimens in a plastic or Teflon^{TM} container filled
    with 10% formalin (preservative) and seal the container for
    transporting to its destination.

    · =Liver.= If possible collect liver core specimens, using a
    large-gauge needle (18-gauge, 5-inch long) via intercostal
    or abdominal puncture. Or, if the family consents, perform
    a minilaparotomy and obtain one or two 2×2×2 cm sections of
    liver. Store and package the specimen as directed for tissue
    specimens. For suspect biological agents, see Table B-1 for
    specific types of specimens, amount, collection medium, and
    from whom to collect.

        NOTE

        Before attempting any of the above procedures, collector must
        be certified by a qualified person (medical doctor) on the
        correct procedures to collect specimens from cadavers.


_Table B-4. Standard Sizes of CB Samples/Specimens to be Collected_

  ========================================================================
      TYPE                    SIZE                    NOTES
  ------------------------------------------------------------------------
                           =CHEMICAL WARFARE SAMPLES=
  SOIL             (10 CM X 5 CM X 1 CM)    CIGARETTE-PACK SIZE OR LARGER
                                              AREA IS MORE USEFUL THAN
                                              GREATER DEPTH
  DILUTE AGENT     10 ML
  WATER            500 ML (MAXIMUM)
  C18 SEP-PAK^{TM}  200 ML
  VEGETATION       (EQUIVALENT TO 3 LEAVES  DEPENDS ON AMOUNT OF CONTAMIN-
                   OR 3 HANDSFUL OF GRASS)    ATION. BEST SAMPLES WILL BE
                                              FOUND NEAR THE RELEASE POINT
  ------------------------------------------------------------------------
                           =BIOLOGICAL WARFARE SAMPLES=
  SOIL             (10 CM X 5 CM X 1 CM)    CIGARETTE-PACK SIZE OR LARGER
                                              AREA IS MORE USEFUL THAN
                                              GREATER DEPTH
  LIQUID           25 TO 50 ML              DO NOT USE C18 SEP-PAK^{TM}
                                              WITH MEDICAL SPECIMENS
  VEGETATION       SIZE OF SOFT DRINK CAN   BEST SAMPLES DEPEND ON THE
                                              AMOUNT OF CONTAMINATION
                                              FOUND NEAR THE RELEASE POINT
  ------------------------------------------------------------------------
                              =MEDICAL SPECIMENS=
  URINE            20 TO 50 ML              MUST OBTAIN CONSENT TO COLLECT
                                              SPECIMENS FROM OTHER THAN US
                                              CASUALTIES
  WHOLE BLOOD OR   5 ML                     MUST OBTAIN CONSENT TO COLLECT
    SERUM                                     SPECIMENS FROM OTHER THAN US
                                              CASUALTIES
  CEREBRAL SPINAL  2 ML                     MUST OBTAIN CONSENT TO COLLECT
    FLUID                                     SPECIMENS FROM OTHER THAN US
                                              CASUALTIES
  ORGAN TISSUE     30 G (MINIMUM)
  MEDIASTINAL      2                        SHOULD BE REMOVED BY A SURGEON
    LYMPH NODES                               DURING AN AUTOPSY
  ========================================================================


B-15. Reporting, Packaging, and Shipment

Although a sample/specimen collected from an alleged attack area
can be significant, it can become useless if proper steps are
not taken to record critical information about its collection
or if it is improperly packed and breaks during shipment to an
analysis center. This section discusses the information needed when
acquiring samples/specimens and the preferred methods for handling
and packing samples/specimens for shipment.

_a._ A complete background information history of the circumstances
about each sample's/specimen's acquisition must be provided to the
agency analyzing the sample/specimen.

_b._ Critical background information includes--

    · Circumstances of acquisition. How the sample/specimen was
    obtained, where it was found, and how it was collected.

    · Physical description. The physical state (solid, liquid,
    powder, apparent viscosity), color, approximate size, identity
    of the specimen (such as military nomenclature), dirt, leaves,
    or so forth.

    · Circumstances of agent deposition. The type of delivery
    system, a description of how the weapon functioned, how the
    agent acted on release, sounds heard during dissemination, a
    description of any craters or shrapnel found associated with
    a burst, and colors of smoke, flames, or mist that may be
    associated with the attack.

_c._ Provide information on the agent effects on vegetation for
soil or environmental samples. A description of the general area
(jungle, mountain, grassland) and changes in the vegetation after
agent deposition (such as color change, wilting, drying, dead) in
the main attack and fringe areas.

_d._ Provide information on the agent effects on humans for medical
specimens. Describe how the agent affected personnel in the main
attack area versus fringe areas; the duration of agent effects;
peculiar odors that may have been noticed in the area prior to,
during, and/or after an attack; measures taken that alleviated or
deteriorated the effects; and the approximate number of victims and
survivors, to include their ages and genders.

_e._ Describe the agent effects on animals. Provide information on
the types of animals that were or were not affected by an attack
and of how they were affected.


B-16. Handling and Packaging Materials

Materials used for packaging samples/specimens primarily consist of
Mylar collection bags, Teflon^{TM} specimen jars and tubes, pigs
and piglettes, ice chests, sealing materials, and wrapping and
cushioning supplies.

_a._ _Collection Bag._ Use the Mylar bag as the initial container
for such samples as protective masks and filter canisters,
individual antidote and decon kits, munition fragments, and other
items too large to place in a specimen jar. Use it also to package
sample/specimen containers to ensure a vapor barrier in case the
container is broken in transit. The bag acts as an initial or
secondary vapor barrier to prevent air from leaking inward and
toxic material outward. Follow the procedures below when using the
bag.

    · If packaging a specimen container or nonenvironmental
    sample/specimen, first, verify it has a sample/specimen number.
    Carefully place the sample/specimen in a bottom corner of the
    Mylar bag.

    · Squeeze all the air out of the bag and seal it by removing
    the adhesive's protective strip, and pressing the two sides
    together.

    · Place a piece of 2-inch-wide fiber or cloth tape across the
    end of the bag that you just sealed to reseal the Mylar bag
    on the outside. This serves as extra insurance in case the
    internal seal is broken.

    · With the bag lying in front of you and the seal at the top,
    fold the bag across its width to as small a size as possible
    without damaging the sample/specimen. At this point, use tape
    to hold the fold. Next, fold the bag from the top down to the
    bottom of the bag to as small a size as possible. The sealing
    of the bag is the most critical step during the packaging
    process.

    · At this point, turn the bag over and use a marker or file
    label to put the sample/specimen number on the outside of
    the bag so that analysis center personnel can identify the
    sample/specimen.

    · Place the folded Mylar bag in a clear plastic reclosable
    bag, if available. Following the same steps you used for
    the Mylar bag, fold and seal the plastic bag. When this has
    been completed, again mark the sample/specimen number on the
    exterior of the bag.

_b._ _Glass Specimen Jars and Polypropylene Tubes._ Use glass
containers to hold small environmental samples, water samples, and
medical and post mortem specimens. Use polypropylene containers
to hold medical specimens such as blood or urine. Polypropylene
containers may be used for post mortem specimens if required;
however, glass containers are preferred. The use of glass rather
than plastic containers is preferred for environmental samples
because toxic agents may leach chemicals from plastics into a
sample, introducing contamination and confusing the analysis
efforts.

    · If the container has a screw-on lid, place Teflon^{TM}
    plumber's tape (NSN 8030-00-889-3535; Tape, Antiseize) on the
    threads of the container before putting on the lid. This helps
    to limit the leakage of liquids and vapor from the container
    and to assure the lid will not fall off while in transit. If
    the lid has a cardboard liner, remove the liner and replace it
    with one or two layers of parafilm (a laboratory sealant film).

    · Once the lid is on, stretch parafilm around the outside of
    the container at the junction of the lid and the glass. Two
    wraps of the film are enough to provide a leakage barrier and
    more assurance that the lid cannot fall off.

    · At this point, ensure the sample/specimen number is on the
    outside of the container. Use a diamond etching pencil or
    an adhesive label to put the sample/specimen number on the
    exterior of the container.

_c._ _Six-Pound Metal Can._ Use metal cans as the external
container for packaging small items that have been sealed in Mylar
bags, specimen jars, and polypropylene tubes containing medical
specimens. The metal can helps absorb shock from rough handling
during shipment and eliminates the spread of contamination if a
specimen container is broken. The six-pound metal can is capable
of holding more than one sample/specimen (depending upon size of
samples/specimens).

    · Before placing samples/specimens in the can for shipping,
    ensure a sample/specimen number is assigned and is visible on
    each item.

    · Place about 1 to 2 inches of packing material in the bottom
    of the can.

    · Wrap jars and tubes in plastic bubble wrap or ⅛- to
    ¼-inch-thick foam rubber sheeting, secure the wrap with tape or
    a rubber band, and place the wrapped item in the can.

    · If bubble wrap or foam rubber is not available, use
    newspaper. The guiding principle is that the sample/specimen
    containers should fit snugly and not be able to move in the can.

_d._ _Ice Chest._ Standard polyethylene or metal ice chests are
the most easily procured items used for transworld shipment of CB
samples/specimens. The most easily used size is about 24 inches
long by 18 inches high by 15 inches deep. This size permits the
sender to ship two or three 6-pound metal cans in each chest with
sufficient dry ice to maintain freezing temperatures for about four
days. Also, each chest remains at a weight that one individual can
handle.

_e._ _Transport Container._ When the samples/specimens must be
transported on commercial aircraft, an IATA-approved sample
transport container must be used for shipment/delivery to the CONUS
laboratory.

_f._ _Coolants._ Samples/specimens submitted for laboratory
analysis must be properly packaged, labeled, and shipped to
ensure they arrive in an analytically acceptable condition.
All samples should be maintained at a temperature of 1° to 4°C
during transport. Ideally, samples/specimens should arrive at
the in-theater laboratory within 6 hours of collection. The
samples/specimens should be delivered to the CONUS laboratory
within 24 to 48 hours. If the samples/specimens cannot be delivered
to the CONUS laboratory within this time, then they should
be flash frozen to -165°C, if capabilities are available. If
available, dry ice should be used when flash freezing cannot be
accomplished. If the samples/specimens cannot be delivered to the
CONUS laboratory within 24 hours, the supporting laboratory should
subculture the samples/specimens and send the subculture with the
samples/specimens to the CONUS laboratory. The subculturing date
should also be provided.

_g._ _Internal Insulation._ While a commercial ice chest provides
good insulation of both the samples/specimens and the coolant, it
is best to place extra insulation and cushioning around the metal
cans inside the chest. Newspapers, plastic bubble wrap, and foam
rubber may all be used with almost equally good results except
newspapers and standard ice do not mix well.


B-17. Collection Reporting

_a._ The collector must provide a formatted message for
transmission as soon as possible to report acquisition and shipment
of samples/specimens. During special operations in a theater in
which a Special Forces Group (SFG) is deployed, the message is
transmitted by the fastest means through the fewest channels to the
NBC control (NBCC) center. If a NBCC center has not been deployed
to the area of operations, as in low-sample/specimen volume
peacetime NBC sampling operation, the message is transmitted
by the fastest means through the fewest channels to the message
addressees below. In addition, a written report accompanies each
sample/specimen or batch of samples/specimens. The collector
ensures that the acquisition message has been properly classified.

_b._ The collection report includes at least the following
addressees:

    SECSTATE WASHDC
    SECDEF WASHDCHOSD-ISA/OUS-DREH
    JCS WASHDC//J-3/J-5H
    CIA WASHDCHOSWR-STD-LSBNIC-NIO(STP)H
    DIA WASHDC//DT-3B/DT-5A//
    DIR AFMIC FT DETRICK MD//AFMIC-CR/AFMIC-SA//
    DA WASHDC//DAMI-FIT/DAMO-SWC//
    CMDT USACMLS FT LEONARD WOOD MO//ATSN-CM-CO//
    CDR SBCCOM APG
    MDHSMCCR-OPF/SMCTE-OPE-RA-ID2H
    CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2H
    CDR USAMRIID FT DETRICK MD (For suspect biological
        samples/specimens only.)

_c._ A collection message contains the following information:

    · The sample/specimen identification number is part of the
    subject line if only a single sample/specimen is referred to in
    the text. Otherwise, refer to the sample/specimen number within
    the message body with its background information.

    · The shipment date, mode of transportation, courier
    identification, air bill of lading number, flight number
    destination, and estimated time of arrival are included if
    the sample/specimen is to be shipped immediately. Also, the
    material courier receipt form (DD Form 1911) should be used to
    maintain chain of custody.

    · Background information on the sample/specimen. Questionable
    circumstances surrounding acquisition of a sample/specimen.
    The name of another country or agency that acquired a
    sample/specimen from the same event or area and is not shown on
    the message address.

    · A recommended priority and rationale for analysis to guide
    the analysis center on the assessment of the potential value of
    the sample/specimen.

    · All details relating to the collection of the
    sample/specimen, regardless of how insignificant they may seem
    to the collector.

_d._ Ship all samples/specimens by the fastest, safest means,
preferably by a technical escort unit (TEU) to the theater
Chemical-Biological Sampling Control Element (CBSCE) or to a
location the CBSCE designates. If there is no CBSCE in the theater,
send the samples/specimens IAW preplanned instructions from the
Chemical-Biological Sampling Control Center (CBSCC) at CBDA,
Aberdeen, Maryland. The CBSCC uses the following criteria to
determine the final destination of each sample:

    · Is the sample/specimen chemical or biological in content?

    · Is the sample/specimen content completely unknown?

    · Is the sample/specimen a possible biological material?

    (1) In any case, the NBCC center must be notified in advance of
    shipment of the sample so additional instructions or deviations
    from standard instructions can be given. Figure B-l shows an
    example of a shipping notification message. The NBCC center
    will direct, in advance, that samples be sent to one or more
    of the following locations, depending on the category of the
    samples. Prior to shipment of samples/specimens, contact must
    be made with--

      Commander
      Technical Escort Unit
      ATTN: SMCTE-OPE
      Aberdeen Proving Ground, MD 21010
      DSN: 584-4381 (Duty hours) DSN: 584-2773 (After duty hours)

    (2) This unit controls the transport of samples/specimens
    to their final destination(s). Do not ship suspected toxic
    samples/specimens or munition systems to CONUS technical
    centers or intelligence agencies without coordination and prior
    approval by the recipient.

        NOTE

        Suspect CB samples/specimens are first delivered to the
        supporting medical laboratory in the AO for in-theater
        analysis before they are transported out of the AO. The
        supporting laboratory will withdraw an aliquot of selected
        samples/specimens for analysis. The supporting medical
        laboratory is responsible for providing the AO commander
        confirmatory identification within the AO. The CONUS-based
        reference laboratory is responsible for providing confirmatory
        identification for President and Secretary of Defense purposes.


    FM AMEMBASSY DDTTTTZ JAN 02
    TO CDR TEU APG MD//SMCTE-OPE//
    SECSTATE WASHDC
    SECDEF WASHDC//OSD-ISA/OUS-DRE//
    INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)//
    JCS WASHDC//J-3/J-5//
    DIA WASHDC//DT-3B/DT-5A//
    DIR NSA FT MEADE MD
    DIR AFMIC FT DETRICK MD//AFMIC-CR/AFMIC-SA//
    DA WASHDC/DAMI-FIT/DAMO-SWC//
    CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2//
    CDR CBDA APG MD//SMCCR-OPF//
    CDR USACMLS FT MCCLELLAN//ATZN-CM-CU//

    CLASSIFICATION

    SECSTATE FOR...
    SECDEF FOR...
    CIA FOR...
    JCS FOR J-3/J-5 FOR...
    DA FOR DAMO-SWC FOR...
    AFMIC FOR...
    CBDA FOR FIO...
    FSTC FOR AMXST-FW...
    USACMLS FOR THREAT MGR...

    E.0.12356: DECL: OADR (Note: This is included if the message is
    classified.)
    TAGS: ...

    Subject: Shipment of CB Samples/Specimens
    REF(S): TEU MSG #, (DTG DDTTTT [time zone] JAN 02)

    1. (W) SHIPPING INFORMATION:

        A. DATE SHIPPED: JANUARY 11, 2002.
        B. MODE OF TRANSPORTATION: AIR EXPRESS, AIR BILL NUMBER RPT
        C. FLIGHT SCHEDULE: TO TYO BY JAL XXX, JANUARY 11, 2002. TO JFK
           BY JAL YYY, JANUARY 12, 2002. TO IAD BY DEC ZZZ,
           JANUARY 12, 2002.
        D. DESTINATION: DULLES INTERNATIONAL AIRPORT.
        E. ESTIMATED TIME OF ARRIVAL: 2010 HOURS, JANUARY 12, 2002.

    2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.

    3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMIC)
    CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE
    IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID
    BREAKAGE. THE FOLLOWING SAMPLES ARE INCLUDED IN THE SHIPMENT:

    SAMPLE/SPECIMEN NUMBER                           MESSAGE REFERENCE
    TH-850102-001AG THRU TH-850102-005AG             BANGKOK DDTTTTZ JAN 02

    4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.

_Figure B-l. Sample shipping notification message._


B-18. Sample/Specimen Background Documents

The sample/specimen background document allows a collector
to note the most relevant details associated with pre- and
post-sample/specimen collection conditions. Do not consider the
report to be all-inclusive. The information collected should
include at least the items listed in Figure B-2. Interviews should
be conducted with individuals exposed to the CB agent as well as
individuals not exposed (see Figure B-3).

  1. ID NUMBER___________

  2. COLLECTION (DATE/TIME):______________________

  3. COLLECTOR/UNIT:_______________________________

  4. TYPE: ENVIRONMENTAL___ BIOMEDICAL___ SINGLE___ MULTIPLE___

  5. PURPOSE: ATTACK___ CHEM/BIO ALARM___ CHEM DETECT___
     RECON ILLNESS/DEATH___ OTHER___

  6. POSTEXPOSURE: HOURS___ DAYS___ WEEKS___ UNKNOWN___

  7. LOCATION: TOWN_______________ COORDINATES__________________________

    A. TERRAIN: FLAT___ HILLS___ MOUNTAIN___ DESERT___ JUNGLE___
       SPARSE TREES___ GRASS___ BODY OF WATER/TYPE___

    B. WEATHER: CLEAR___ CLOUDY___ RAIN___ FOG___ SNOW___ DUST___

    C. WIND: LIGHT___ HEAVY___ GUSTY___ NONE___

    D. ODOR: SWEET___ FRUITY___ PEPPER___ FLOWER___ IRRITATING___
       CHANGING___ NONE___ OTHER_____

    E. TEMPERATURE AT TIME OF ATTACK:_____ TEMPERATURE AT TIME OF SAMPLE
       COLLECTION:_____

  8. COMMENTS:
  ______________________________________________________________________
  ______________________________________________________________________

  9. ATTACK: DATE/TIME_______ METHOD: ARTILLERY___ ROCKET___ AIRCRAFT___
     MORTAR___ RPG/GRENADE___ OTHER, DESCRIBE:__________________________

    A. EXPLOSION: AIR_______ (HEIGHT)_______ GROUND_________ SIZE_______
       DISTANCE_________ DESCRIBE:____________________

    B. CONSISTENCY: SMOKE___ MIST___ DUST___ RAIN___ GEL___
       INVISIBLE, DESCRIBE:_______

  10. ENVIRONMENTAL SAMPLE: SOIL__ WATER__ VEGETATION__ AIR__ OTHER___

  11. BIOMED SPECIMEN: ACUTE___ CONVALESCENT___ EXPOSED___ NOT ILL___
      POSTMORTEM___ CONTROL, EXPLAIN:_________________ BLOOD___ LIVER___
      LUNG___ SPLEEN___ BRAIN___ SKIN___ KIDNEY___ URINE___
      OTHER, DESCRIBE:_________________________

  12. COMMENTS:
      __________________________________________________________________

  13. CASUALTY: SSN_______________ UNIT_______________________ SEX______

  14. SIGNS/SYMPTOMS: ONSET__ DURATION__

     A.  HEAD: FEVER___ CHILLS___ HEADACHE___ FLUSHED___  DIZZINESS___
         UNCONSCIOUSNESS___ COMA___ HALLUCINATIONS___

     B.  EYES: SUNLIGHT SENSITIVE___ PAINFUL___ BURNING___
         DROOPY EYELIDS___ DOUBLE VISION___ BLURRED VISION___
         LARGE PUPILS___ PINPOINT PUPILS___

     C.  NOSE: RUNNY___ BLEEDING___

     D.  THROAT: SORE___ DRY___ SALIVATING___ BLOODY SPUTUM___
         HOARSENESS___ DIFFICULTY SPEAKING___

     E.  RESPIRATION: DIFFICULTY BREATHING___ CHEST/PAIN DISCOMFORT___
         WHEEZING (IN/OUT)___ COUGHING___ LABORED BREATHING___

     F.  HEART POUNDING OR RUNNING___ IRREGULAR HEARTBEAT___

     G.  GI: LOSS OF APPETITE___  NAUSEA___ FREQUENT VOMITING___
         FREQUENT DIARRHEA___ VOMITING BLOOD___ DIARRHEA WITH BLOOD___

     H. URINARY: BLOODY URINE___ UNABLE TO URINATE___

     I.  MUSCULOSKELETAL: NECK PAIN____ MUSCLE TENDERNESS___
         MUSCLE TREMBLING/TWITCHING___  WEAKNESS___
         PARALYSIS, DESCRIBE:_____________________ CONVULSIONS___
         TREMORS___ MUSCLE ACHES___ BACK PAIN___ JOINT PAIN___

     J. SKIN: RASH___ REDDENING___ ITCHING___ BLISTERS___ PAIN___
        NUMBNESS___ PROFUSE PERSPIRATION___

  15. COMMENTS:
  ______________________________________________________________________

  16. ANIMALS AFFECTED: YES___ NO___ DESCRIBE:__________________________

  17. RELATED SPECIMENS_________________________________________
      ID NUMBER_____________________________________
      DESCRIPTION__________________________________

  18. COLLECTOR
      SIGNATURE____________________________
      NAME___________________________
      PHONE NUMBER______________________
      E-MAIL________________________

  19. REVIEWER
      SIGNATURE
      NAME
      PHONE NUMBER_________________
      E-MAIL_________________

_Figure B-2. Sample/specimen background document._


  CB INCIDENT INTERVIEW

  DATE:_____________________ INTERVIEWER: ______________________________
  SUBJECT'S NAME: ______________________________________________________
  ALIAS #1_____________________________ #2______________________________
  AGE:____________   SEX:  ____ M   ____F       YEAR OF BIRTH:__________
  NATIONALITY:__________________________________________________________
  SUBJECT'S ADDRESS:____________________________________________________
  IDENTITY CARD #:______________________________________________________
  DELIVERY METHODS:
  TYPE: ____UNKNOWN _____GROUND ____AIR  _____ARTILLERY/ROCKET  ____MINE
  OTHER, DESCRIBE:______________________________________________________
  HEIGHT: ______(M)
  SIZE: _____________ (AFFECTED AREA IN METERS)
  DISTANCE: __________(M)
  AGENT CHARACTERISTICS
  ODOR: _____NONE  _____SWEET  _____FRUITY  _____IRRITATING  _____PEPPER
  _____FLOWER _____CHANGING _____OTHER, DESCRIBE:_______________________
  COMMENTS:_____________________________________________________________
  ______________________________________________________________________
  CONSISTENCY:
  ______SMOKE   ______MIST   _____DUST  _____RAIN  ______GEL   ______DRY
  ____VISIBLE ____INVISIBLE ____OTHER, DESCRIBE:________________________
  COLOR:_____________ DESCRIBE DEVELOPMENT OF COLOR:____________________
  AREA COVERAGE:________________________________________________________
  PHYSICAL DISSEMINATION/COVERAGE (i.e., DROPLET SIZE AND DISTRIBUTION):
  WRITE OR DRAW_________________________________________________________
  SYMPTOMS:_____________________________________________________________
  ______________________________________________________________________
  INDIVIDUAL'S ACTIONS:
  DURING ATTACK:________________________________________________________
  ______________________________________________________________________
  AFTER ATTACK:_________________________________________________________
  ______________________________________________________________________
  PROTECTIVE MEASURES:__________________________________________________
  TREATMENT RECEIVED:___________________________________________________
  ______________________________________________________________________
  ENVIRONMENTAL EFFECTS: VEGETATION CHANGE?  ___YES  ___NO
  DESCRIBE:_____________________________________________________________
  ______________________________________________________________________
  ANIMALS AFFECTED?  ___YES  ___NO
  DESCRIBE:_____________________________________________________________

  OTHERS AFFECTED:

  NAME               AGE               SYMPTOMS               RESOLUTION
  ______________________________________________________________________
  ______________________________________________________________________
  ______________________________________________________________________

_Figure B-3. Chemical/biological incident interview._


  FM AMEMBASSY DDTTTTZ JAN 02

  1.00
  SHIPPING

  TO CDR TEU APG MD/SMCTE-OPEI/
  SECSTATE WASHDC
  SECDEF WASHDC//OSD-ISA/OUS-DRE//
  INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)//
  JCS WASHDC//J-3/J-5//
  DIA WASHDC//DT-3B/DT-5A//
  DIR NSA FT MEADE MD
  DIR AFMIC FT DETRICK MD//AFMIC- CR/AFMIC-SA//DA WASHDC//
    DAMI-FIT/DAMO-SWC//
  CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2//
  CDR CRDEC APG MD//SMCCR-OPE//
  CDR USACMLS FT LEONARD WOOD MO//ATSN-CM-CO//
  CDR USAMRIID FT DETRICK MD// (FOR SUSPECT BIOLOGICAL
    SAMPLES/SPECIMENS ONLY)

  CLASSIFICATION

  SECSTATE FOR...
  SECDEF FOR
  CIA FOR
  JCS FOR J-3/J-5 FOR
  DA FOR DAMO-SWC FOR
  AFMIC FOR
  CRDEC FOR FIO
  FSTC FOR AMXST-FM
  USACMLS FOR THREAT MGR
  E.O. 12356: DECL: OADR (NOTE: This is included if the message is
     classified.) TAGS:

  =SUBJECT: SHIPMENT OF CB SAMPLES=
  REF(S): TEU MSG, #______. (DTG DDTTTT [time zone] Jan 02)

  1. INFORMATION:
     A. DATE SHIPPED: JANUARY 11.2002.
     B. MODE OF TRANSPORTATION: AIR EXPRESS. AIR BILL NUMBER RPT
     C. FLIGHT SCHEDULE: TO TYO BY JAL XXX JANUARY 11, 2002. TO JFK BY
         JAL YYY, JANUARY 13, 2002. TO IAD BY DEC ZZZ, JANUARY 12, 2002.
     D. DESTINATION: DULLES INTERNATIONAL AIRPORT
     E. ESTIMATED TIME OF ARRIVAL; 2010 HOURS. JANUARY 12, 2002.

  2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.

  3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMICO)
     CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE
     IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID
     BREAKAGE. THE FOLLOWING SAMPLES/SPECIMENS ARE INCLUDED IN THE
     SHIPMENT:

  SAMPLE/SPECIMEN NUMBER                MESSAGE REFERENCE TH-8501
  1AG THRU TH-850102-005AG              BANGKOK DDTTTTZ JAN 0202-00

  4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.

_Figure B-4. Sample/specimen shipping report._




APPENDIX C

GUIDELINES FOR OPERATIONAL PLANNING FOR HEALTH SERVICE SUPPORT IN A
NUCLEAR, BIOLOGICAL, AND CHEMICAL ENVIRONMENT


C-1. General

As the HSS unit prepares for its support role, NBC, TIM, and CBRNE
considerations must be included. This appendix provides guidelines
for HSS planning, preparing for, and conducting operations in an
NBC environment and responding to a homeland defense CBRNE event.


C-2. Predeployment

When preparing the unit's mobilization plan and TSOP, include
the supplies and equipment that will be required for the unit
to operate in an NBC environment. DO NOT wait until ordered to
mobilize to begin preparation for the mission. A well-prepared
and trained unit stands a much better chance of surviving and
accomplishing their assigned mission. At a minimum include the
following:

    · Nerve agent pretreatment and antidotes (see FM 8-285).

    · Blister agent antidote/treatment (see FM 8-285).

    · Incapacitating agent treatment (see FM 8-285).

    · Lung-damaging agents (choking agents) treatment (see FM
    8-285).

    · Blood agent (cyanogen) treatment (see FM 8-285).

    · Biological agent immunizations and chemoprophylaxis (see FM
    8-284).

    · Biological agent treatment (see FM 8-284).

    · Nuclear and radiological treatment (see FM 4-02.283).

    · Protective mask with hood for each individual (see FM 3-4).

    · Replacement filters for protective mask (see FM 3-4).

    · Two sets of MOPP per individual assigned to unit (see FM 3-4).

    · All authorized radiation detection equipment.

    · All authorized chemical agent detection equipment.

    · All authorized NBC alarm systems.

    · Biological agent detection equipment, if available.

    · Sample/specimen collection, packaging, and shipping supplies
    for suspect NBC agents.

    · Decontamination equipment and supplies (DS2, STB, pails,
    sponges, mops, decontaminant application apparatus, individual
    skin decontamination kits, and individual equipment
    decontamination kits [see FM 3-5]).

    · Material for covering supplies and equipment (such as plastic
    sheeting, tape, and tarpaulins).

    · Material for preparing improvised protection in shelters
    (such as plastic sheeting, tarpaulins, tape, and sandbags).

    · Collective protection shelter systems with repair parts, if
    available.

    · Chemical agent patient decontamination Medical Equipment Set
    (MES). The MES can also be used to decontaminate nuclear and
    biological patients, if authorized.

    · Chemical agent patient treatment MES. Some components may
    also be used to treat nuclear and biological patients, if
    authorized.

    · Water supply for patient decontamination, if required.

    · Shovels, picks, and axes.

    · Lightweight decontamination system M17 and other
    decontamination apparatuses.

    · Applicable references (Army Regulations [ARs], Joint
    publications, FMs, technical manuals [TMs], training circulars
    [TCs], and TSOPs).


C-3. Mobilization

During mobilization the unit must ensure that all supplies and
equipment are on hand and are serviceable. Commanders and leaders
must also ensure that--

    · Movement plans are prepared.

    · Transportation support requirements are identified and
    requested.

    · Load plans include provisions for the transportation of NBC
    supplies and equipment (medical and nonmedical).

    · A MOPP level has been established for the movement, if
    applicable.

    · A checklist of training shortfalls is prepared and a training
    plan is in place.


C-4. Establish a Medical Treatment Facility

Plans for establishing a BAS, DCS, or FST for operating in a
NBC environment must include employment of CBPS systems. When
establishing a hospital using Deployable Medical Systems (DEPMEDS),
the chemically protected (CP) DEPMEDS must be set up as the
conventional shelters are being set up. Once the conventional
shelter has been set up and is operational, CP DEPMEDS cannot be
established without first taking down the existing shelter. Follow
the technical manual provided with the CP DEPMEDS system issued to
your unit. Plans for operating a DEPMEDS equipped hospital in the
NBC environment should include, but not be limited to--

    · Coordinating with the supported unit to ensure unit casualty
    collecting points and patient decontamination points are on the
    HSS template. If possible, integrate HSS units/elements into
    local units NBC detection systems and communications systems.

    · Surveying the AO. Survey the area to ensure contamination is
    not present before establishing the MTF.

    · Establishing detection stations on the unit's perimeter.

    · Determining direction of prevailing wind. All contaminated
    patients, ambulances, and helicopters must arrive on the
    downwind side of the MTF; this must be done with or without CPS.

    · Setting up the contaminated triage, patient decontamination,
    and contaminated treatment areas (including overhead cover).

    · Establishing the contaminated ambulance point.

    · Establishing the contaminated helicopter landing area.

    · Preparing the contaminated waste dump.

    · Establishing the clean ambulance point.

    · Establishing the clean helicopter landing area.

    · Marking the hot line and preparing the shuffle pit.

    · Employing CP DEPMEDS system (close shelter, turn on CB
    filtration units, close air locks, and maintain overpressure),
    if available.

    · Establishing the clean treatment area 30 to 50 yards (meters)
    upwind of hot line, when CPS is not available.

    · Ensuring provisions for overhead cover at the patient
    decontamination area.

    · Requesting patient decontamination personnel from supported
    units for the BAS and DCS, or from units located within the
    geographic area for hospitals.

    · Requesting issue of chemical patient treatment and chemical
    patient decontamination MESs, if not on-hand.

    · Establishing contamination monitoring procedures in CPS.

    · Establishing control procedures for personnel crossing the
    hot line (through the shuffle pit).

    · Establishing CPS entry and exit control procedures (see
    Appendix F).

    · Making improvisations; if the MTF must operate in a
    nuclear/radiological environment. For optional improvisations,
    see Appendix H.


C-5. Operate a Medical Treatment Facility Receiving Contaminated
Patients

Individuals should have decontaminated themselves or have been
decontaminated by unit personnel; however, an MTF must plan for
and be prepared to receive contaminated patients. The patients may
not have been decontaminated at the unit, or they may have become
contaminated en route to the MTF. Selected CSHs may be designated
as the primary NBC MTF and be augmented with additional supplies
and medical staff. When designated as such, plans must be prepared
designating the location of the CSH that can best support the
forward deployed MTFs. All actions listed in paragraph C-4 must be
taken. During operations, actions that must be taken are--

    · Establishing a MOPP level commensurate with the operation.

    · Requiring all ambulances and helicopters with contaminated
    (or suspected) patients to stay downwind of the MTF.

    · Conducting initial triage, decontamination, and contaminated
    treatment downwind of the clean treatment area (Appendixes F
    and H).

    · Ensuring all personnel crossing the hot line are
    decontaminated.

    · Monitoring personnel entering clean area to ensure that they
    are contamination free.

    · Monitoring for contamination in the clean treatment area
    (with or without CPS).

    · Establishing an internal monitoring program to periodically
    verify that the MTF is contamination free.

    · Monitoring CPS for entry of contamination.

    · Providing protection for patients if contamination enters the
    MTF.

    · Ensuring personnel drink sufficient quantities of water to
    prevent heat injury (see FM 21-10).

    · Providing protection for personnel and patients in a
    cold environment. Use sheltered/heated area for patient
    decontamination.

    · Providing protection of personnel and patients in a hot
    environment.

    · Controlling contaminated waste.

    · Isolating biological agent patients, if necessary, to control
    spread of agent/disease (see FM 8-284).

    · Protecting supplies and equipment from contamination.

    · Providing medical resupply to clean areas.

    · Providing food service for personnel and patients in CPS.

    · Providing latrine facilities in CPS.

    · Providing drinking water in CPS.

    · Providing waste disposal support. Remove waste from the CPS
    at least two times dally. More frequently if large amounts are
    collected or if odors become a problem.

    · Collecting suspect BW agent specimens from patients.
    Packaging, preparing chain of custody document, and shipping
    specimens to supporting medical laboratory.


C-6. Preventive Medicine Services

Plans for providing preventive medicine services must include
monitoring water supplies for contamination. To perform this
mission, equipment and supplies must be available and operational.
Essential equipment and supplies include--

    · Radiation detection equipment such as AN/PDR77, AN/PDR27,
    AN/VDR2.

    · Preventive Medicine Water Quality Control Set.

    · M272 Chemical Agent Detection Set.

    · Biological sample collection kit, shipping containers,
    refrigerant, and chain of custody forms.


C-7. Veterinary Services

Plans for veterinary services must include provisioning for
treatment to government-owned animals and quality control of
food supplies. To perform their mission, essential supplies and
equipment include--

    · Treatment for NBC injured animals. Especially, antidotes and
    treatment for CB agents.

    · Radiation detection equipment.

    · M272 Chemical Agent Detection Set.

    · Biological sample/specimen collection kit, shipping
    containers, refrigerant, and chain of custody forms.


C-8. Dental Services

Most dental services at the dental treatment facilities will have
to be suspended in NBC contaminated areas due to a lack of CPS.
Plans must include for emergency dental services to be provided
in a clean area or in an MTF with a CPS. Essential supplies and
equipment include--

    · Dental treatment set for maxillofacial injuries.

    · Material for covering and protecting supplies and equipment.


C-9. Combat Operational Stress Control

Although specific supplies and equipment are not required for
COSC, plans must be prepared to provide these services under NBC
conditions. The COSC staff must locate clean areas to conduct COSC
activities or manage the COSC patients in a MOPP level commensurate
with the command MOPP guidance.


C-10. Medical Laboratory Services

Planning for medical laboratory support must include plans for
conducting analysis on suspect NBC samples/specimens. Designated
supporting medical laboratories must be prepared to analyze and
provide confirmation/identification on specimens/samples of suspect
NBC agents from humans, water sources, food supplies, and the
environment (air and soil). The samples/specimens may be collected
by MTF personnel, chemical corps personnel, PVNTMED personnel,
veterinary personnel, or other services personnel. To perform this
mission, supplies and equipment should include--

    · General supplies and equipment.

      · Biological sample/specimen collection kits and supplies. To
      provide capabilities for others to collect samples/specimens
      (in the event that they do not have these items otherwise
      available).

      · Biological test kits or apparatus.

    · Microbiology services.

      · Immunology/serology MES.

      · Microbiology MES.

      · Laboratory, general MES.

    · Veterinary services.

      · Laboratory, veterinary MES.

      · Veterinary postmortem field MES.

    · Preventive medicine services.

      · Water, biological sampling and analysis supplies and
      equipment.

      · Radiation protection MES.

      · Entomology MES.

      · Alpha/beta detectors.

      · Microscope, phase.

      · Ambient air analyzer.

      · Epidemiology MES.


C-11. Health Service Logistics

Plans must include health service logistics support to continue
under NBC conditions. To continue this role, all supplies must be
protected from contamination. Materials required include--

    · Detection equipment.

    · Plastic sheeting.

    · Tape.

    · Tarpaulins.

    · NBC detection equipment such as, M8 chemical agent detection
    paper, M9 chemical agent detection tape, radiation detection
    equipment, and biological agent sample/specimen collection
    supplies.

        NOTE

        This guideline contains items that are required specifically
        for HSS operations in an NBC environment. The items are in
        addition to supplies and equipment required for conventional
        operations. This guideline is not all inclusive, but is
        a starting point for HSS units to develop their specific
        guidelines.


C-12. Homeland Security

Health service support units and installation medical
activities/centers must be prepared to provide support in the
event that CBRNE are used on the United States. Medical commanders
and leaders should develop plans on how the provision of medical
support will be provided to a CBRNE event. The plan should include,
but not be limited to--

    · Number and type of units required to respond.

    · Medical equipment and supplies required.

    · Personal protective equipment required for medical response
    personnel.

    · Time required to prepare unit/personnel to respond.

    · Length of time response support is required.

    · Sources for food, shelter, local transportation, and resupply
    of expended or lost equipment and supplies.




APPENDIX D

MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR, BIOLOGICAL,
AND CHEMICAL BATTLE CASUALTIES


Section I. INTRODUCTION


D-1. General

The primary purpose of the Medical Planning Guide for the
Estimation of Nuclear, Biological, and Chemical Battle
Casualties--AMedP-8(A), a three-volume publication for NBC, is to
assist medical planners, medical logisticians, and medical staff
officers in predicting NBC warfare contingency requirements for
HSS personnel, medical materiel stockpiles, patient transport
or evacuation capabilities, and facilities needed for patient
decontamination, triage, treatment, and supportive care. The
optional use of these guides is for projecting medical NBC
operational estimates at brigade, division, corps, and EAC.

    NOTE

    The use of "the guide" in this appendix refers to AMedP-8(A),
    Volume I, II, or III. The AMedP-8(A), Volume I, II, or III, is
    the text for each of the STANAGs. The contents of this appendix
    are extracts from Sections 1, 2, and 3 of the guide.


D-2. Medical Planners' Tool

Medical planners' estimates (such as casualty, logistics,
evacuation, and personnel cross leveling) must be modified for
the NBC environment. Estimates of NBC medical workload can be
found in AMedP-8(A). A compact disk containing these documents
and an automated version of AMedP-8(A), the Casualty Requirements
Estimation Tool (CREST), can be obtained from Headquarters,
Department of the Army, ATTN: DASG-HCZ-FD, 5109 Leesburg Pike,
Falls Church, VA 22041-3258. The CREST is primarily an Army tool
focusing on corps, brigades, and battalions, but also models aerial
ports of debarkation, seaports of debarkation, and other units.


    +--------------------------------------+
    | This Section Implements STANAG 2475. |
    +--------------------------------------+


Section II. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR,
BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES (NUCLEAR)--AMedP-8(A),
VOLUME I


D-3. General

_a._ Volume I of the guide provides estimates of casualties and
remaining operational strength after a nuclear detonation in a
brigade-sized unit during an out-of-area contingency operation.
These estimates include the numbers, injury type (initial nuclear
radiation, blast, and thermal injuries), and injury severity of
nuclear patients based on several brigade scenarios. The scenarios
include three different brigade-sized units, in warned or unwarned
posture, which have single detonation of 5, 20, or 50 KT in the
unit area.

_b._ The guide is organized into 10 sections. Section 1
introduces the guide and presents background and medical planning
considerations. Section 2 provides information on the methodology
used to develop the estimates of fatalities, casualties, and
effectiveness of individuals remaining in the unit. Section 3
explores the use of the casualty prediction tables based on combat
effectiveness decrements and estimates of the number of casualties
categorized by insult level. Sections 4 through 10 contain tables
of casualty estimates.

_c._ A sample of this information is graphically depicted in
Tables 1-1 and 1-2 of the guide. The casualty estimates used to
prepare these tables are presented in the guide as Tables 6-4
and 10-4 in Sections 6 and 10 respectively. The use of these
tables is explained in paragraphs 3.1 through 3.6 of the guide.
Paragraphs 3.7 and 3.8 of the guide discuss how to use the guide
for situations not explicitly addressed.

_d._ The effects of residual radiation on personnel are not
included in the guide. AMedP-6 and AMedP-7 provide information
on planning, operations, and treatment for a residual radiation
situation. Also not included is the impact of tumbling; impact
of glass shards from windows of vehicles or buildings; crushing
deaths from building failure; or COSC casualties; thus causing
underestimations on the number of patients. Further, there will be
personnel who get radiation doses or burns and do not seek medical
care.

_e._ A nuclear detonation may introduce new levels of destruction
to the battlefield. There is very little experience with nuclear
effects and there is certainly no experience with these weapons
on a modern, highly technological battlefield. Therefore, there
is little historical data on which to base estimates of personnel
injured. Computer simulations are generally used to estimate
numbers of personnel injured. Although these estimates may include
significant uncertainty, they provide the best estimates to date.


D-4. Medical Planning Considerations

_a._ For effective mass casualty management, key medical and
related considerations must be well planned and practiced. These
include on-site triage and emergency care, communications, health
service logistics, evacuation by ground and air resources, and
personnel training in self-aid/buddy aid. Plans need to be made
for requirements that may differ from the usual combat situation.
For example, in combat situations, severe burn injuries in large
numbers are relatively uncommon. Therefore, no special planning
for the care of large numbers of burn patients is required. In a
nuclear environment, this may not be true, and consideration must
be given to the increased need for medical support that would
result from a high incidence of burn patients.

_b._ Prior to an attack, the data may be used by medical planners
to augment the requirements for conventional combat as appropriate
for the nuclear situation. The tables can be used to prepare
estimates of the number of patients at all echelons.

_c._ After an attack, the effectiveness and adequacy of the medical
support effort during the first 24 hours are critical. Commanders
should be informed rapidly of the estimated medical load in order
to provide rescue and treatment resources or request assistance
from higher headquarters, adjacent units, or allied units. These
estimates should be updated postattack based on aerial or ground
reconnaissance and survey.

_d._ In addition to casualties, a nuclear weapon detonation can
generate an EMP that may cause catastrophic failures of electronic
equipment components and may adversely affect the capability of
all units in the area of the detonation. Electromagnetic pulse has
no direct effect on personnel and is not further addressed in this
publication.


D-5. Triage

Since a nuclear detonation may produce mass casualties, plans for
a triage system must be in place. Paragraphs 3.4 through 3.5 of
the guide describe patient categories by injury severity and may
be used to estimate the number and injury severity of patients
for a particular operational scenario. The guide does not,
however, provide estimates of the number of patients by triage
classification.


D-6. Evacuation

_a._ An efficient and flexible evacuation plan is absolutely
essential for the preservation of life and to retain the mobility
of forward medical resources. In a potential mass casualty
situation, the full range of evacuation assets should be considered.

_b._ The extended hospital time of nuclear casualties will
influence levels of evacuation or hospitalization. In addition,
estimates of the different types of casualties can be a
consideration in evacuation planning. In planning for evacuation,
estimates provided in the guide can be used as a starting point
from which to estimate evacuation resources.


D-7. In-Unit Care

_a._ Some personnel within the military unit may not be classified
medically as casualties, but will require some self-aid and buddy
aid. A casualty is defined as anyone entering the medical system.
Paragraph 2.5 of the guide further describes the basis for casualty
calculation.

_b._ Nuclear detonations will produce a large number of blast,
burn, and projectile injuries that initially must be treated by
individual soldiers trained in first aid procedures. The physical
damage to the surrounding area as a result of a nuclear detonation
will increase delays in medical assistance and evacuation. Training
in self-aid/buddy aid will improve casualty survival rates and
conserve medical resources. The guide can be used to provide a
conservative estimate of the numbers of injured that will require
first aid. The tables in Sections 4 through 10 of the guide,
showing the status of unit personnel by time period, can be used
to indicate the numbers of personnel who are injured (but not
casualties) who may require first aid.


D-8. Hospital Bed Requirements

The data provided in the guide can be used to determine immediate
additional bed requirements resulting from a nuclear detonation.
In addition to the numbers of patients who will need beds, the
data provided in the guide can also indicate the increased
hospitalization time of nuclear casualties. Long-term bed
requirements, greater than 30 days, are not provided. Based on the
theater evacuation policy specified for the operation, the hospital
bed days may be in theater or in CONUS.


D-9. Medical Logistics

The data provided in the guide can assist in estimating the needed
supplies. The supply system must be prepared for increased demands
for certain types of medical and general supplies and equipment,
kits, dressings, and antibiotics. The treatment of combined
injuries will not require any special types of supplies, although
demands for certain types of supplies will increase.


D-10. Medical Force Planning

The assignment of medical support is normally based upon the
total military population and the expected conventional casualty
rate. The data provided in the guide may be used to assess the
requirement for additional medical units. The planning guidance
presented in this document can (and should) be modified to reflect
the needs of the anticipated operation, including operational
tempo, national/coalition priorities, medical resource allotment,
and so forth. When trying to augment personnel, consider that
the use of a nuclear weapon in a tactical situation could be an
indication of an increased tempo of warfare. Therefore, even though
a unit may be targeted with a nuclear detonation, that unit may
not be the site where the highest numbers of casualties are being
produced, and another unit may have priority of support.


    +--------------------------------------+
    | This Section Implements STANAG 2476. |
    +--------------------------------------+


Section III. MEDICAL PLANNING GUIDE FOR THE ESTIMATION
OF NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES
(BIOLOGICAL)--AMedP-8(A), VOLUME II


D-11. General

The guide, AMedP-8(A), Volume II, provides estimates of casualties,
and remaining operational strength, after single BW attacks on
tactically deployed, brigade-sized land force units, offshore naval
and marine forces, and selected strategic targets in rear areas.
These worst-case casualty estimates are for personnel within
both the targeted and the downwind hazard areas of the attacked
forces. They assume that all affected personnel will be unsheltered
and unwarned. To further estimate worst-case outcomes, the guide
assumes that exposed individuals have not been vaccinated against
any of the evaluated agents, nor have they undergone any type
of medical prophylactic treatment prior to exposure. The tables
included in the guide are designed to show numbers of expected
casualties; expected fatalities; personnel at different performance
levels; and times after exposure. In selected scenarios, the guide
provides a method for estimating casualties among collocated
civilians based on local population density.

_a._ The guide presents casualty estimates for all possible
combinations of the following conditions:

    · Eleven operational scenarios.

    · Seven biological agents.

    · Four types of delivery systems.

    · Three attack intensities.

_b._ The guide is subject to limitations of extent and content.
Since there are many more possible attack variables than those
considered, the guide presents a limited number of estimates and
provisional guidance for estimating cases not modeled. These
estimates are based upon the best available medical data, but
such data result in qualified estimates. Therefore, for more
authoritative medical descriptions, medical planners and staff
personnel should use FM 8-9, NATO Handbook on the Medical Aspects
of NBC Defensive Operations, AMedP-6(B), Part II--Biological.
Users of the guide must amplify or modify these estimates to meet
emergent requirements such as injuries resulting from combined
biological and conventional attacks.

_c._ Computer models that integrate available information have been
used to predict the effects of future biological attacks. These
resultant estimates may include substantial uncertainties when
applied to specific situations. However, they provide the best
estimates available to date.

_d._ The guide is also organized into 10 sections. Section 1
introduces features of the guide, and then presents background and
medical planning considerations. Section 2 provides information on
the methodology used to develop the estimates. Section 3 describes
how to use the tables presented in the guide. Sections 4 through 10
of the guide contain tables of casualty estimates, with one section
for each of the seven biological agents.

_e._ Biological attacks are likely to have a significant impact on
the medical system. As detailed elsewhere in the guide, victims
may number in the hundreds or even thousands. Demand for medical
care may quickly overwhelm available resources; this problem will
be exacerbated if medical personnel themselves become victims of
the attack. Local civilian populations will be victimized as well,
limiting host-nation support and potentially adding to the demands
on the military medical system.

_f._ A variety of medical responses to BW attacks are available,
depending on the agent used and whether medical countermeasures are
employed prior to attack or after exposure has already occurred.
For many agents, immunization or pre-exposure prophylaxis with
antibiotics may prevent illness in those subsequently exposed.
After exposure, disease can often be prevented or ameliorated via
immunization and therapeutic use of antibiotics, antiviral drugs,
and hyperimmune gammaglobulins.


D-12. Medical Planning Considerations

_a._ Effective mass casualty management requires careful planning.
The guide is designed to support such planning by providing medical
planners and staff personnel with a systematic means for estimating
the number of biological casualties. However, casualty management
also involves practice of self-aid and buddy aid, on-site triage
and emergency care, decontamination, transport to medical
facilities, infection control measures, communications, health
services, logistics, and evacuation by ground or air transportation.

_b._ Medical requirements resulting from attacks with biological
agents may be substantially different from those resulting from
conventional, nuclear, or chemical combat. There would be no
indication of the presence of biological agents in most tactical
situations. Units downwind from an attack area may be unexpectedly
exposed to biological agents. In some cases, there will also be a
risk of secondary infection and subsequent epidemics amongst troops
and/or the local population. Additionally, use of biological agents
may generate reservoirs within the local animal population that may
serve as a further source of infection.

_c._ Often the first indication of an attack with a biological
agent will be the development of symptoms in exposed personnel.
Diagnosis and treatment are complicated by the fact that many
of the agent-induced diseases described in the guide begin with
symptoms associated with common illnesses, such as influenza. In
such cases, biological agent attacks may generally be distinguished
from naturally occurring epidemics by the sudden onset of disease,
the large number of personnel presenting with similar symptoms, and
the concentration of those personnel in geographically contaminated
areas.


D-13. Triage

_a._ Since a biological attack may produce mass casualties,
preparations for a triage system should be in place before the
attack. Paragraph 3.3.8 of the guide describes patient categories
by illness severity. For a particular described operational
scenario, this information may be used to estimate the number
of patients with specified levels of illness. The guide does
not provide estimates of the number of patients by triage
classification or usual medical descriptions.

_b._ Decontamination of patients must be considered before further
evacuation.


D-14. Evacuation

_a._ An efficient and flexible evacuation plan is essential for
adequate casualty treatment and to retain mobility of forward
medical resources. For an assessment of a potential mass casualty
situation, the medical planner should consider the full range of
evacuation assets, limitations, and obstacles. After an attack,
the medical staff may need to estimate the number of casualties
that could require evacuation at given postexposure times.

_b._ Evacuation requirements will vary with the type of biological
agent used. Casualties resulting from some agents may not be
evacuated because the time course of effects is relatively short.
For others, like botulinum toxin, casualties may require evacuation
to a facility where they can receive care for weeks or even months.
Estimates provided in the guide can be used as a starting point
from which to plan for evacuation resources, including those
required for decontamination of personnel and transportation assets.


D-15. In-Unit Care

The casualty estimates in the guide are presented without
allowance for in-unit care. However, there may be need for rapid
intervention. Delays in obtaining medical care may occur because of
physical damage or contamination of the surrounding area. Soldiers
trained in first aid procedures may be the first to provide aid
to biological agent casualties. The guide provides a conservative
estimate of the numbers of exposed personnel who will require first
aid. The tables described in paragraphs 3.3.2 through 3.3.4 of the
guide give the time courses of effects that may apply to estimation
of in-unit care and delayed medical requirements.


D-16. Patient Bed Requirements

Bed requirements can be estimated using the tables described in
paragraphs 3.3.2 through 3.3.4 of the guide. The latter type of
table is useful after an attack since it shows gains and losses
of casualties over time. The type of table described in paragraph
3.3.5 of the guide may be more useful for long-range planning. It
shows maximum numbers of personnel by illness severity category.
The tables in the guide only provide estimates for the first 35
days after attack. Based on the theater evacuation policy specified
for the operation, hospital days may be in theater or in the
national area.


D-17. Medical Logistics

_a._ The estimates provided in the guide are intended to support
projections of medical materiel and logistical requirements.
Increased demands may occur for certain types of medical and
general supplies, including equipment, kits, antibiotics,
disinfectants, and other critical medical materiel. Demands may
also increase for items unique to the prevention and treatment of
biological agent casualties, such as vaccines, antibiotics, and
antisera, as well as items adapted to contaminated environments.
Tables showing maximum numbers of personnel by illness severity
category can provide useful input for logistical planning.

_b._ Often the first indication of an attack with a biological
agent will be the development of symptoms in exposed personnel.
Diagnosis and treatment are complicated by the fact that many
of the agent-induced diseases described in the guide begin with
symptoms associated with common illnesses, such as influenza. In
such cases, biological agent attacks may generally be distinguished
from naturally occurring diseases.


D-18. Medical Force Planning

_a._ The assignment of medical support is normally based upon the
total military population and the expected conventional casually
rate. The guide may be used to assess requirements for additional
medical units.

_b._ Although a specific unit may be the target of a biological
attack, more casualties could be suffered by other units downwind.
Accordingly, a unit other than the targeted one may have priority
for support. The tables presented in the guide can be used in
planning for either situation. Some tables show estimated maximum
numbers of personnel by illness severity category. Such estimates
should be combined with a comprehensive array of other available
information to increase the effectiveness of medical force planning.


    +--------------------------------------+
    | This Section Implements STANAG 2477. |
    +--------------------------------------+


Section IV. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR,
BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES (CHEMICAL)--AMedP-8(A),
VOLUME III


D-19. General

_a._ The primary purpose of Volume III is to assist medical
planners, logisticians, and staff officers in predicting CW
contingency requirements. Requirements include medical personnel,
medical materiel stockpiles, patient transport or evacuation
capabilities, and facilities needed for patient decontamination,
triage, treatment, and supportive care. An optional purpose is to
support medical operational estimates.

_b._ The guide provides medical worst-case estimates of casualties
and remaining operational strength after a single CW attack on
a tactically deployed, brigade-sized land force units, with
protection available and protection unavailable. These worst-case
casually estimates are for personnel located within both the
targeted and the downwind hazard areas of the brigade. It is
assumed that all targeted personnel will be unsheltered and without
medical pre-exposure prophylactic treatment. Tables in the guide
are designed to show total numbers of--

    · Casualties with different types and severities of injury at
    various times after exposure.

    · Personnel at different performance levels and times after
    exposure.

    · Fatalities at specified times after exposure.

_c._ The guide presents estimates of personnel status at specific
time points. These range from 1 to 3 hours to 7 to 30 days after an
attack, depending on the type of agent considered. Such estimates
are projected from all possible combinations of the following
conditions:

    · Seven operational scenarios involving three types of units:
    heavy brigade, support brigade, and light infantry brigade.

    · Three chemical agents: the nerve agents GB and VX, and the
    blister agent HD.

    · Three types of munitions delivering the agents: aerial bombs,
    tactical ballistic missiles, and rounds from multiple launch
    rocket systems/artillery batteries--

      · Three attack intensities for each type of munition: light,
      moderate, and heavy.

      · Two postures of individual physical protection against the
      attacks: unavailable and available.

_d._ An index to essential information and four sample problems
to illustrate use of this information are at the end of the guide
(see Section 11). Section 11 provides a planning guide overview,
describes applications, and presents a brief explanation of
modeling methods used to prepare estimates.

_e._ The guide is subject to limitations of extent and content.
Since there are many more possible attack variables than those
considered, the guide presents a limited number of estimates.
These estimates are based upon the best available toxicological
values, but such values are qualified estimates. Therefore, medical
planners and staff personnel should use FM 8-9, NATO Handbook on
the Medical Aspects of NBC Defensive Operations, AMedP-6 (B), Part
III--Chemical, for more authoritative medical descriptions and
information on effects of longer duration.

_f._ The guide is most value to the user who needs to know what
kinds of casualties to expect, relative numbers of each, and the
time frames in which they are likely to appear. To assist the
user, who lacks experience in actual CW, the guide describes types
of injury, relevant factors, general magnitudes of effects, and
effects of time courses on chemical casualty numbers. The casualty
estimates are appropriate for training exercises. However, this
initial attempt to provide complex estimates has limitations for
battlefield use. The limitations are described as follows:

    · The guide provides estimates for a few of many possible
    chemical attacks. Each estimate is based upon computer modeling
    of the consequences of specified conditions. This is like
    saying that the numbers of men who sneeze, after inhaling
    an allergic flower pollen, might be predicted if specific
    information (EXAMPLE: The wind speed and direction, the current
    weather, altitude, time of day, and sites of concentrated
    flower growth) is known for the specific geographic location
    of a particular brigade on a given mountain. If such estimates
    are made for a few widely different mountains, a user of the
    estimates may be able to guess the numbers of sneezing men in
    his own brigade, located on a separate mountain. However, if
    the conditions on both mountains are not nearly identical, the
    user will need to estimate a scaling factor and apply it to
    adjust the number predicted for a different environment.

    · It is unlikely that exactly identical conditions will exist
    for any two mountains or chemical attacks. The user of the
    guide must decide which scenario best represents his conditions
    (or interpolate from two scenarios), then use or adjust the
    estimates. Therefore, each user must recognize any differences
    from modeled conditions that might require him to increase, or
    decrease, an estimate. The user may need to apply a commander's
    guidance on acceptable risk levels, or consider restrictions
    of available resources, before accepting, interpreting, or
    modifying the relevant planning guide numbers. The most
    difficult problem for the user will be to determine how much to
    increase, or decrease, planning guide numbers to fit the user's
    situation. This problem is discussed in paragraph 3.4 of the
    guide.

    · The user should be aware that medical worst-case targeting
    selects for maximal numbers of survivors entering the medical
    system, not for maximal operational losses. The tabulated
    estimates are very highly sensitive to the degree of clustering
    of personnel and their assumed location within a standardized
    brigade area. Accordingly, use of this targeting method leads
    to large variations that are based upon the probabilities of
    hitting clustered personnel, not evenly or widely distributed
    personnel. Therefore, these estimates do not provide a good
    basis for estimating the most likely outcomes for a series of
    "average" attacks, or for comparing a scenario with an actual
    attack. Although the tabular format of the guide suggests
    that the listed numbers are exact, the user should understand
    that different targeting could readily produce other numbers.
    Selection of a scaling factor Is discussed in paragraph 3.4 of
    the guide.


D-20. Medical Planning Considerations

_a._ The guide provides medical planners and staff personnel
with a systematic means for estimating chemical casualties in
various-sized units, without regard to composition. This document
provides more accurate and detailed estimates and is based upon
detailed operational scenarios for brigade-sized units. Both
chemical planning guides support estimates of combat performance
from individuals remaining in the unit.

_b._ Effective mass casualty management requires careful planning.
The guide is designed to support such planning by providing medical
planners and staff personnel with a systematic means for estimating
the number, type, and time-related status of chemical casualties.

    NOTE

    Each user is advised to consult any available national military
    NBC defense doctrinal publications of similar nature.

_c._ Medical requirements during CW may be substantially different
from those for the usual combat situation. There may be no
indication of the presence of chemical agents in some tactical
situations. Unprotected units downwind from an attack area, or
those entering contaminated areas in an unprotected posture, may
be unexpectedly exposed to chemical agents. However, casualty
management also involves practice of self-aid and buddy aid,
on-site medical triage and emergency care, transport to medical
facilities, communications, health services, logistics, and
evacuation by ground or air transportation.

_d._ The signs and symptoms of chemical agent exposure may be
sudden and intense, or delayed and subtle, depending on the
agent used and the level of exposure. Individuals may not reach
the first level of care for 15 to 60 minutes after the onset of
effects. Decontamination may delay medical treatment. Stabilization
should occur before casualties leave emergency care areas, but
contamination of these areas may delay the stabilization process.
However, effects of decontamination or secondary contamination
on estimated doses and effects are not considered in the guide.
For medical planning, users of the guide need to consider the
various qualifications of its casualty estimates, as discussed in
paragraphs 3.4 and 3.4.2 of the guide.

_e._ A chemical burn caused by HD can require more care than a
same-sized burn induced by conventional munitions. Therefore, the
initial prognosis may require revision after treatment is underway,
and estimates of percent capable by performance band may require
adjustment.


D-21. Triage

Since a chemical attack may produce mass casualties, preparations
for a triage system should be in place before the attack. Paragraph
2.5.1 of the guide describes patient categories by injury severity.
For a particular described operational scenario, this information
may be used to estimate the number of patients with specified
levels of injury. The guide does not provide estimates of the
number of patients by triage classification or usual medical and
toxicological descriptions.


D-22. Evacuation

_a._ An efficient and flexible evacuation plan is essential for
adequate casualty treatment and to retain mobility of forward
medical resources. For assessment of a potential mass casualty
situation, the full range of evacuation assets, limitations, and
obstacles should be considered by the medical planner. After an
attack, the medical staff may need to estimate the number of
casualties that require evacuation resources at given postexposure
times.

_b._ Evacuation requirements will vary with the type of chemical
agent used. Nerve agent casualties may not be evacuated because
the time course of severe effects is relatively short. Depending
upon exposure conditions, HD casualties may or may not require
evacuation to a facility where they can receive care for several
days, or possibly 6 to 9 months. Estimates provided in the guide
can be used as a starting point from which to plan for evacuation
resources.


D-23. In-Unit Care

The casualty estimates in the guide are presented with no allowance
for in-unit care such as self-aid or buddy aid. Soldiers trained in
first aid procedures may be the first to see chemical injuries. The
guide can provide an estimate of the numbers of injured personnel
who will require first aid. However, there may be need for rapid
augmentation, support, or other intervention. Delays in obtaining
medical care may occur because of physical damage or contamination
of the surrounding area. The tables described in paragraphs 3.3.2
and 3.3.3 of the guide give the time courses of effects that may
apply to estimation of in-unit and delayed medical requirements.


D-24. Patient Bed Requirements

Requirements for patient beds and hospitalization time may be
greater after chemical exposures than after a conventional attack.
Such increases are particularly important for agents, such as
HD, that produce injuries followed by a long recovery period.
Bed requirements can be estimated using the tables described in
paragraphs 3.3.2 and 3.3.3 of the guide. Casualties Occurring by
Time Period tables (see paragraph 3.3.3) in the guide are useful
after an attack since they show gains and losses of casualties
over time. Personnel by Injury Category tables (as described in
paragraph 3.3.4) in the guide may be more useful in long-range
planning. They show maximum numbers of personnel by injury severity
category. The tables in the guide only provide estimates for the
first 30 days after attack. Depending upon the theater evacuation
policy specified for the operation, hospital days may be either in
theater or in the national area.


D-25. Medical Logistics

The estimates provided in the guide are intended to support
projections of medical materiel and logistical requirements.
Increased demands may occur for certain types of medical and
general supplies. These may include specific equipment, kits,
dressings, antibiotics, and other critical medical materiel.
Demands may also increase for items unique to the chemical
battlefield (such as nerve agent antidote autoinjectors), as
well as items adapted to chemical environments (including IV
systems and special self-contained intensive care units). Tables
showing maximum numbers of personnel by injury severity category
(see paragraph 3.3.4 in the guide) can provide useful input for
logistical planning.


D-26. Medical Force Planning

_a._ The assignment of medical support is normally based upon the
total military population and the expected conventional casualty
rate. The guide may be used to assess requirements for additional
medical units. The use of chemical weapons in tactical situations
could be one indication of an increased tempo of warfare and need
for additional personnel.

_b._ Although a unit may be targeted for chemical attack, that
unit might not be located where the highest number of casualties
could occur (as in a downwind hazard area). Accordingly, another
unit might have priority for support. The tables presented in the
guide can be used in planning for either situation. Some tables
(see paragraph 3.3.4 in the guide) show estimated maximum numbers
of personnel by injury severity category. Such estimates should be
combined with a comprehensive array of other available information
to increase the effectiveness of medical force planning.

_c._ The guide is organized into 11 sections. Section 1
introduces the guide and presents background and medical planning
considerations. Section 2 provides information on the methodology
used to develop the estimates of fatalities, casualties, and
effectiveness of individuals remaining in the unit. Section 3
explores the use of the casualty prediction tables based on combat
effectiveness decrements and estimates of the number of casualties
categorized by insult level. Sections 4 through 10 contain tables
of casualty estimates. Section 11 is a tutorial on use of the tool.

_d._ These medical worst-case casualty estimates (see paragraph
2.1.2 through 2.1.7 in the guide) are for personnel in the
chemical-targeted and downwind hazard areas of the brigade sector.
The actual areas presenting chemical agent hazards to personnel
are relatively small and localized when compared to the entire
brigade sector. These estimates are not valid for acute effects
from repeated exposures, possible delayed effects of low dosage
exposures, operational worst-case targeting, targets with different
numbers or distributions of exposed personnel, or attacks involving
different conditions (of meteorology, terrain, protective status,
and so forth) than are modeled. Although the guide is primarily
designed to support medical force planning for future CW defense,
it may be used to anticipate short-term requirements. For example,
delayed requirements of HD victims for care or evacuation resources
may be predicted from tables that give estimates of casually
numbers by injury type at given times after a CW attack (see
paragraphs 3.3.2 and 3.3.3 in the guide).




APPENDIX E

Example X-__, ANNEX__, TO HSS PLAN/OPERATION ORDER__, MEDICAL NBC
STAFF OFFICER PLANNING FOR HSS IN AN NBC ENVIRONMENT


1. PURPOSE. Establish standardized procedures for medical NBC
staff officers planning, preparing for, detecting, reporting, and
providing preventive/protective measures for NBC/TIM hazards.
Establish planning procedures for conducting HSS in NBC/TIM
environments. Also, establish procedures for providing technical
guidance/support to leadership before, during, and after an NBC/TIM
event.

2. PROCEDURES

    _a._ Medical NBC staff officers prepare list of equipment and
    procedural guidelines for HSS operations under NBC/TIM conditions.
    (_Provide a list of radiological detection devices, chemical agent
    detection/identification kits/devices, components of biological
    sample/specimen collection, and shipping containers. Provide
    guidelines/references for operating detection/identification
    devices._)

    _b._ Planning actions for use before an NBC/TIM event. (_Provide
    preventive/protective measures that the leadership can employ
    to reduce the health effects of a NBC/TIM event. Also, provide
    preventive/protective measures that leadership can employ to reduce
    the health effects of existing NBC/TIM hazards/contamination in an
    AO. Provide HSS leadership with procedures that can be employed to
    protect their unit and patients._)

    _c._ Planning action for use during an NBC/TIM event. (_Provide
    preventive/protective measures that the leadership can employ
    to reduce the health effects of a NBC/TIM event. Provide HSS
    leadership with procedures that can be employed to protect their
    unit and patients._)

    _d._ Planning actions for use after an NBC/TIM event. (_Provide
    preventive/protective measures that line leadership can employ
    to reduce/mitigate the health effects of an NBC/TIM event on the
    force. Provide HSS leadership with procedure that can be employed
    to mitigate the effects on their unit and patients._)

    _e._ Planning actions for preventive medicine support for NBC/TIM
    events. (_Provide types and numbers of PVNTMED units/personnel
    required to perform PVNTMED missions during such events. Describe
    mission requirements for units/personnel preparing for and reacting
    to the event. Describe types of samples required and how samples
    must be collected, preserved, packaged, and shipped to supporting
    medical laboratory for analysis. Describe detection/monitoring
    equipment required for the event; such as AN/PDR77, AN/VDR2 radiac
    meter, chemical agent monitor (CAM), and M272 water test kit._)

    _f._ Planning actions for veterinary support for NBC/TIM events.
    (_Provide types and numbers of veterinary units/personnel required
    to perform the veterinary service missions during such events.
    Describe mission requirements for units/personnel preparing for and
    reacting to the event. Describe types of samples/specimens required
    and how samples/specimens must be collected, preserved, packaged,
    and shipped to supporting medical laboratory for analysis. Describe
    food contamination and decontamination procedures. Describe
    detection/monitoring equipment required for the event; such as
    AN/PDR77, AN/ VDR2 radiac meter, and CAM._)

    _g._ Planning actions for medical laboratory support for NBC/TIM
    events. (_Provide requirements for medical laboratory support for
    an NBC/TIM event. Describe types of laboratory test/ procedures
    required to provide command verification on the use of an NBC
    device/weapon. Provide medical laboratory reporting requirements;
    example: provide report to command surgeon; Joint Task
    Force/theater commander; senior commander in affected operational
    area._)

    _h._ Planning actions for combat health logistics support for
    NBC/TIM events. (_Provide requirements for combat health logistics
    support units and personnel. Describe types of Class VIII supplies
    required to support HSS response to an event. Examples: Numbers of
    chemical agent patient decontamination MESs, chemical agent patient
    treatment sets, number of packets of chemical agent pretreatment
    tablets required, and chemoprophylaxis required for personnel
    exposed to a biological agent._)

    _i._ Planning actions for combat stress control/mental health
    support for NBC/TIM events. (_Provide requirements for COSC/mental
    health support units/personnel. Describe where and how COSC/ mental
    health personnel will provide their support in response to the
    event._)

    _j._ Planning for medical treatment of NBC/TIM event casualties.
    (_Provide requirements for medical evacuation and treatment
    (including emergency dental care) support units/personnel.
    Provide requirements for nonmedical personnel to perform patient
    decontamination at the MTF. Describe where and how evacuation and
    treatment personnel will provide their support in response to
    include supervision of patient decontamination procedures._)

3. COORDINATION REQUIREMENTS. (_Provide requirements for support
such as who should transport/escort samples/specimens from unit
of origin to support medical laboratory and on to the CONUS gold
standard laboratory. Example: The Technical Escort Unit normally
provides transportation and escort for suspect NBC samples, in
their absence describe who will provide this service. Provide
requirements for numbers of personnel required to perform patient
decontamination at supporting MTFs. Describe decontamination
support requirements for medical units; especially hospitals and
major combat health logistics facilities._)

4. REPORTS. (_Describe types of reports required and frequency
of reporting on HSS aspects of NBC/TIM events. Reports should
provide, at a minimum, aspects of event and recommended preventive/
protective actions needed to prevent or minimize casualties._)




APPENDIX F

EMPLOYMENT OF CHEMICAL AND BIOLOGICAL COLLECTIVE PROTECTION SHELTER
SYSTEMS BY MEDICAL UNITS


Section I. INTRODUCTION


F-1. General

To continue the HSS mission under CB conditions, MTFs must search
out contamination free areas or employ CPS systems. Levels I and
II MTFs may be able to locate contamination free areas; however,
due to the mobility limitations of hospitals, they must always
be prepared to operate under CB conditions if the area is under
attack. Systems that can be employed as an MTF (Levels I, II, III,
and IV) are described in this appendix.


F-2. Types of Collective Protection Shelter Systems

_a._ The CBPS system is employed at the BAS, DCS, and FST. The CBPS
is attached to the hard-walled box on the rear of a high mobility
multi-purpose wheeled vehicle (HMMWV). The BAS will have one CBPS
system per treatment team; the DCS will have four CBPS systems; the
FST will have three CBPS systems. Also, systems will be issued to
other selected medical treatment teams. When employed at the DCS,
the patient holding team will also require GP tents to hold their
required number of patients (see Chapter 4). Patients held inside
the CBPS will be those that have been decontaminated and admitted
into the system for treatment and are recovering from the treatment
procedures and are awaiting evacuation. Any patients held in the
GP tent must remain in MOPP Level 4 (the GP tent will not have
collective protection); these patients are those that are expected
to RTD within 72 hours.

    NOTES

    1. Normally, patients will not be held at the DCS under NBC
    conditions unless evacuation cannot be accomplished. They
    should be RTD or evacuated to a clean MTF, as soon as the
    mission permits.

    2. The CBPS can also be employed as the DCS in the conventional
    mode. Employment in either mode still requires GP tentage for
    patient holding to meet total patient holding requirements.

_b._ The DEPMEDS-equipped patient care areas of the US Army Force
XXI hospital and the hospital unit base (HUB) of the Medical
Force 2000 (MF2K) will employ the CP DEPMEDS. It will not protect
personnel or patients from the thermal, blast, and initial
radiation effects of nuclear weapons; however, it will provide
some protection against fallout effects. Areas of the hospital
that are not included in the chemically protected (CP) DEPMEDS
are MF2K general hospital unit medical (HUM), MF2K field hospital
unit holding (HUH), MF2K combat support and general hospital unit
surgical (HUS), minimum care wards, administrative areas, food
service, supply (including Class VIII), and staff quarters. The
system includes--

    · Chemically/biologically protected liners for tent,
    expandable, modular, personnel (TEMPER) and passageways.

    · CB-filtered and conditioned (heated or cooled) air (field
    deployable environmental control unit [FDECU] or H80 Army
    Standard Heater).

    · Chemically/biologically protected ambulatory, litter, and
    supply air locks.

    · Chemically/biologically protected latrines.

    · Chemically/biologically protected seals for ISO shelters.

    · Chemically/biologically protected water supply system.

_c._ The M20 simplified collective protection system is another
system that is available. It consists of a chemically protected
room liner, a CB filter blower, and an ambulatory air lock.
However, it does not have a litter air lock making it unsuitable
for litter patient care. The M20 may be used to protect medical
staffs at the DCS, FST, and hospitals, patients held in the GP
tents at the DCS and in the minimum care wards and staff quarters
of the hospitals. Thus providing additional CB protection for
staffs and patients.


Section II. EMPLOYMENT OF THE CHEMICALLY BIOLOGICALLY PROTECTED
SHELTER SYSTEM


F-3. Establish a Battalion Aid Station in a Chemically Biologically
Protected Shelter

To establish a BAS in a CBPS, use one CBPS per treatment team
for conventional operations in a split-team mode. When operating
in a squad configuration and in the conventional mode, the two
CBPS systems may be complexed to provide more workspace. However,
keep in mind that the treatment squad is not staffed to operate
the two systems in the CB mode. Therefore, when the two systems
are complexed and the treatment squad must convert and operate
in the CB mode, they may want to close the complexing door and
only use one system. When initially setting up the CBPS for
operations in the CB mode, only one CBPS is setup; see Note 2
below. Set up the system as described in TM 10-5410-228-10. To
be operational as a BAS, set up medical supplies and equipment
as required or as designated in the TSOP. A PDS consisting of
a contaminated ambulance point, contaminated triage point, a
patient decontamination area, and a contaminated treatment area is
established on the downwind (prevailing wind) side of the CBPS. An
overhead cover of plastic sheeting (approximately 20 feet wide by
50 feet long) is set up over the PDS, the hot line, and the clean
treatment/waiting area; the cover overlaps the air locks. The clean
treatment/waiting area should have an area at least 20 feet wide by
15 feet long to allow space for placing patients into the litter
air lock without crossing the hot line. A second area covered with
20 × 25 feet of plastic sheeting (the evacuation holding area) is
set up beside the shelter on the opposite side from the generator.
The clean treatment area is separated from the decontamination area
by a hot line with a shuffle pit. Only clean (decontaminated)
patients or personnel are allowed to cross the hot line into the
clean treatment area, or are admitted into the CBPS. Figure F-1
presents one layout of a BAS using the CBPS. See TM 10-5410-228-10
for complete details on setting up, operating, and maintaining the
CBPS. Each CBPS provides 300 square feet of work area.

    NOTES

    1. The overhead cover is not needed when the wind speed exceeds
    10 knots per hour. The plastic will not stay in place.

    2. Although each treatment team of the BAS has a CBPS; only one
    system is set up when operating in the CB mode. This is due to
    the lack of authorized personnel to operate all systems at one
    time in the CB mode. =Eight medical= personnel are required to
    operate the BAS (employing one CBPS) in the CB mode. At least
    eight nonmedical personnel are required to perform patient
    decontamination =under medical supervision=. Also, only setting
    up one system in the CB mode provides the BAS the ability to
    retain its flexibility in order to maintain its support mission
    of being where it is needed and when it is needed. The CBPS can
    be used as the treatment shelter in the conventional mode as
    well. When the treatment squad is operating in the split-team
    mode, each team will have a CBPS for use as its treatment
    shelter. When operating one system in the CB mode, the other
    system provides a replacement in the event the one in use in
    the CB mode is damaged beyond repair. This ensures continued
    HSS to the command.

[Illustration: _Figure F-1. Battalion aid station using the
chemically biologically protected shelter._]


F-4. Division Clearing Station in a Chemically Biologically
Protected Shelter

To establish a DCS using the CBPS, set up four shelters as
described in the TM. To be operational, medical supplies and
equipment are set up as outlined in the unit TSOP. The four
shelters are complexed as shown in Figure F-2. With four CBPS
systems set up and operational, a total of 1,200 square feet of
work area is available. The contaminated triage, decontamination,
and contaminated treatment areas are separated from the clean
treatment/waiting area by a hot line with a shuffle pit. Overhead
covering is provided as described for the BAS. Patients are
admitted through the EMT litter or ambulatory air lock. Patients
are released through the patient holding air locks. This aids in
controlling entry and exits; thus preventing the introduction
of contamination into the systems. At least eight nonmedical
personnel from supported units are required to perform patient
decontamination under medical supervision at the DCS.

    NOTE

    In the event that the overpressure system fails on a system
    that is in use with entry/exit air locks, move to the available
    shelter with an entry/exit air lock in the same direction
    for use as the entry/exit until the failed system can be
    restored. Example 1: At the DCS the EMT system fails, move to
    the ATM shelter to receive patients until the EMT system has
    been restored. Example 2: At the DCS the patient hold system
    fails, move exits to the dental/lab/x-ray shelter until the
    patient hold system can be restored. Example 3: At the FST the
    postoperative system fails, use the preoperative shelter until
    the postoperative system can be restored. These options will
    allow patient care operations to continue until the failed
    systems can be restored.

[Illustration: _Figure F-2. Chemically biologically protected
shelter configuration as a division clearing station._]


F-5. Forward Surgical Team in a Chemically Biologically Protected
Shelter

To establish a FST using the CBPSs, follow the procedures for the
DCS except set up three CBPSs. All equipment is set up inside the
CBPS as required by your unit TSOP. With three CBPSs set up and
operational, a total of 900 square feet of work area is available
(Figure F-3). When the FST is forward in support of a medical
company and operating in the CB mode, the FST systems are connected
to the DCS of the supported medical company. Figure F-4 shows the
FST and DCS connected. When operating in the CB mode with the
medical company, all patients are received through the EMT air
lock of the DCS. The patients are triaged in the DCS and, based
upon their injuries, they are routed to the DCS treatment area or
to the FST for surgical care. Patients released from the FST for
evacuation are placed in a PPW and processed through the litter
air lock in the FST recovery section. Patient decontamination is
performed at the PDS operated by the DCS. The FST cannot operate in
a CB environment without being complexed with the DCS. They do not
have any patient decontamination capabilities.

[Illustration: _Figure F-3. Forward surgical team configuration for
operations in conventional mode._]

[Illustration: _Figure F-4. Forward surgical team and division
clearing station configuration for operations in a nuclear,
biological, chemical environment._]


Section III. EMPLOYMENT OF THE CHEMICALLY PROTECTED DEPLOYABLE
MEDICAL SYSTEMS AND SIMPLIFIED COLLECTIVE PROTECTION SYSTEMS


F-6. Collective Protection in a Deployable Medical System-Equipped
Hospital

_a._ When the threat of NBC action is anticipated in the AO, the
CP DEPMEDS components must be set up as the hospital is being
established. The system cannot be set up in a hospital that has
already been established; to do so requires the hospital to be
closed, all TEMPERs be struck, and erected with the M28 liners
installed during the erection process. To establish CPS in a
DEPMEDS-equipped hospital, follow the procedures as described in
TM 10-5410-283-14&P. Training Circular 8-13 provides instructions
on establishing a US Army DEPMEDS-equipped hospital (without CPS).
Figure F-5 presents one layout of the DEPMEDS-equipped patient
care area of a MF2K CSH HUB employing the CP DEPMEDS with an
internal water supply system. Figure F-6 presents a layout of the
patient care area of the DEPMEDS-equipped portion of an 84-bed MRI
hospital. Figure F-7 presents a layout of the patient care area of
the DEPMEDS-equipped portion of a 164-bed MRI hospital.

_b._ When employing CP DEPMEDS, provisions for waste disposal
and protected water and food supplies within the system are
established. Additionally, Class VIII supplies must be protected
from contamination. Supplies not in use or needed in the protected
operational areas are stored in medical chests, shipping
containers, or wrapped in layers of plastic that are inside
covered areas, such as closed MILVANs or tents. When contamination
is present, only open these storage areas for operational area
emergency resupply. Use plastic sheeting or other leak-proof
material to provide an additional barrier between the supplies
and the contamination. Wrap supplies in plastic or other barrier
material for movement from the storage area to the resupply air
lock of the CP DEPMEDS.

    · A water supply system with distribution hoses is established
    inside the CP DEPMEDS areas (Figure F-5). Pumps continuously
    circulate the water from the storage tank through the hose
    system back to the storage tank. The continuous circulation
    ensures that the chlorine residual is maintained in the water
    supply. Personnel in areas that are not included in the
    continuous flow system must draw water from the system and
    carry it to their work areas in 5-gallon water cans or other
    containers. Water resupply is accomplished by passing a hose
    through the utility port at the end of the TEMPER and M28 liner
    for a connection to the water transport vehicle. The ends of
    both hoses must be decontaminated with a 5 percent chlorine
    solution before connecting them together. The vehicle must
    have a tank or water supply container that is NBC protected to
    ensure that the water supplied is free of NBC contamination.

    · Rations, as determined by the hospital commander, should be
    available within the protected area for personnel and patients.
    Under emergency conditions the commander can authorize feeding
    patients MRE rations for limited periods of time (up to 72
    hours), if they are able to chew and swallow. However, attempts
    must be made to ensure the required types of rations for
    patient feeding are available in the CPS. The rations can be
    stored in any available space; however, the rations must be
    protected from exposure to possible contaminants, especially
    liquids. Ration control measures are established to ensure that
    the rations are only consumed as provided for in the hospital
    TSOP.

    · Two CB protected latrine systems are included in the CP
    DEPMEDS. The latrines contain bedpan wash areas. The waste from
    the latrines is collected in an outside receiving container.
    The waste is removed from the container and disposed of as
    outlined in the unit TSOP.

    · Solid waste (including medical) must be placed in plastic
    bags. Seal the top of the bags to prevent spillage, odors, or
    spread of infections/disease. NEVER overfill the bags; always
    leave enough room in the bag to make a good seal. Place the
    sealed bags in the supply air lock. Inside personnel close the
    inner door to the air lock. Outside personnel check to ensure
    that the inner air lock door is closed before opening the
    outside door. Remove the bags and take them to the designated
    waste collection/disposal site. Disposal may be by burial
    on site or by transport to a designated disposal facility.
    Transport may be by organic vehicles or contractor support
    vehicles. The specific technique for disposal will be outlined
    in the unit TSOP.

    · All liquid waste produced within the CP DEPMEDS is collected
    through a piped liquid waste system to a central collection
    container. The waste container for the latrines may be used to
    collect the liquid waste from the operational areas of the CP
    DEPMEDS. The container is emptied and the waste disposed of as
    outlined in the unit TSOP.

[Illustration: _Figure F-5. Sample layout of a medical force 2000
combat support hospital unit base employing chemically protected
deployable medical system._]

[Illustration: _Figure F-6. Sample layout of an 84-bed medical
reengineering initiative hospital employing chemically protected
deployable medical system._]

[Illustration: _Figure F-7. Sample layout of a 164-bed medical
reengineering hospital employing chemically protected deployable
medical system._]


F-7. Chemically/Biologically Protecting the International
Organization for Standardization Shelter

To chemically/biologically protect the ISO shelters, seal all seams
and openings of the ISO to prevent the entry of CB agents. The
seals connecting the various sides and floor of the shelter may be
a CB protected material; thus providing a seal to the shelter. When
the seals are not of a CB protected material, the seams must be
taped to provide a CB protected barrier over the soft seals. Any
openings not being used for introduction of support power lines,
water lines or waste water lines must be sealed to prevent entry
of CB agents. All access panels must be securely closed to prevent
entry of vapors.


F-8. Chemically/Biologically Protecting the Vestibules

The vestibules connect TEMPERs to TEMPERs, ISOs to ISOs, and ISOs
and TEMPERs. To harden the vestibules, install the CB liners inside
and fasten the ends to the liners of the TEMPER or to the doors of
the ISOs. Vestibule liner connectors are provided for use at the
entry of each ISO.


F-9. Chemically/Biologically Protecting Air Handler Equipment

_a._ The FDECU is chemically/biologically protected. The system
can be operated without the CB filters. When required to operate
in the CB mode, 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 CPS.
Additionally, 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 system.

_b._ When heaters are required, they must be
chemically/biologically protected to prevent entry of
contamination. 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/ISO.


F-10. Establish Collective Protection Shelter Using the M20
Simplified Collective Protection System

The M20 is used to establish a CPS within a room of opportunity, or
inside a tent; however, the available space will be limited by tent
poles and other components of the tent. Currently this system only
provides ambient temperature air. See the TM and manufacturer's
publication provided with the system and system components for
details.

    NOTE

    The M20 does not have a litter air lock. Only staff or
    ambulatory patients can enter. See the TM provided with the
    system for setup procedures.


F-11. Casualty Decontamination

Patients admitted into the MTF must be contamination free.
Therefore, a casualty decontamination area must be established
near the MTF. The casualty decontamination area should be provided
with an overhead cover as described for the CBPS system, except
that it does not overlap the entry to the hospital. Also,
consideration must be given to the location of other operations at
the hospital site when establishing the casualty decontamination
area. However, 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 recontamination. Keep in mind that under NBC
conditions personnel outside of the CPS are at MOPP Level 4
(except decontaminated patients; they have their mask on), thus
increasing the stress load and reducing their overall performance
capabilities. The entry/exit area must have overhead cover to
protect patients awaiting access to the CPS. See Appendix I for
setting up a casualty decontamination area and for decontamination
procedures.


Section IV. OPERATIONS, ENTRY, AND EXIT GUIDELINES


F-12. Operations

These operations, entry, and exit guidelines may be used to prepare
a unit SOP for the operation of CPS systems in your unit.

_a._ When using these guidelines, the following should be
considered:

    · Location of the shelter (flat, hilly, rocky ground).

    · General climate of the AO (high and low temperature
    variations during operation).

_b._ Information on setting up, striking, and operating the CPS is
contained in the equipment publications. Where applicable, special
procedures are provided in these publications for setting up in
both clean and CB vapor hazard areas. However, the CP DEPMEDS is
NOT set up in a CB vapor hazard area. The commander will determine
which procedures to use.

_c._ During operations, periodic checks are made of the atmosphere
within the shelter. These checks are made by using available
chemical agent detection equipment and material to determine if
chemical agent penetration has occurred. Should chemical agent
penetration occur, all personnel must mask; then ensure that
patients are protected until the agent has been purged from the
shelter.


F-13. Decontamination of Entrance Area

_a._ Normally, the MTF will not operate in a CB vapor hazard
environment. However, if the MTF must remain in an area on a
temporary basis and liquid agent contamination is present, the
immediate area around the entrance must be decontaminated.

_b._ To decontaminate the area around the entrance, use one or more
of the following methods:

    · Turn over about 2 inches of soil.

    · Remove the top 1-inch layer of soil containing the liquid
    agent. Use the CAM or M8 detector paper to check the area after
    the topsoil is removed to ensure complete agent removal.

    · Add several inches of clean soil or sand.

    · Mix STB into the top 1/2 to 1 inch of soil.

    · Use DS2 on contaminated hard-surfaced areas or frozen ground.


F-14. Procedures Prior to Entry

All personnel (staff and patients) must be decontaminated before
they are permitted entry into the CPS.

    · Use chemical detection equipment to check for the presence of
    contamination on individuals and their equipment; also check
    for presence of contamination on individual weapons if they
    are allowed in the CPS. Normally, weapons will not be allowed
    in the patient care areas, but will be stored outside near the
    entry/exit. Thorough decontamination is critical in preventing
    contamination transfer into the CPS.

    · When a chemical agent is detected, follow the procedures
    in Appendix C for patient decontamination and FM 3-5 for
    other personnel decontamination before entering the CPS.
    All contaminated clothing and equipment are placed in the
    contaminated dump. Weapons should not have been evacuated with
    patients. However, if weapons are evacuated with the patient,
    they are decontaminated and held by the MTF (administrative
    personnel or hospital supply) for disposition instructions.

    · Decontamination must be thorough; procedures must be strictly
    followed. Failure to do so can contaminate the interior of the
    MTF and injure medical treatment personnel; thus reducing their
    mission support capabilities.

        +-------------------------------------------------+
        |                  =WARNINGS=                     |
        |                                                 |
        | 1. ALWAYS PURGE THE AIR LOCK BEFORE OPENING     |
        | THE INNER DOOR, IF THE OUTER DOOR HAS BEEN      |
        | OPENED.                                         |
        |                                                 |
        | 2. WHEN OPERATING IN A TOXIC ENVIRONMENT, NEVER |
        | OPEN THE OUTER AND INNER DOORS OF THE AIR LOCKS |
        | AT THE SAME TIME.                               |
        |                                                 |
        +-------------------------------------------------+


F-15. Entry/Exit for the Collective Protection Shelter System

_a. Ambulatory Personnel._

    (1) _Entry procedures._

      (_a_) Ambulatory patients and others remove their MOPP (except
      their mask), BDUs, and boots outside the air lock. This
      procedure reduces the amount of possible contamination entering
      the air lock.

      (_b_) A check is made to ensure that the ambulatory air lock is
      empty and the inner door is closed.

      (_c_) The individual enters the air lock and closes the outer
      door.

      (_d_) The air lock is purged for 3 minutes. At the end of
      the purge cycle, the individual checks for contamination. If
      contaminated, the individual must return to the outside and
      decontaminate his skin; then return to the air lock and repeat
      the purge cycle and contamination check. If no contamination
      is detected, the protective mask is removed and placed in
      a plastic bag. The plastic bag is sealed and labeled. The
      individual opens the inner air lock door and enters the CPS;
      the plastic bag is carried into the shelter with the individual.

    (2) _Exit procedures._

      (_a_) A check is made to ensure that the ambulatory air lock is
      empty and the outer door is closed.

      (_b_) The individual enters the air lock and closes the inner
      door.

      (_c_) The individual puts on his protective mask; then exits
      through the outer door.

      (_d_) The individual puts on his BDU and boots then assumes the
      established MOPP level before departing the immediate area of
      the exit door.

        +-------------------------------------------------+
        |                 =WARNING=                       |
        |                                                 |
        | DO NOT OPEN THE OUTER DOOR UNTIL THE PROTECTIVE |
        | MASK HAS BEEN PUT ON.                           |
        +-------------------------------------------------+


        NOTES

        1. 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 issue.

        2. Exits must be spaced so that at least a 3 minute purge of
        the air lock is accomplished before the inside door is opened.
        Only open the doors long enough to permit passage.

_b._ _Litter Patients._

    (1) _Entry procedures._

      (_a_) An outside aidman notifies an inside aidman that a litter
      patient is ready for admission.

      (_b_) The inside aidman ensures that the inner litter air lock
      door is closed. The outside aidmen open the outer air lock door
      and place the litter on the litter rails; they push the patient
      into the air lock headfirst; then they close the outer door.
      After a purge time of 3 minutes, an aidman inside the CPS opens
      the inner door and checks the patient to ensure that he is
      contamination free. The patient is checked by placing the CAM
      nozzle near absorptive surfaces, such as the patient's hair.
      If no contamination is found, the aidman removes the patient's
      mask and places it in a plastic bag. The inside aidmen remove
      the patient from the air lock and position him on treatment
      litter stands, or move him to the treatment area as directed by
      supervisory personnel.

      (_c_) Patients received at the treatment facility in the PPW
      are checked for contamination; if they are contamination free,
      they may be processed through the litter air lock in the PPW.
      The inside aidmen ensure that the inner litter air lock door
      is closed. 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 headfirst, then close the outer door.
      Purge the air lock for 3 minutes. After the purge time, 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 contamination. If no contamination is found, the inside
      aidmen remove the patient from the air lock. (If the patient is
      wearing a protective mask, the mask is removed and placed in a
      plastic bag before the patient is moved from the air lock.) As
      the patient is removed from the air lock, the PPW is opened and
      rolled inside out so that any desorbing vapors are adsorbed by
      the charcoal layer. The inside aidmen remove the patient from
      the air lock and position him on litter stands. The patient
      is transferred to a clean litter; then moved to the treatment
      area as directed by supervisory personnel. The receiving litter
      and PPW is returned to the outside; dispose of the PPW in the
      contaminated waste dump. Decontaminate the litter and return it
      to the litter pool.

        NOTE

        Should contamination be found when monitoring the air lock in
        (_b_) or (_c_) above, repeat the purge cycle, then retest for
        contamination. All vapor hazards must be eliminated before
        the patient is moved into the CPS. Repeating the purge cycle
        may NOT be possible if the patient is in need of immediate
        lifesaving care. The patient may have to be returned to the
        outside treatment area for immediate care.

    (2) _Exit procedures._

      (_a_) The litter patient is placed in a PPW. A battery operated
      blower unit with a CB filter may be attached to the PPW to
      provide fresh air to the patient; thus reducing the heat load
      on the patient and the carbon dioxide buildup inside the PPW.

      (_b_) An inside aidman notifies an outside aidman that the
      patient is ready to exit the shelter. An outside aidman ensures
      that the outer air lock door is closed. The patient is placed
      in the litter air lock feet first. The inner air lock door is
      closed. The outside aidmen open the outer door and remove the
      patient.

      (_c_) Hospital staff, visitors, or ambulatory patients exit
      through the ambulatory air lock. Before entering the air lock,
      each individual must ensure that the outer air lock door is
      closed. The individual enters the air lock and closes the
      inner door; puts on his protective mask and exits through the
      outer door. The individual puts on his BDU and boots, and
      then assumes the established MOPP level before departing the
      immediate area of the exit door.

        +-------------------------------------------------+
        |                    =WARNING=                    |
        |                                                 |
        | DO NOT OPEN THE OUTER DOOR UNTIL THE INNER DOOR |
        | HAS BEEN CLOSED.                                |
        +-------------------------------------------------+

        NOTE

        Exits must be spaced at least 3 minutes apart to allow for a
        complete purge cycle of the air lock.


F-16. 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 lock, or processing it through the
supply air lock. The litter air lock must be purged for 3 minutes.
The supplies must be checked for contamination before they are
removed and placed within the CPS. The supply air lock must be
purged for the stated time as outlined in the supporting technical
manual; usually 45 minutes. Again the supplies must be checked for
contamination before they are removed and placed within the CPS.




APPENDIX G

PATIENT DECONTAMINATION


Section I. INTRODUCTION

G-1. General

_a._ Patient decontamination presents special problems for units
and HSS personnel. Nuclear, biological, and chemical contaminated
patients create increased hazards to rescuers and HSS personnel;
thus, causing delays in providing essential first aid and medical
treatment for injuries from sources other than the exposure to NBC
weapons/agents. Casualty decontamination procedures are performed
by each individual, as buddy aid, or at a unit decontamination
station prior to the arrival of medical personnel. See FM 3-5 for
procedures on individual, buddy aid, and unit decontamination.
Patient decontamination procedures are normally performed at an MTF
under medical supervision. Patient decontamination stations may be
established (collocated) at central unit decontamination faculties,
if medical support is available. However, augmentation medical
support must be requested to provide patient care and supervise
the patient decontamination process. Because, when the unit is
undergoing decontamination operations, organic medical personnel
must also decontaminate their equipment and personnel. Therefore,
they are not available to provide medical support for operating the
patient decontamination station that is collocated with the central
unit decontamination facility.

_b._ The term "decontamination" as used herein means the removal
or neutralization of radioactive particles, BW agents, and
CW agents to levels low enough that patients may be treated
without contaminating the MTF and without posing health risks to
unprotected medical providers. "Decontamination" does not imply
absolute removal of contaminants.

    NOTE

    The decontamination procedures described below are for NBC
    contaminated patients. These procedures may also be used for
    most TIM contaminated patients. However, soap and water will
    suffice for most TIMs; but some TIMs react with water. For
    those TIMs another material must be used to decontaminate
    patients. For detailed information on decontamination of TIM
    contaminated patients, see FM 8-500.

_c._ Physical removal of contaminants is the primary method of
decontamination. Physical removal does not require vigorous
scrubbing; in fact, vigorous scrubbing can force some agents deeper
into the skin; thus, increasing the agent effect rather than
reducing its effects. The use of a M291 skin decontaminating kit
(SDK) neutralizes/reduces the effects of an agent, but physical
removal is of utmost importance. When a SDK is not available, the
use of soap and water should be considered as the next best method.
However, 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 soap. An alternate
skin decontaminant is a hypochlorite solution; but it should
only be used when SDKs and/or sufficient quantities of water are
not available. Use a 0.5 percent hypochlorite solution on the
protective mask and skin. A 5 percent hypochlorite solution can be
used on the mask hood, gloves, and other outer garments.

    +-------------------------------------------------------+
    |                          CAUTION                      |
    |                                                       |
    | Do not use the 5 percent solution on the skin; it can |
    | cause severe skin irritation.                         |
    +-------------------------------------------------------+


G-2. Immediate Decontamination

Decontamination must begin at the platoon and company level
with the individual soldier, prior to the arrival of medical
personnel. The soldier himself or members of his team must perform
immediate decontamination. When the casualty's condition and the
mission permits, they may go through a MOPP gear exchange at
their unit before evacuation (see FM 3-5). Performing a MOPP gear
exchange at the unit before evacuation will reduce the amount of
contamination that can be transferred to the MEDEVAC vehicle.
However, the MOPP gear exchange must not cause further injury
to the casualty. First aid for CW agent must be administered;
such as administering nerve agent antidotes (such as nerve agent
antidotes and convulsant antidote for nerve agent [CANA]), as
required. Enter the time and type of contamination on a field
expedient NBC casualty card (Figure G-1). Use the CAM, M8 chemical
agent detector paper, or M9 tape to determine the type of chemical
contamination. Use a radiation detection meter/device to determine
the level of radioactive contamination, if required. Currently,
there are no BW agent detectors that can be used to check patients
for BW agent contamination. Therefore, all patients suspected of
being contaminated with a BW agent must be decontaminated. When
medical personnel arrive, 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 (DD) Form
1380 (Field Medical Card [FMC]).

[Illustration: _Figure G-1. Field expedient nuclear, biological,
and chemical patient card._]


G-3. Patient Decontamination and Thorough Decontamination
Collocation

_a._ Collocating patient and thorough decontamination operations in
the BSA may provide several advantages (Figure G-2). It--

    · Preserves the principle of limiting the spread of
    contamination.

    · Reduces confusion on the battlefield.

    · Reduces demand on logistics support elements.

    · Improves contamination control and reporting: One location
    and one person in charge.

    · Reduces overall security requirements.

    · Speeds PDS closure by using the thorough decontamination site.

_b._ An identified disadvantage is the increased size of the
site and the requirement for medical support augmentation (a
treatment squad from another organization with required patient
decontamination and treatment MESs) to operate the PDS.

    NOTE

    Organic medical personnel must not be used to perform the
    HSS mission at the collocated site. They must go through the
    decontamination process with their unit.

_c._ These operations do not require that both patient
decontamination and unit thorough decontamination be executed
simultaneously. The PDS can be running while the thorough
decontamination site is being prepared. Patient decontamination
cannot be delayed since patients may be suffering life-threatening
injuries as well as exposure to NBC agents. Therefore, the PDS must
be established and operational before the first patients arrive.
The wind direction must be common to both sites.

_d._ The decontamination platoon leader is responsible for
establishing the combined decontamination site. The medical unit
commander/surgeon coordinates with the decontamination platoon
leader for the location of the patient receiving, PDS, and MTF.
The lowest level at which this operation will usually be planned
is brigade. This operation requires extensive planning and must
involve the brigade chemical officer, brigade S4, and the medical
company commander/brigade surgeon. Decontamination support for
special operation forces, other unique operational organizations,
or for nonlinear operations may require execution at a lower level.
The supporting medical personnel operate the PDS. Nonmedical
personnel perform patient decontamination procedures under medical
supervision. Patient decontamination procedures are described below.

    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
    process.

_e._ Although a PDS may be collocated with thorough
decontamination, a PDS must be operational at Levels I, II, III,
and IV MTFs. Contaminated patients may present directly to the
MTF for care, or patients previously decontaminated may become
contaminated en route. Therefore, all patients arriving at an MTF
must be checked for contamination. If contaminated, they must be
decontaminated before they are admitted to the MTF.

[Illustration: _Figure G-2. Thorough decontamination site
collocated with patient decontamination station, without collective
protection shelter._]


G-4. Patient Decontamination at the Battalion Aid Station (Level I)

_a._ When battle conditions prevent patient decontamination
procedures forward or the patient is contaminated en route, the
patient may have to be decontaminated at the BAS. Contaminated
patients arriving at the BAS must be decontaminated before
admission into the clean treatment area.

_b._ Patient decontamination is performed by eight nonmedical
personnel from the supported unit at the BAS. The patient
decontamination personnel operate as two-man teams to perform the
patient decontamination procedures. 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 process. Each team receives a patient from
the triage point and performs both clothing removal and skin
decontamination procedures. The team requires assistance from
another team to perform litter changes; see details below.


G-5. Patient Decontamination at the Medical Company Clearing
Station (Level II)

The medical company clearing station may receive patients from the
BAS or directly from other areas who have not been decontaminated.
The clearing station must also have a patient decontamination area.
As with the BAS, the clearing station must have a minimum of eight
nonmedical personnel from the supported units to perform patient
decontamination. Procedures for patient decontamination at the
clearing station are the same as for the BAS.


G-6. Patient Decontamination at a Hospital (Level III or IV)

To the maximum extent possible, hospitals are located away
from tactical or logistical targets. Contaminated patients
will arrive from forward MTFs and units located within the
geographical area of the hospital. Patient decontamination is
done by at least 20 nonmedical personnel from units located in
the geographical area/base cluster of the hospital. Procedures
for patient decontamination at the hospital are the same as for
the BAS. However, several patient decontamination stations can be
operated simultaneously at the hospital patient decontamination
site. Further, all patients arriving at the hospital will be
decontaminated and receive full treatment within the capabilities
of the hospital.


G-7. Prepare Hypochlorite Solutions for Patient Decontamination

An alternative patient decontamination agent is a hypochlorite
solution; however, the hypochlorite solution must be prepared.
Two concentrations of the hypochlorite solution are required.
A 5 percent hypochlorite solution to decontaminate gloves,
aprons, litters, cutting devices, the patient's mask hood, and
other nonskin contact areas. The patient's mask, skin, splints,
and tourniquets and their wounds are irrigated using a 0.5 (½)
percent hypochlorite solution. To prepare the solutions, use
calcium hypochlorite (HTH) granules (supplied in 6-ounce jars in
the chemical agent patient treatment and chemical agent patient
decontamination MES), bulk HTH, or sodium hypochlorite (household
bleach). Prepare the required solutions as shown in Table G-1
below.


_Table G-1. Preparation of Hypochlorite Solutions for Patient
Decontamination_

    ==================================================================
        HTH       HTH MRE       HOUSEHOLD        PERCENT IN 5
       OUNCES    SPOONFULS        BLEACH        GALLONS OF WATER
    ------------------------------------------------------------------
         6         [*]5          2 QUARTS            0.5
        48           40           [**]               5.0
    ------------------------------------------------------------------

    [*] THESE MEASUREMENTS ARE USED WHEN BULK HTH IS USED. TO MEASURE
    THIS PREPARATION, USE THE PLASTIC SPOON SUPPLIED WITH YOUR MEAL,
    READY-TO-EAT (MRE). THE AMOUNT OF HYPOCHLORITE TO BE USED IS A
    HEAPING SPOONFUL (THAT IS, ALL THAT THE SPOON WILL HOLD). DO NOT
    SHAKE ANY GRANULES OFF OF THE SPOON BEFORE ADDING TO THE WATER.

    [**] DO NOT DILUTE IN WATER; HOUSEHOLD BLEACH IS 5 TO 6.25 PERCENT
    SOLUTION; IT IS USED FULL STRENGTH FOR 5 PERCENT APPLICATIONS.
    ==================================================================


        +------------------------------------------------------+
        |                         CAUTIONS                     |
        |                                                      |
        | 1.  Do not use the 5 percent hypochlorite solution   |
        | on the patient's skin. The 5 percent solution can    |
        | burn the skin.                                       |
        |                                                      |
        | 2.  Only wipe the skin when applying the 0.5 percent |
        | hypochlorite solution. Vigorous scrubbing may force  |
        | the agent into the skin.                             |
        +------------------------------------------------------+


G-8. Classification of Patients

On the NBC battlefield, two classifications of patients will be
encountered--contaminated and uncontaminated. Those contaminated
may suffer from the effects of an NBC agent, of a conventional
wound, or both. Some may suffer combat stress or heat injuries
induced by the stress of NBC conditions and extended time spent
in MOPP Level 4. It is important to follow proper decontamination
procedures to limit the spread of contamination to others and
equipment. The most important decontamination is performed at the
site of contamination. Decontamination at a later time may be too
late to prevent injury to the individual, especially when exposed
to vesicants. All agents should be promptly removed from the skin.


G-9. Patient Treatment

_This appendix only describes patient decontamination procedures._
For NBC treatment procedures, refer to FM 4-02.283, FM 8-284, and
FM 8-285.


Section II. PATIENT DECONTAMINATION PROCEDURES


G-10. Decontaminate a Litter Chemical Agent Patient

Before contaminated patients receive medical treatment in the
clean treatment area, they must be decontaminated. Place the
cutting device in a container of 5 percent hypochlorite solution
between each use. Each decontamination team member decontaminates
his gloves and apron with the 5 percent hypochlorite solution
frequently to prevent spreading any contamination to patient's
skin. Decontaminate the patient's skin, bandages, wounds, mask,
identification tags with chain, and splints with a 0.5 percent
hypochlorite solution. The litter patient is decontaminated and
undressed as follows:

    NOTE

    Litter patients requiring EMT or ATM in the clean area of the
    MTF will be completely decontaminated. A patient not requiring
    clean EMT or ATM at the MTF, but requiring further evacuation
    (for example: a stable patient with a partial amputation of a
    lower extremity) should only have his wound area and MOPP spot
    decontaminated to remove any gross contamination. The patient
    should be evacuated in his MOPP.

_a._ =Step 1. Physically remove gross contamination.= Use any stiff
material (stick, cardboard, plastic strip, metal banding strap)
to physically remove gross contamination from the patient's MOPP
ensemble. Much of the CW agent contamination can be removed through
physical means.

_b._ =Step 2. Decontaminate the patient's mask and hood.= The
patient has been triaged and stabilized (if necessary) by the
senior trauma specialist in the patient decontamination area. A
two-man decontamination team moves him to the litter stands at the
clothing removal station.

    (1) =Decontaminate the mask and hood.= Use the SDK, or use a
    5 percent hypochlorite solution or household bleach to sponge
    down the front, sides, and top of the mask hood. Decontaminate
    spots with the SDK or the 5 percent hypochlorite solution.

    (2) =Remove hood.= Remove the hood by cutting the hood. Before
    cutting the hood, dip the cutting device in a 5 percent
    hypochlorite solution. For the M17-series mask, cut the neck
    cord and the small string under the voicemitter. Release or cut
    the hood shoulder straps and unzip the hood zipper. Cut the
    hood, close to the filter inlet cover and eye-lens outsert,
    upward to the top of the eye-lens outsert, and across the
    forehead to the outer edge of the other eye-lens outsert.
    Proceed downward toward the patient's shoulder, staying close
    to the eye-lens, then across the lower part of the voicemitter
    to the zipper. After dipping the cutting device in the 5
    percent hypochlorite solution, cut the hood from the center
    of the forehead over the top of the head (see Figure G-3).
    Fold the left and right sides of the hood to the side of the
    patient's head, laying the sides of the hood on the litter. For
    the M40-series protective mask cut the hood shoulder straps,
    then cut the quick-doff hood from the front bottom center to
    the chin through the elastic band under the chin. Fold the left
    and right sides of the hood over the shoulders away from the
    head.

[Illustration: _Figure G-3. Cutting the M17 protective mask hood._]

    (3) =Decontaminate the protective mask and exposed skin.=
    Using the SDK, soap and water, or a 0.5 percent hypochlorite
    solution, wipe the external parts of the mask. Cover the mask
    air inlet(s) with gauze or your hand to keep the mask filter
    dry. Continue by wiping the exposed areas of the patient's
    face, including the neck and behind the ears.

    (4) =Remove the Field Medical Card.= Cut the patient's FMC tie
    wire, allowing the FMC to fall into a plastic bag. Seal the
    plastic bag and rinse the outside of the bag with a 5 percent
    hypochlorite solution. Place the plastic bag with the FMC under
    the back of the protective mask head straps. The FMC will
    remain with the patient.

_c._ =Step 3. Remove gross contamination from the patient's
overgarment.= Remove all visible gross contamination by scraping
with a stick or other device.

_d._ =Step 4. Remove the patient's personal effects and protective
overgarment.=

    (1) =Remove patient's personal effects.= Remove the patient's
    personal effects from his protective overgarment and BDU
    pockets. Place the articles in a plastic bag, label with the
    patient's identification, and seal the bag. If the articles are
    not contaminated, return them to the patient. If the articles
    are contaminated, place them in the contaminated holding area
    until they can be decontaminated, and then return them to the
    patient.

    (2) =Cut the patient's overgarment.= The overgarment jacket and
    trousers may be cut simultaneously. Two persons may be cutting
    clothing at the same time. =Cut around bandages, tourniquets,
    and splints, leaving them in place.=

        NOTE

        A cut is a separation of material by use of a cutting device
        that cuts material into two pieces. EXAMPLE: Cutting the sleeve
        from the cuff to the jacket collar is one cut.

        +-----------------------------------------------------------+
        |                         CAUTION                           |
        |                                                           |
        | Bandages may have been applied to control severe bleeding |
        | and are treated like tourniquets. Only medical personnel  |
        | remove bandages, tourniquets, and splints.                |
        +-----------------------------------------------------------+

    (3) =Remove overgarment jacket.= Make two cuts, one up each
    sleeve from the wrist up to the shoulder, and then through
    the collar (Figure G-4). Do not allow the gloves to touch the
    patient along the cut line. Dip the cutting device in the 5
    percent hypochlorite solution before making each cut to prevent
    contamination of the patient's uniform or underclothing. Keep
    the cuts close to the inside of the arms so that most of the
    sleeve material can be folded outward. Unzip the jacket; roll
    the chest sections to the respective sides, with the inner
    surface outward. Continue by tucking the clothing between
    the arm and chest. Roll the cut sleeves away from the arms,
    exposing the black liner.

[Illustration: _Figure G-4. Cutting the overgarment jacket._]

    (4) =Remove overgarment trousers.= Cut both trouser legs
    starting at the ankle as shown in Figure G-5. Keep the cuts
    near the inseams to the crotch. With the left leg, continue
    cutting to the waist, avoiding the pockets. With the right leg,
    cut across at the crotch to the left leg cut. Place the cutting
    device in the 5 percent hypochlorite solution. Fold the cut
    trouser halves away from the patient and allow the halves to
    drop to the litter with contaminated (green) side down. Roll
    the inner leg portion under and between the legs.

[Illustration: _Figure G-5. Cutting the overgarment trousers._]

    (5) =Remove outer gloves.= This procedure can be done with one
    person on each side of the patient working simultaneously.
    The decontamination team will decontaminate their gloves in 5
    percent hypochlorite solution. Next, lift the patient's arms
    up and out of the cutaway sleeves unless detrimental to the
    patient's condition. Grasp the fingers of the glove, roll the
    cuff over the fingers, turning the glove inside out. Do not
    remove the inner cotton glove liners at this time. Carefully
    lower the arms across the chest after the outer gloves have
    been removed (Figure G-6). Do not allow the patient's arms to
    come into contact with the exterior of his overgarment. Drop
    his gloves into the contaminated waste bag. Dip your gloves in
    the 5 percent hypochlorite solution.

[Illustration: _Figure G-6. Remove outer gloves and position arms
after glove removal._]

    (6) =Remove overboots.= Cut the overboot laces and fold the
    lacing eyelets flat outwards. If the green vinyl overboot
    (GVO) is worn, first try to remove the overboot without
    cutting; if necessary, cut the boot along the front. While
    standing at the foot of the litter, hold the heel with one
    hand, pull overboot downwards, and then pull towards you to
    remove the overboot over the combat boot heel. Remove the
    two overboots simultaneously. This reduces the likelihood of
    contaminating one of the combat boots. While holding the heels
    off the litter, have a decontamination team member wipe the
    end of the litter with the 5 percent hypochlorite solution to
    neutralize any liquid contamination that was transferred to the
    litter from the overboots. Lower the patient's heels onto the
    decontaminated litter. Place the overboots in the contaminated
    waste bag. Decontamination personnel dip their gloves in the 5
    percent hypochlorite solution.

_e._ =Step 5. Remove patient's battle dress uniform.=

    (1) =Remove battle dress uniform.= Cut the BDU jacket and
    trousers as described above for the protective overgarment.
    Roll the jacket and trousers as described for the protective
    overgarment.

    (2) =Remove combat boots.= Cut the bootlaces along the tongue.
    Remove the boots by pulling them towards you. Place the boots
    in the contaminated waste bag. Do not touch the patient's skin
    with contaminated gloves when removing his boots.

    (3) =Remove undergarments.= Remove the patient's tee shirt.
    Dip the cutting device in the 5 percent hypochlorite solution
    between each cut. Cut both sleeves from the inside, starting
    at the elbow, up to the armpit. Continue cutting across the
    shoulder to the collar. Cut around bandages or splints, leaving
    them in place. Next, peel the tee shirt away from the body to
    avoid spreading contamination. If the patient is wearing a
    brassiere, cut it between the cups. Cut both shoulder straps
    where they attach to the cups and lay them back off of the
    shoulders. Remove the patient's under shorts/panties by cutting
    from the lower side of the hip to the waist on both sides. Fold
    the front flap of the shorts/panties down between the patient's
    legs onto the litter. Do not allow the outside of the garment
    to touch the patient's skin. Remove the socks and cotton glove
    liners. Do not remove the patient's identification tags.

_f._ =Step 6. Transfer the patient to a decontamination litter.=
After the patient's clothing has been cut away, he is transferred
to a decontamination litter or a canvas litter with a plastic
sheeting cover. Three decontamination team members decontaminate
their gloves and aprons with the 5 percent hypochlorite solution.
One member places his hands under the patient's legs at the thighs
and Achilles tendons, a second member places his arms under the
patient's back and buttocks, and a third member places his arms
under the patient's shoulders and supports the head and neck. They
carefully lift the patient using their knees (not their backs)
to minimize back strain. While the patient is elevated, another
decontamination team member removes the litter from the litter
stands and replaces it with a decontaminated (clean) litter.
The patient is carefully lowered onto the clean litter. The
contaminated clothing and overgarments are placed in bags and moved
to the contaminated waste dump. The dirty litter is rinsed with the
5 percent hypochlorite solution and placed in the litter storage
area.

_g._ =Step 7. Decontaminate skin.=

    (1) =Spot decontamination.= With the patient in a supine
    position, spot decontaminate the skin using the SDK or a 0.5
    percent hypochlorite solution. Decontaminate areas of potential
    contamination. Include areas around the neck, wrists, and lower
    parts of the face. Decontaminate the patient's identification
    tags and chain, if necessary.

        NOTE

        Complete body wash is not appropriate and may be injurious to
        the patient. During complete body wash, the patient would have
        to be rolled over to reach all areas of the skin. This is not
        necessary for adequate decontamination.

    (2) =Trauma specialist care.= During decontamination, the
    clothing around bandages, tourniquets, and splints was cut and
    left in place.

      · The trauma specialist replaces the old tourniquet by placing
      a new tourniquet ½ to 1 inch above the old one. He then removes
      the old tourniquet and decontaminates the patient's skin using
      the M291 pads or a 0.5 percent hypochlorite solution.

      · The trauma specialist gently cuts away bandages and
      decontaminates the area around the wound; dusts the wound
      with the SDK, or irrigates soft tissue wounds with the 0.5
      percent hypochlorite solution. If bleeding begins, the
      trauma specialist replaces the bandage with a clean one.
      The trauma specialist ensures splints are not removed, but
      are decontaminated in place by applying the 0.5 percent
      hypochlorite solution to them, to include the padding and
      cravats. Splints will only be removed by a physician or under
      the supervision of a physician.

        +----------------------------------------------------+
        |                     =WARNINGS=                     |
        |                                                    |
        | 1.  DO NOT apply the SDK or irrigate wounds in the |
        | abdominal and thoracic cavities or intracranial    |
        | head injuries.                                     |
        |                                                    |
        | 2.  DO NOT remove splints.                         |
        +----------------------------------------------------+

    (3) =Check patient for completeness of decontamination.= The
    patient is checked with the CAM or with M8 detector paper for
    completeness of decontamination.

        NOTE

        Other monitoring devices may be used when available.

    (4) =Dispose of contaminated waste.= Dispose of contaminated
    bandages and coverings by placing them in a contaminated waste
    bag. Seal the bag and place it in the contaminated waste dump.


_h._ =Step 8. Transfer the patient across the shuffle pit.=

    (1) The patient's clothing has been cut away; his skin,
    bandages, and splints have been decontaminated. Now the litter
    is transferred to the shuffle pit and placed upon the litter
    stands. The shuffle pit is wide enough to prevent the patient
    decontamination team members from straddling it while carrying
    the litter. Four decontamination team members transfer the
    patient to a clean treatment litter in the shuffle pit. 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 it. A trauma specialist on the clean
    side of the hot line prepares a new FMC before the patient is
    moved to the clean area. The old FMC is disposed of with other
    contaminated waste.

    (2) Decontamination team members rinse or wipe down their
    aprons and gloves with the 5 percent hypochlorite solution.

    (3) Three decontamination team members lift the patient off the
    decontamination litter (see Step 6 for lifting procedures).

    (4) While the patient is elevated, another decontamination
    team member removes the litter from the stands and returns
    it to the decontamination area. A trauma specialist from the
    clean side of the shuffle pit replaces the litter with a clean
    one. The patient is lowered onto the clean litter. Two trauma
    specialists from the clean side of the shuffle pit move the
    patient to the clean treatment area. The patient is treated
    in this area or waits for processing into the CPS. The litter
    removed by the decontamination team member is wiped down with
    the 5 percent hypochlorite solution in preparation for reuse.

        NOTE

        Before decontaminating another patient, each decontamination
        team member drinks approximately one-half quart of water.
        The exact amount of water consumed is increased or decreased
        according to the temperature (see Table G-2 below).


_Table G-2. Heat Injury Prevention and Water Consumption._

  ===========+=========+===============+================+===============
             |         |   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
  -----------+---------+-------+-------+-------+--------+-------+-------
   1 (WHITE) | 78-81.9 |  NL   |   ½   |  NL   |   ¾    | 40/20 |    ¾
   2 (GREEN) | 82-84.9 |  NL   |   ½   | 50/10 |   ¾    | 30/30 |    1
   3 (YELLOW)| 85-87.9 |  NL   |   ¾   | 40/20 |   ¾    | 30/30 |    1
   4 (RED)   | 88-89.9 |  NL   |   ¾   | 30/30 |   ¾    | 20/40 |    1
   5 (BLACK) |   >90   | 50/10 |   1   | 20/40 |   1    | 10/50 |    1
  -----------+---------+-------+-------+-------+--------+-------+-------

  THE WORK/REST TIMES AND FLUID REPLACEMENT VOLUMES WILL SUSTAIN
    PERFORMANCE AND HYDRATION FOR AT LEAST 4 HOURS OF WORK IN THE
    SPECIFIED HEAT CATEGORY.

  NL=NO LIMIT TO WORK TIME PER HOUR.

  REST MEANS MINIMAL PHYSICAL ACTIVITY (SITTING OR STANDING) ACCOMPLISHED
    IN SHADE, IF POSSIBLE.

  CAUTION: HOURLY FLUID INTAKE SHOULD NOT EXCEED 1 QUART.

  DAILY FLUID INTAKE SHOULD NOT EXCEED 12 QUARTS.

  WEARING BODY ARMOR ADDS 5° F TO WBGT INDEX.

  WEARING ALL MOPP OVERGARMENTS ADDS 10° F TO WBGT INDEX.

    +----------------------------------------------------------+
    |                      =WARNING=                           |
    |                                                          |
    | Do not exceed a fluid intake of 1 quart per hour. Do not |
    | exceed a fluid intake of 12 quarts per day.              |
    |                                                          |
    +----------------------------------------------------------+


G-11. Decontaminate an Ambulatory Chemical Agent Patient

_a._ All ambulatory patients requiring EMT or ATM in the clean area
of the BAS will be decontaminated. A member of the decontamination
team or other ambulatory patients will assist the patient in
removing his clothing and decontaminating his skin.

_b._ Patients requiring only minimal care will undergo spot
decontamination of their MOPP gear as required for their medical
treatment. They will be treated in the contaminated EMT area and
returned to duty. They will undergo decontamination and a MOPP gear
exchange with their unit.

_c._ Stable patients not requiring treatment at the BAS, but
requiring evacuation to a higher level of care for treatment
(example: A patient with a broken arm) should be evacuated in
MOPP Level 4 by any available transportation. However, before
evacuation, spot remove all thickened/persistent agents from
protective clothing.

    NOTES

    1. Remember, do not remove clothing from an ambulatory patient
    unless he requires treatment in the clean treatment area of the
    BAS or clearing station. Only spot decontaminate the patient's
    clothing and evacuate him to the next level of care.

    2. Place cutting device used in this procedure in a container
    of 5 percent hypochlorite solution when not in use. Most
    ambulatory patients will be treated in the contaminated
    treatment area and returned to duty. Upon removal of an
    ambulatory patient's clothing, he becomes a litter patient. The
    BAS and clearing station do not have clothing to replace those
    cut off during the decontamination process. The patient must
    be placed in a PPW for protection during evacuation. A battery
    operated blower unit with a CB filter may be attached to the
    PPW to provide fresh air to the patient; thus reducing the
    carbon dioxide buildup inside the PPW (Figure G-7).

[Illustration: _Figure G-7. Chemical warfare agent protective
patient wrap._]

_d._ =Step 1. Remove load-carrying equipment.= Remove load-carrying
equipment (LCE) by unfastening/unbuttoning all connectors or
tie straps; then place the equipment in a plastic bag. Place
the plastic bag in the designated storage area for later
decontamination.

_e._ =Step 2. Decontaminate the patient's mask and hood.= After the
patient has been triaged and treated (if necessary) by the senior
trauma specialist in the PDS, the patient (assisted by another
ambulatory patient or a member of the patient decontamination team,
if necessary) begins the clothing removal process.

    (1) =Decontaminate and remove mask hood.= Sponge down the
    front, sides, and top of the hood with a 5 percent hypochlorite
    solution. Remove the hood by cutting (Figure G-3) or, with
    the quick-doff hood or other hoods, by loosening the hood
    from the mask attachment points. Before cutting the hood, dip
    the cutting device in the 5 percent hypochlorite solution.
    Begin by cutting the neck cord and the small string under the
    voicemitter. Next, release or cut the hood shoulder straps and
    unzip the hood zipper. Proceed by cutting the hood upward,
    close to the filter inlet cover and eye-lens outserts, to the
    top of the eye-lens outsert, across the forehead to the outer
    edge of the other eye-lens outsert. Proceed downward toward
    the patient's shoulder, staying close to the eye-lens and
    filter inlet. Cut across the lower part of the voicemitter to
    the zipper. After dipping the cutting device in the 5 percent
    hypochlorite solution again, 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 head, removing
    the hood.

    (2) =Decontaminate the mask and patient's face.= Decontaminate
    the mask and the patient's face by using the SDK or a 0.5
    percent hypochlorite solution. Wipe the external parts of the
    mask; cover both mask air inlets with gauze or your hands to
    keep the mask filters dry. Continue by wiping the exposed areas
    of the patient's face, to include the neck and behind the ears.

_f._ =Step 3. Remove Field Medical Card.= Cut the FMC tie wire,
allowing the card to fall into a plastic bag. Seal the plastic bag
and rinse it with the 5 percent hypochlorite solution. Place the
plastic bag under the back of the protective mask head straps.

_g._ =Step 4. Remove all gross contamination from the patient's
overgarment.= Remove all visible contamination spots by using
the SDK (preferred method) or a sponge dipped in a 5 percent
hypochlorite solution.

_h._ =Step 5. Remove overgarments.=

    (1) =Remove the patient's personal effects.= Place the
    patient's personal effects in a clean bag and label with the
    patient's identification. If they are not contaminated, give
    them to him. If his personal effects are contaminated, place
    the bagged items in the contaminated storage area until they
    can be decontaminated, then return them to the patient.

    (2) =Remove overgarment jacket.= Have the patient stand with
    his feet spread apart at shoulder width. Unsnap the jacket
    front flap and unzip the jacket. If the patient can extend his
    arms, have him clinch his fists and extend his arms backward
    at about a 30° angle. Move behind the patient, grasping his
    jacket collar at the sides of the neck, peel the jacket off
    the shoulders at a 30° angle down and away from the patient.
    Avoid any rapid or sharp jerks that can spread contamination.
    Gently pull the inside sleeves over the patient's wrists and
    hands. If the patient cannot extend his arms, you must cut the
    jacket to aid in its removal. Dip the cutting device in the 5
    percent hypochlorite solution between each cut. As with the
    litter patient, cut both sleeves from the inside, starting
    at the wrist, up to the armpit. Continue cutting across the
    shoulder to the collar. Cut around bandages or splints, leaving
    them in place. Next, peel the jacket back and downward to avoid
    spreading contamination. Ensure that the outside of the jacket
    does not touch the patient or his inner clothing.

    (3) =Remove overgarment trousers.= Unfasten or cut all ties,
    buttons, or zippers before grasping the trousers at the waist
    and peeling them down over the patient's combat boots. Again,
    the trousers are cut to aid in removal. If necessary, cut both
    trouser legs starting at the ankle, keeping the cuts near the
    inside of the legs, along the inseam, to the crotch. Cut around
    all bandages, tourniquets, or splints. Continue to cut up both
    sides of the zipper to the waist and allow the narrow strip
    with the zipper to drop between the legs. Place the cutting
    device in the 5 percent hypochlorite solution. Peel or allow
    the trouser halves to drop to the ground. Have the patient step
    out of the trouser legs, one at a time. Place the trousers in
    the contaminated disposal bag.

    (4) =Remove overboots.= Remove the patient's overboots by
    cutting the laces with cutting device dipped in the 5 percent
    hypochlorite solution. Fold the lacing eyelets flat on the
    ground. Step on the toe and heel eyelets to hold the overboot
    on the ground and have the patient step out of it. Repeat this
    procedure for the other overboot. If the GVO are worn, first
    try to remove the overboots without cutting; if necessary, cut
    the overboots along the front. If the overboots are in good
    condition, they can be decontaminated and reissued.

    (5) =Remove the patient's outer gloves.= Grasp the heel of the
    glove, peel the glove off with a smooth downward motion. Place
    the contaminated gloves in a plastic bag with the overgarment
    jacket. Do not allow the patient to touch his clothing or other
    contaminated objects with his exposed hands.

    (6) =Remove the patient's cotton glove liners.= Have the
    patient remove his cotton glove liners to reduce the
    possibility of spreading contamination. Have the patient grasp
    the heel of one glove liner with the other gloved hand, peeling
    it off of his hand. Hold the removed glove by the inside and
    grasp the heel of the other glove, peeling it off of his hand.
    Place both glove inserts in the contaminated waste bag.

_i._ =Step 6. Remove patients BDU.=

    (1) =Remove the patient's personal effects.= Place the
    patient's personal effects in a clean bag and label with the
    patient's identification. If they are not contaminated, give
    them to him. If his personal effects are contaminated, place
    the bagged items in the contaminated storage area until they
    can be decontaminated, then return them to the patient.

    (2) =Remove BDU jacket.= Have the patient stand with his feet
    spread apart at shoulder width. Unbutton the front flap of the
    jacket. If the patient can extend his arms, have him clinch
    his fists and extend his arms backward at about a 30° angle.
    Move behind the patient, grasping his jacket collar at the
    sides of the neck, peel the jacket off the shoulders at a 30°
    angle down and away from the patient. Avoid any rapid or sharp
    jerks that can spread contamination. Gently pull the inside
    sleeves over the patient's wrists and hands. If the patient
    cannot extend his arms, you must cut the jacket to aid in its
    removal. Dip the cutting device in the 5 percent hypochlorite
    solution between each cut. As with the litter patient, cut
    both sleeves from the inside, starting at the wrist, up to the
    armpit. Continue cutting across the shoulder to the collar. Cut
    around bandages or splints, leaving them in place. Next, peel
    the jacket back and downward to avoid spreading contamination.
    Ensure that the outside of the jacket does not touch the
    patient or his inner clothing.

    (3) =Remove BDU trousers.= Unfasten or cut all ties, buttons,
    or zippers before grasping the trousers at the waist and
    peeling them down over the patient's combat boots. Again, the
    trousers are cut to aid in removal. If necessary, cut both
    trouser legs starting at the ankle, keeping the cuts near the
    inside of the legs, along the inseam, to the crotch. Cut around
    all bandages, tourniquets, or splints. Continue to cut up both
    sides of the zipper to the waist and allow the narrow strip
    with the zipper to drop between the legs. Place the cutting
    device in the 5 percent hypochlorite solution. Peel or allow
    the trouser halves to drop to the ground. Have the patient step
    out of the trouser legs, one at a time. Place the trousers in
    the contaminated disposal bag.

    (4) =Remove undergarments.= Remove the patient's tee shirt.
    Dip the cutting device in the 5 percent hypochlorite solution
    between each cut. Cut both sleeves from the inside, starting
    at the elbow, up to the armpit. Continue cutting across the
    shoulder to the collar. Cut around bandages or splints, leaving
    them in place. Next, peel the tee shirt away from the body to
    avoid spreading contamination. If the patient is wearing a
    brassiere, cut it between the cups. Cut both shoulder straps
    where they attach to the cups and lay them back off of the
    shoulders. Remove the patient's under shorts/panties by cutting
    from the lower side of the hip to the waist on both sides.
    Allow the shorts/panties to fall to the ground. Do not remove
    the patient's identification tags.

_j._ =Step 7. Check patient for contamination.= After the patient's
BDU and underwear has been removed check the skin for contamination
by using M8 detector paper or the CAM. Carefully survey all areas
of the patient's skin, paying particular attention to areas around
the neck, wrist, ears, and dressings, splints, or tourniquets.

_k._ =Step 8. Decontaminate skin.=

    (1) =Spot decontamination.= Use the SDK or the 0.5 percent
    hypochlorite solution to spot decontaminate exposed neck
    and wrist areas, splints, other areas where the protective
    overgarment was damaged, and where dressings or bandages were
    removed. Decontaminate the patient's identification tags, if
    necessary. Have the patient hold his breath and close his
    eyes. Have him, or assist him, lift his mask at the chin. Wipe
    his face with the M291 pad or the 0.5 percent hypochlorite
    solution. Wipe quickly from below the top of one ear, being
    careful to wipe all folds of the skin, top of the upper lip,
    chin, dimples, earlobes, and nose. Continue up the other side
    of the face to the top of the other ear. Wipe the inside of the
    mask where it touches the face. Have the patient reseal and
    check his mask.

        +-----------------------------------------------+
        |                  CAUTION                      |
        |                                               |
        | Keep the decontamination solution out of the  |
        | patient's eyes.                               |
        +-----------------------------------------------+

    (2) =Trauma specialist care.= During clothing removal, the
    clothing around bandages, tourniquets, and splints was cut and
    left in place.

      · The trauma specialist replaces the old tourniquet by placing
      a new one ½ to 1 inch above the old tourniquet. When the old
      tourniquet is removed, the skin is decontaminated with the SDK
      or the 0.5 percent hypochlorite solution.

      · _Do not remove splints._ Decontaminate them by thoroughly
      rinsing the splint, padding, and cravats with the 0.5 percent
      hypochlorite solution.

      · Usually, the trauma specialist will gently cut away bandages.
      The area around the wound is dusted with the M291 pad or rinsed
      with the 0.5 percent hypochlorite solution, and the trauma
      specialist applies the M291 pad or irrigates the soft tissue
      wound with the 0.5 percent hypochlorite solution. If bleeding
      begins, the trauma specialist replaces the bandage with a clean
      one.

_l._ =Step 9. Dispose of contaminated waste.= Dispose of
contaminated bandages and coverings by placing them in a plastic
bag and sealing the bag with tape. Place the plastic bags in the
contaminated waste dump.

_m._ =Step 10. Proceed through the shuffle pit to the clean
treatment area.= Have the decontaminated patient proceed through
the shuffle pit to the clean treatment area. Make sure that the
patient's boots are thoroughly decontaminated by stirring the
contents of the shuffle pit with his boots as he crosses it. The
patient will remove his combat boots and socks at the entrance of
the clean treatment area or CPS; remove the protective mask at the
entrance to the clean treatment area or inside the ambulatory air
lock of the CPS.


G-12. Biological Patient Decontamination Procedures

The decontamination station as established for chemical agent
patients is also used for biologically contaminated patients. The
eight-man patient decontamination team is required for biologically
contaminated patient decontamination procedures.


G-13. Decontaminate a Litter Biological Agent Patient

_a._ =Remove the patient's personal effects.= Place the patient's
personal effects in a clean bag and label with the patient's
identification. If they are not contaminated, give them to him. If
his personal effects are contaminated, place the bagged items in
the contaminated storage area until they can be decontaminated, and
then return them to the patient.

_b._ =Remove the Field Medical Card.= Remove the FMC by cutting the
tie wire and allowing the FMC to drop into a plastic bag. Keep the
FMC with the patient.

_c._ =Remove the patient's clothing.= Patient decontamination
team members first apply the 5 percent hypochlorite solution to
the patient's clothing and the litter. Then, remove the patient's
clothing as in decontamination of chemical agent patients.
Bandages, tourniquets, and splints are not removed. Move patient
to a clean litter as described for a chemical agent patient. Place
patient's clothing in a plastic bag and dispose in the contaminated
waste dump.

_d._ =Decontaminate the patient's skin.= Bathe the patient with
soap and warm water or apply the 0.5 percent hypochlorite solution.
The trauma specialist places a new tourniquet ½ to 1 inch above
the old tourniquet, and then he removes the old one. The trauma
specialist removes bandages and decontaminates the skin and wound
with the 0.5 percent hypochlorite solution; he replaces the
bandage, if needed, to control hemorrhage. Splints are disinfected
by soaking the splint, cravats, and straps with the 0.5 percent
hypochlorite solution.

    NOTE

    Use a 0.5 percent hypochlorite solution to decontaminate
    patients suspected of being contaminated with mycotoxins.

_e._ =Transfer patient to hot line.= Two decontamination team
members move patient to the hot line. Request assistance from
two other decontamination team members to transfer him to a
clean litter as described for chemical agent patients. Place the
patient's FMC in the plastic bag on the clean litter with him. Two
trauma specialists from the clean side of the hot line move the
patient from the hot line to the clean treatment/holding area.


G-14. Decontaminate an Ambulatory Biological Agent Patient

_a._ =Remove the patient's personal effects.= Place the patient's
personal effects in a clean bag and label with the patient's
identification. If they are not contaminated, give them to him. If
his personal effects are contaminated, place the bagged items in
the contaminated storage area until they can be decontaminated,
then return them to the patient.

_b._ =Remove the Field Medical Card.= Remove the FMC by cutting the
tie wire and allowing the FMC to drop into a plastic bag. Keep the
FMC with the patient.

_c._ =Remove the patient's clothing.= Patient decontamination
team members first apply the 5 percent hypochlorite solution to
the patient's clothing. Then remove the patient's clothing as in
decontamination of chemical agent patients. Bandages, tourniquets,
and splints are not removed. Place patient's clothing in a plastic
bag and dispose in the contaminated waste dump.

_d._ =Decontaminate the patient's skin.= Have the patient bathe
with soap and warm water or apply the 0.5 percent hypochlorite
solution. If the patient is unable to bathe himself, a member of
the decontamination team must bathe him. The trauma specialist
places a new tourniquet ½ to 1 inch above the old tourniquet,
and then he removes the old one. The trauma specialist removes
bandages and decontaminates the skin and wound with the 0.5 percent
hypochlorite solution; he replaces the bandage, if needed, to
control hemorrhage. Splints are disinfected by soaking the splint,
cravats, and straps with the 0.5 percent hypochlorite solution.

    NOTE

    Use a 0.5 percent hypochlorite solution to decontaminate
    ambulatory patients suspected of being contaminated with
    mycotoxins.

_e._ =Direct patient across hot line.= Direct the patient to
cross the hot line to the clean treatment area. His boots must be
decontaminated at the hot line before he enters the clean treatment
area.

    NOTES

    1. Remember, do not remove clothing from an ambulatory patient
    unless he requires treatment in the clean treatment area of the
    BAS or clearing station. Only spot decontaminate the patient's
    clothing and evacuate him to the next level of care.

    2. Place cutting device used in this procedure in a container
    of 5 percent hypochlorite solution when not in use. Most
    ambulatory patients will be treated in the contaminated
    treatment area and returned to duty. Upon removal of an
    ambulatory patient's clothing, he becomes a litter patient. The
    BAS and clearing station do not have clothing to replace those
    cut off during the decontamination process. The patient must be
    placed in a PPW for protection during evacuation (Figure G-7).


G-15. Decontaminate Nuclear-Contaminated Patients

The practical decontamination of nuclear-contaminated patients is
easily accomplished without interfering with the required medical
care.

    NOTE

    Patients must be monitored by using a radiac meter (AN/VDR2,
    AN/PDR27, or AN/PDR77) before, during, and after each step of
    the decontamination procedure.


G-16. Decontaminate a Litter Nuclear-Contaminated Patient

_a._ =Remove patient's personal effects.= Patient decontamination
team members remove the patient's personal effects and place them
in a plastic bag. Place plastic bag in a clean holding area.

_b._ =Remove patient's clothing.= Patient decontamination team
members remove the patient's outer clothing as described for
chemical agent patients. Do not remove bandages, tourniquets, or
splints. Move the patient to a clean litter. Place the patient's
contaminated clothing in a plastic bag and move the bagged clothing
to the contaminated waste dump.

    NOTE

    Patients arriving at the MTF in MOPP will only have their MOPP
    removed. They can remain in their BDU unless contamination is
    found on it.

_c._ =Spot decontaminate patient's skin.= Wash exposed skin
surfaces with soap and warm water. Wash the hair with soap and warm
water, or clip the hair and wash the scalp with soap and warm water.

_d._ =Transfer patient to hot line.= Move the patient to the hot
line. Two trauma specialists from the clean side of the hot line
move the patient into the clean treatment area.


G-17. Decontaminate an Ambulatory Nuclear-Contaminated Patient

_a._ =Remove patient's personal effects.= Have the patient remove
his personal effects and place them in a plastic bag.

_b._ =Remove patient's outer clothing.= Have the patient remove
his outer clothing (or have a decontamination team member assist
him). Place his contaminated clothing in a plastic bag and move the
bagged clothing to the contaminated waste dump.

    NOTE

    Patients arriving at the MTF in MOPP will only have their
    MOPP removed. They can remain ambulatory in their BDU unless
    contamination is found on it.

_c._ =Spot decontaminate patient's skin.= Have the patient wash his
exposed skin surfaces with soap and warm water. Wash his hair with
soap and water, or clip the hair and wash the scalp with soap and
water.

_d._ =Transfer patient to hot line.= Direct the patient to move to
the hot line. Decontaminate his boots by stirring the shuffle pit
contents with his feet before he crosses into the clean treatment
area.

    NOTE

    If a new protective overgarment is not available, after
    treatment, the ambulatory patient must be placed in a PPW for
    protection during MEDEVAC to the next level of care MTF. Thus,
    he becomes a litter patient for evacuation.




APPENDIX H

FIELD EXPEDIENT PROTECTIVE SYSTEMS AGAINST NUCLEAR, BIOLOGICAL, AND
CHEMICAL ATTACK


H-1. General

Medical units must have protection from NBC attack and
contamination to survive and function effectively. The extent of
protection provided is only limited by the resources available and
efforts of unit personnel. Protection as simple as an individually
dug foxhole or as elaborate as the subbasement of a concrete
building may be used. Expedient protection from the effects
of biological and chemical agents are usually much less labor
intensive.


H-2. Protection Against Radiation

The level of protection from radiation is expressed in terms
of shielding. Material is available on the battlefield to
construct/prepare expedient fallout shelters that offer substantial
shielding against gamma radiation (see Table H-1). Generally,
the denser or heavier the material, the better shielding it
offers. The degree of protection afforded by a fallout shelter is
expressed as a "protection factor," or a "transmission factor."
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 person. Thus,
a protection factor of 2 indicates that an individual in the
shelter receives one-half of the radiation dose he would receive
if unprotected. A protection factor of 100 (associated with about
six half-value thicknesses) indicates that only 1/100 or 1 percent
of the radiation dose reaches the inside. Transmission factors
are expressed in percentages, or in decimals. Either refers to
that fraction of the ambient unshielded dose that is received by
personnel within the shelter. Fallout gamma transmission factors
for some common shelters are shown in Table H-2.


_Table H-1. Shielding Potential of Common Materials--Fallout Gamma
Protection_

    =============================================================
         MATERIAL           1/2 VALUE LAYER THICKNESS[*]
    -------------------------------------------------------------
         STEEL                     1.8 CM  (.7")
         CONCRETE                  5.6 CM (2.2")
         EARTH                     8.4 CM (3.3")
         WATER                    12.2 CM (4.8")
         WOOD                     22.4 CM (8.8")
    -------------------------------------------------------------

    [*] 1/2 VALUE LAYER THICKNESS--THICKNESS OF A GIVEN MATERIAL
    WHICH REDUCES THE DOSE OR DOSE RATE TO APPROXIMATELY ONE-HALF
    OF THAT FALLING UPON IT.
    =============================================================


_Table H-2. Transmission factors for Nuclear Radiation[*]_

    ==================================================================
                                                 INITIAL
      ENVIRONMENTAL SHIELDING        NEUTRONS     GAMMA      RESIDUAL
    ------------------------------------------------------------------

      BUILT-UP CITY AREA (IN OPEN)     1.0         0.5         0.7
      FOXHOLES                         0.3         0.2         0.1
      FRAME HOUSE:
        FIRST FLOOR                    1.0         0.9         0.5
        BASEMENT                       0.5         0.3         0.1
      MULTISTORY BUILDINGS:
        TOP FLOOR                      1.0         0.9          0.1
        INTERMEDIATE FLOORS            0.9         0.9          0.02
        LOWER FLOOR                    0.9         0.5          0.1
        BASEMENT                       0.5         0.3          0.01
      SHELTER, CLOSED 91 CM (3 FT)
        (EARTH COVER)                  0.05        0.02         0.005
      ARMORED VEHICLES:
        ARMORED PERSONNEL CARRIER      0.3         0.2          0.1
        TANKS                          0.3         0.2          0.1
      WOODED FOREST                    1.0         1.0          0.8
    ------------------------------------------------------------------

    [*] INSIDE DOSE = TRANSMISSION FACTOR TIMES OUTSIDE DOSE.
    ==================================================================


H-3. Expedient Shelters for Protection Against Radiation

_a._ In many cases it will be unnecessary to construct field
expedient or other types of fallout shelters. There are many
structures and terrain features available that afford a degree of
fallout protection. Existing fallout shelters are tunnels, caves,
culverts, overpasses, ditches, ravines, and man-made structures.
The best existing shelters are basements. Figure H-1 shows typical
protection provided in buildings. Windows can be sandbagged or
covered with dirt from the outside to provide additional protection.

[Illustration: _Figure H-1. Typical shelter protection provided in
buildings._]

_b._ Planners should attempt to locate HSS units near existing
shelters, whenever possible. However, if an HSS unit is already
established, or must be established where fallout shelters are not
available, then a shelter must be constructed. Elaborate shelters
are not required, since they usually only need to be occupied for a
few days. 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 days.

_c._ When engineer support is available, a bulldozer trench about
2.7 meters (9 feet) wide and 1.2 meters (4 feet) deep can be dug
(Figure H-2). The length of the trench will be determined by the
number of patients/personnel to be sheltered. About 0.6 meter (2
feet) length of trench is required for each person to be sheltered.
These trenches reduce exposure of personnel lying on the floor to
about 20 to 30 percent of the radiation that they would receive in
the open. Protection and comfort can be improved, as time permits,
by digging the trenches deeper; undercutting the walls (care must
be taken in this option; the earth may cave in); erecting tents
over the trenches; and providing improved flooring. When used with
other individual and collective protection measures, bulldozer
trenches provide adequate fallout shelters for most situations;
they can be provided in a minimum of time and effort. Trenches
should not be dug in areas subject to flooding during rainstorms;
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 area.
Undercutting will not be possible in sandy soil; also some form of
support to keep the walls from caving in is required.

[Illustration: _Figure H-2. Dozer trench._]

_d._ Dug-in tents (Figure H-3) for hospitals provide more comfort
and require less movement than the bulldozer trench; however, they
have two drawbacks. First, they offer far less radiation protection
than the bulldozer trench, and second, they require considerably
more engineer effort. This option should work well with GP tents,
but will probably be hard to accomplish with the TEMPER.

[Illustration: _Figure H-3. Dug-in tents._]

_e._ Sandbagged walls around the hospital tents, as shown in
Figure H-4, or lightly constructed buildings provide protection
from fallout. Sandbagged walls 1.2 meters high give significant
protection (20 to 40 percent transmission factor); however,
the effort required to achieve the protection is such that it
is marginally feasible. Sandbagging is an effective means for
supplementing other shelters by--

    · Bolstering the shielding at weak points.

    · Forming baffles at entryways.

    · Blocking open ends of trenches.

    · Covering windows and gaps.

_f._ When other shelters are not available, HSS units must
prepare foxholes and trenches for patients and unit personnel.
As time permits, improve these shelters by deepening, covering,
undercutting, and sandbagging.

[Illustration: _Figure H-4. Sandbag walls around tents._]


H-4. Expedient Shelters Against Biological and Chemical Agents

_a._ When CPS systems are not available, well-sealed shelters
(TEMPER, ISO, and GP) can significantly minimize or prevent the
entry of CB agents. The ventilation system must be turned off, and
kept off, before, during, and after the attack. The shelter must be
totally sealed during this time to maximize protection. Table H-3
provides examples of protection values for well-sealed shelters.
For example, a well-sealed TEMPER will only permit 1/60 of the
CB agent outside to enter the shelter. If a persistent agent is
used, be aware of agent off-gassing hazards. Persistent agents can
penetrate TEMPER fabric and create a vapor hazard inside. In a CB
agent attack, ensure that all staff and patients are protected by
wearing their MOPP or are in PPWs.


_Table H-3. Ratio at Nonpersistent Agent Concentrations
(Inside/Outside) for Different Shelters_

  =================================================================
                    SHELTER                   RATIO INSIDE/OUTSIDE
  -----------------------------------------------------------------
  TEMPER TENT                                         1:60[*]
  GENERAL PURPOSE TENT, MEDIUM, WITH COTTON LINER     1:50
  GENERAL PURPOSE TENT, LARGE, WITH COTTON LINER      1:30
  ISO SHELTER                                         1:60
  -----------------------------------------------------------------

  [*] THE VENTILATION SYSTEM MUST BE TURNED OFF ON ALL SHELTERS TO
  PROVIDE THIS LEVEL OF PROTECTION.
  =================================================================

_b._ Sealing shelters to prevent entry of CB agents does not
require elaborate materials or procedures.

    (1) Materials needed for sealing shelters include, but are not
    limited to the following:

      · Duct tape (or similar tape) for sealing.

      · Velcro kits for TEMPER.

      · Sand/dirt to seal base of GP tents.

      · Plastic sheeting and tape to seal large openings, such as
      doors and windows of GP tents.

    (2) All vulnerable areas must be sealed. Seal--

      · Joints in ISO shelters and GP tents with tape. Tape does not
      work very well on TEMPER fabrics; use Velcro kits.

      · Base of GP tents with sand/dirt.

      · Stove pipe openings with tape and plastic.

      · Windows of GP tents with tape and plastic. Seal TEMPER tent
      windows by aligning and securing the Velcro border tightly;
      tape may be applied to the seams to provide some additional
      barrier.

      · All ISO shelter doors that do not have CB protective seals,
      with tape. Seal GP tent doors with plastic sheeting and tape.

      · All windows, doors, and other openings of fixed sites with
      plastic and tape.

      · All air ventilation system vents.

          NOTES

          1. Do not allow any entries/exits to shelters during a CB
          attack.

          2. In hot climates the heat load will rise in sealed shelters
          with the ventilation system turned off. Personnel must
          carefully monitor each other and the patients. All personnel
          must drink plenty of water to prevent heat injuries; see FM
          21-10.




APPENDIX I

DETECTION AND TREATMENT OF NUCLEAR, BIOLOGICAL, AND CHEMICAL
CONTAMINATION IN WATER


I-1. General

Water supplies in areas with NBC contamination and in surface
water supplied by runoff from such areas will most likely be
contaminated. The contamination of water, whether intentional or
inadvertent, may reach concentrations that will produce casualties.
By special methods of analysis, the presence of contamination can
be determined. Treatment of contaminated water requires chemicals
and equipment that are only available to quartermaster water
purification units; individuals or units should not attempt to
treat their water. Decontamination of water is only undertaken
when uncontaminated sources are not available; then ONLY with the
approval of the medical authority (PVNTMED or surgeon).


I-2. Detection of Contamination in Water

_a._ Detection of nuclear contamination in water is accomplished by
using the AN/PDR77, AN PDR/27 or AN VDR/2 radiac meters.

    +------------------------------------------------------+
    |                        CAUTION                       |
    |                                                      |
    | DO NOT allow the probe to come into contact with the |
    | water source; allow at least one inch of air space   |
    |  between the probe and water surface.                |
    +------------------------------------------------------+

_b._ Detection of BW agents in water is accomplished by the use of
field biological water test kits and specially designed collection
and detection kits. The specialty kits will be provided as needed,
and will be available to PVNTMED and supporting medical laboratory
personnel. When required for the President and Secretary of Defense
purpose, samples must be collected and prepared for shipment to the
supporting medical laboratory. A chain of custody document must be
prepared by the collector and maintained as the sample(s) is being
transported to the supporting medical laboratory and throughout
its transit to the CONUS laboratory. See Appendix F for details
on suspect BW sample collection, packaging, chain of custody, and
handling.

_c._ The Chemical Agent Water Testing Kit, M272, provides a rapid
field test to detect chemical agent contamination in water. The
test must be conducted before the water is treated with chlorine;
the chlorine will affect the accuracy of the test for chemical
agents.


I-3. Procedures on Discovery of Contamination in Water

When contamination is discovered the following actions are taken:

_a._ Mark the water source, using the standard NBC contamination
markers, and ensure that personnel do not consume the water until
approved.

_b._ Notify the commander that the water source is contaminated and
unfit for drinking, food preparation, and personal hygiene.

_c._ Notify the supporting water production unit, such as the
quartermaster water production and distribution unit of the
contaminated water source.

_d._ The commander establishes safeguards to prevent personnel from
using the contaminated water supply.

_e._ An alternative source of uncontaminated water is sought
and used. The primary source for obtaining water is from
quartermaster-operated water production and distribution points.
Other sources are considered only when quartermaster-operated
faculties are not available. Alternative sources that may be
considered include--

    · Ground water sources that are least likely to be contaminated.

    · Local fixed facility water supplies. However, these supplies
    must be tested before use. If NBC contamination is found do not
    use.

    · Using another location to obtain an uncontaminated water
    source, when the tactical situation permits.

_f._ 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 authority.


I-4. Treatment of Contaminated Water

Contaminated water requires additional equipment and supplies to
remove the contamination. Quartermaster water purification and
distribution units are equipped to perform these duties. See FM
10-52 for details.




APPENDIX J

FOOD CONTAMINATION AND DECONTAMINATION


J-1. General

_a. Food Susceptibility._ Stored, transported, and prepared food
is susceptible to NBC contamination throughout the TO. Planning
for any battle or operation must include food protection from
contamination; food contamination detection; and contaminated food
disposition (decontaminate or destroy).

_b. Countermeasures._ There are three primary countermeasures to
overcome or reduce the NBC hazard to food:

    (1) Contamination avoidance.

    (2) Nuclear, biological, and chemical agent detection.

    (3) Nuclear, biological, and chemical agent decontamination.

_c. Priorities._ The priorities for conducting NBC countermeasures
are--

    (1) _Contamination avoidance._ Contamination avoidance
    includes using natural and fabricated barriers to prevent, or
    significantly reduce the spread of contamination. Also, using
    specific procedures for entry and exit between contaminated
    and uncontaminated areas reduce the potential for spreading
    contamination. Use of these barriers and procedures may reduce
    the subsequent need for detection and decontamination.

    (2) _Detection, measurement, and identification._ These
    activities are essential for determining the presence, extent,
    and nature of NBC contamination. This information is essential
    in identifying the existence of uncontaminated supplies, or
    decontamination requirements.

    (3) _Decontamination._ Decontamination removes the contaminant
    and provides food that is safe for consumption.

_d. Decontamination._ Decontamination efforts require an
extensive amount of labor, time, and supplies. The use of hasty
decontamination is emphasized. That is, decontaminate just enough
to sustain operations and keep fighting, rather than to make a
contamination-free environment. Normally, decontamination efforts
will be limited to the packaging and packing materials. Food
decontamination will only occur in critical situations where
other food supplies are not available. Most decontamination is
performed in or very near the AO. Before beginning decontamination
procedures, divide exposed food items into groups based on
protection of item at time of exposure. These groups establish
priorities based on ease of decontamination and the ability to
monitor the food.

    (1) Group I--Canned or packaged items exposed only to a
    chemical agent vapor.

    (2) Group II--Canned or packaged items that are contaminated on
    the outside with a liquid chemical agent, a biological agent,
    or radioactive fallout.

    (3) Group III--Unpacked or poorly packaged items that have been
    exposed to any NBC agent.

    (4) Group IV--Food contaminated through the food chain.


J-2. Protection of Food from Contamination

An adequate defensive posture for a chemical attack will also
protect food against biological contamination and radiation fallout.

_a. Operational Rations._ Operational rations include, but are not
limited to, MREs; unit group ration (UGR), A; unit group ration,
heat and serve; and medical diet supplement.

    (1) Packaging materials and storage methods normally protect
    these rations. The packaging and packing of operational rations
    protect the contents from deterioration. As a result, the
    contents are protected from moisture, to include chemical
    liquids, chemical vapors, and biological agents. Operational
    rations delivered to an AO will usually have increased levels
    of packaging and/or packing protection. Operational rations are
    substantially protected while contained in the shipping cases,
    especially if protected with an overlay of fiberboard, shrink
    wrap, or film wrap.

    (2) Enclosed storage is used whenever possible. Refrigerated
    warehouses, cold storage rooms, and even prefabricated
    refrigerators and trailers provide excellent protection.
    Underground shelters, caves, and tunnels that can be made
    airtight provide maximum NBC protection. Buildings provide
    protection depending on how well they can be closed and sealed.
    The basement of a building is a good storage place. However,
    keep in mind that chemical vapors tend to seek out low-lying
    areas. Storing rations indoors will protect them from liquid
    droplet and fallout contamination unless the building is
    damaged by an attack. Complete protection against chemical
    vapors is only offered by airtight closed spaces like cold
    storage facilities.

    (3) Chemical protective measures are to be integrated into
    daily logistical operation to avoid the contamination of
    operational rations. Maximum use is made of alarm and
    detection equipment, overhead shelter, shielding materials,
    and protective covers. Back up stocks of operational rations
    should be dispersed to minimize the risk of destruction or
    contamination.

    (4) An NBC Protective Cover or similar equipment will help
    greatly. The NBC Protective Cover is discarded and replaced
    upon becoming contaminated; it reduces overall decontamination
    requirements; and it improves the survivability of supplies and
    equipment. The NBC Protective Cover provides 24-hour protection
    against liquid chemical contamination. Detection paper used on
    the NBC Protective Cover will rapidly identify a contaminated
    cover.

_b. Bulk and Fresh Foods._

    (1) Field expedient or improvised storage may be the only
    choice available under high-risk conditions. Expedient storage
    for food supplies may be a natural or man-made depression
    lined to protect contents against moisture, and then covered
    with earth and sod. The earth gives good protection against
    all forms of chemical or biological contamination and nuclear
    fallout.

    (2) Foods are only stored outdoors or in partially protected
    areas when absolutely necessary. Only cases of foods packed in
    cans, bottles, or airtight foil or film wraps, and foods packed
    in sealed boxes or multilayered wrappings can be subjected to
    exposed storage. Partial protection is provided by open sheds,
    temporary roofing, or tents. When subsistence must be stored
    in the open, give as much protection as possible. Protection
    material may include NBC Protective Covers, tarpaulins,
    tarpaulin sheds, or any other available covering such as
    plastic sheeting. Tarpaulins and other treated or waterproof
    coverings do not prevent contamination by chemical vapors,
    but they do reduce contamination from liquid agents. Canvas
    will keep out more than 95 percent of liquid contamination for
    a short period of time after the attack. The canvas must be
    removed soon after the attack to prevent the agent from seeping
    through onto the subsistence; placement of spacers between the
    covering and the food will greatly reduce this problem. Even
    the thinnest material will offer some protection and is better
    than nothing at all. Therefore, food supplies must be covered
    by whatever material is available.


J-3. Nuclear

_a. Contamination._

    (1) Following a nuclear detonation, food can become
    contaminated in three ways:

      · _Direct contamination._ Direct contamination results by
      fallout collecting on plants, animals, and stored food (surface
      contamination). Fallout has two effects. First, it produces
      a gamma radiation field over the fallout area. Second, it
      contaminates the surface of anything on which it is deposited.
      The whole-body gamma irradiation hazard to an individual far
      outweighs any potential hazard from food contamination. The
      basic rule is: If you can safely be in the area to salvage the
      food, then the food salvaged is safe to use (although slightly
      contaminated).

      · _Indirect contamination._ This form of contamination can
      be spread throughout the food chain. Humans can ingest
      contamination by eating plants that have absorbed radioactive
      isotopes; products (milk or meat) from animals allowed to graze
      on contaminated pastures; or fish from contaminated water.

      · _Induced radiation._ It is possible that food will be
      exposed to sufficient neutron flux (an increase in the number
      of free neutrons) as the result of a nuclear explosion to
      produce considerable induced radioactivity in food without
      it being destroyed by blast and heat. This is possible with
      enhanced radiation weapons in the energy range of 1 KT where
      the radiation kill radius exceeds the blast destruction zone.
      The elements that are most prominently involved are sodium,
      potassium, sulfur, copper, bromine, zinc, and especially
      phosphorous. Thus, in an area of induced radiation, foods
      requiring the most caution are dairy products, high salt
      content foods, dry beans, raisins, and ready-mixed cake and
      biscuit flours. The radioactivity has a short half-life;
      therefore, the radiation will decay very rapidly. It should be
      possible to consume foods containing induced radiation within
      a week or two. Cans, particularly those with "C" enamel, may
      incur a high level of induced radiation (from zinc in the
      enamel, not from iron in the can). Glass, because of its high
      salt content, will show very high levels of activity; clear
      glass will turn brown. Container radioactivity has no bearing
      on the food, it is safe to use. The radioactivity is not
      transferred to the contents. No significant toxic by-products
      are formed in the exposed canned food.

    (2) Consumption of food contaminated with radioactive fallout
    may cause a risk of radiation injuries from internal radiation;
    that is, radiation from radioactive sources within the body.
    Most isotopes will pass through the digestive tract or be
    excreted very quickly. However, the intestinal tract may
    receive a considerable dose. Some isotopes are more hazardous
    because they are absorbed from the digestive tract and enter
    the metabolism of man and animals.

      · Strontium-89 (Sr-89) and Strontium-90 (Sr-90) are beta
      emitters and have half-lives of 51 days and 28 years,
      respectively. Therefore, Sr-90 is the greatest radiation hazard
      in the long term. These two isotopes are absorbed in the body
      and used in the same way as calcium. They accumulate in bone,
      where bone marrow with its blood forming cells is vulnerable.
      Milk and other dairy products are the primary sources of Sr-89
      and Sr-90 in the human diet.

      · Iodine-131 (I-131) is a beta and gamma emitter and has
      a short physical half-life of approximately 8 days. It is
      efficiently absorbed and used by the body. Iodine-131 will
      contaminate plants that will be eaten by grazing animals.
      Smaller amounts can also be absorbed by breathing contaminated
      air. Cattle will excrete a large amount of I-131 in milk. Milk
      and other dairy products are the primary sources of I-131
      intake. One can also get smaller amounts by eating contaminated
      fruits and vegetables. Iodine-131 will be concentrated in the
      thyroid gland. The intake of I-131 will have its greatest
      impact the first few days to weeks following a nuclear
      explosion.

      · Cesium-137 (Cs-137) is a beta emitter and has a half-live
      of 30 years, but is eliminated relatively quickly from the
      body. The biological half-live is 70 to 140 days. Cesium-137
      is found in most tissues of the body, but it will concentrate
      in muscle tissue. Cesium-137 is absorbed and used the same way
      as potassium. Meat and milk are the primary sources of Cs-137.
      Much precipitation, lack of minerals in the soil, and extensive
      cultivation increase the plants' absorption of Cs-137; thus,
      the contamination of plant products.

    (3) Operational rations are safe when surface decontamination
    is performed before breaking the package. Operational rations
    stored close to ground zero may become radioactive from induced
    radiation. It is more likely, however, that the food will be
    damaged or destroyed by the blast and thermal effects of the
    nuclear explosion.

    (4) Bulk and fresh food stored in the open without protection
    will be contaminated. Decontamination is very difficult and
    time-consuming. Efforts should be made to ensure proper packing
    to prevent food contamination from radioactive fallout. Packing
    made from hard and nonporous materials, such as plastic or
    multilayer cardboard with a smooth surface, should be used.
    In addition, storage facilities should be enclosed to avoid
    the entry of fallout. Any material used as a protective cover
    will give some protection against nuclear fallout. Protection
    against induced radiation, blast, and thermal effects requires
    a hardened shelter or underground storage.

    (5) Food supplies require protection throughout the chain of
    production or procurement. Protection of the civilian-based
    food supply includes countermeasures along the production
    chain. Meats and milk are the most vulnerable products because
    of the possibility for concentration of radioactive isotopes
    (Strontium, Cesium, and Iodine). The primary, and possibly the
    only, protection of animal products is to keep the animals
    indoors and to avoid contaminated fodder. Immediate slaughter
    of food animals is recommended if there is a shortage of
    uncontaminated fodder. Also, food animals exposed to fallout
    should be considered fit for consumption and slaughtered using
    routine procedures. Unharvested crops cannot be protected.


_b. Inspection and Monitoring._

    (1) Fallout close to ground zero, especially after a surface
    burst, may be visible as dust. The presence of dust is an
    immediate indicator of contamination. Fallout on unprotected
    food produces a grittiness that is unpleasant and warns against
    eating the food. The degree and means of food protection
    (packaging and storage faculties) must be considered. Food
    in a building that remains intact should not receive enough
    contamination to be dangerous when eaten.

    (2) Veterinary units have the AN/VDR2 Radiac Set and UDR13
    dosimeter to conduct ground or aerial surveys for gamma
    radioactive contamination levels in an area. The measurement
    of the external gamma radiation in the fallout area is an
    indication, but not a quantitative measure, for the degree
    of hazard from food contamination. These units also use the
    AN/VDR2 Radiac Set for point detection of gamma and beta
    radiation sources. Food monitoring is conducted in an area with
    low background radiation. If the storage area is contaminated,
    the food must be moved to a cleaner area for monitoring. With
    the AN/VDR2, the initial food monitoring is performed with
    the probe cover in place and the probe passed approximately 6
    inches from the surface. If the reading is twice the background
    dose rate, the food is considered contaminated. If the reading
    is not above the background level but contamination is still
    suspected, place the probe closer to the food with the beta
    probe cover off. Monitor meat and fish with the probe cover
    off; pass the probe approximately one-half inch from the
    surface of the food.

    (3) Monitoring food contaminated through the food chain is
    more complicated; depending on the detection instrument
    used, special procedures must be followed. Gamma and beta
    emitting radionuclides in small volumes may be detected using
    radiac sets such as the AN/VDR2; however, alpha emitting ones
    cannot. They are rough instruments and may be used only for
    screening surface contaminated food. To evaluate the hazards;
    the isotopes contributing to the radioactivity must be
    identified. Surface contaminated food will contain a mixture of
    isotopes with some more hazardous than others, depending upon
    whether they are used by the body. Milk will contain mostly
    I-131, Cs-137, Sr-89, and Sr-90. Meat and fish will contain
    mostly Cs-137. To verify I-131, Cs-137, Sr-89, and Sr-90
    contamination, samples must be sent to laboratories equipped to
    analyze the samples.

    (4) All newly selected food supplies must be surveyed. Begin
    continuous monitoring immediately following receipt of a
    fallout warning, or when increased levels of radiation are
    detected by periodic monitoring.

    (5) Periodic monitoring is needed to establish baseline levels
    of background radiation in the environment and various food
    products. This monitoring is performed during peacetime, when
    possible, and throughout the time US forces are deployed in a
    TO.

        NOTE

        The AN/VDR2 is being replaced by the AN/PDR77 Radiac Set.

_c. Decontamination._ There are two methods for nuclear
decontamination: aging and removing. Aging is the process of
allowing natural radiation decay to occur. The time necessary for
this decay to take place depends upon the isotopes present; each
has a different decay rate (half-life). Aging may not be possible
when there is a short food supply. In some instances, such as with
induced radioactivity, it may be the only way to decontaminate.
Removing nuclear contamination from areas, personnel, food, or
moving equipment to another location eliminates the immediate
hazard. To determine which decontamination method is required, food
supplies are divided into groups. See Table J-1 for additional
information on food items and decontamination.

    (1) Group II--Food in sealed and dust-proof packing such
    as cans, jars, fiberboard, and cellophane. These products
    are easily decontaminated by removing the radioactive dust
    covering the packing; brush, wash with soap and water,
    or remove the packing (depending on the type of packing
    material). If radiation is still detected after removing
    the dust, repeat the brush/wash procedure and remonitor. If
    radiation is still present, the food itself is then considered
    radioactive (induced radiation) and is unfit for consumption.
    Decontamination of induced radiation is possible only through
    aging. After aging one to two weeks, the food should be safe
    for consumption. After surface decontamination, the contents
    are safe to eat unless the food has induced radiation.

    (2) Group III--Unprotected food. The method chosen to
    decontaminate unprotected food items will depend upon whether
    or not the food supply is critical. If the food supply is not
    critical, the contaminated items are isolated and allowed to
    decontaminate by aging. If the food supply is critical, food
    with surface contamination can, in principle, be decontaminated
    by removing the contaminated surface, or by washing.

    (3) Some products can be decontaminated by washing, peeling,
    or trimming the outer skin or leaves. Decontaminate potatoes
    and hard-skinned fruits and vegetables by washing or scrubbing
    under running water, followed by peeling or scraping, then
    washing again. Potatoes, carrots, beets, and turnips can be
    washed at the supply depot. However, do not wash beans, rice,
    and onions until they are delivered to the field kitchen;
    washing reduces their storage quality and shelf life. Citrus
    fruits, pineapples, corn, peas, beans, melons, pumpkins,
    cabbage, and nuts can be peeled. Decontaminate cucumbers,
    tomatoes, cherries, cranberries, grapes, pears, plums, and
    thin-skinned squash by soaking in a water or detergent
    solution and rinsing with vigorous agitation or brushing.
    Apricots, peaches, most berries, asparagus, broccoli, and leafy
    vegetables cannot be satisfactorily decontaminated because of
    fuzzy surfaces, irregular shapes, or small size, which makes
    washing difficult.

      · Fresh carcass meat, sausages, and fish can be decontaminated
      by several washings with cold water. The exterior layer of the
      food item is removed if radioactivity is still present. There
      is, however, a risk of contaminating the inner parts of the
      foodstuff in the process. Cooking with several changes of water
      is the last step in decontamination.


_Table J-1. Decontamination of Food Supplies_

  ========================================================================
                  |
                  |                 TYPE OF CONTAMINATION
   SURFACE        +---------------+----------------------+-----------------
      OR          |               |                      |
   MATERIAL       |   CHEMICAL    |    BIOLOGICAL        |  NUCLEAR
  ----------------+---------------+----------------------+-----------------
                  |               |                      |
  CANNED, BOTTLED,|IMMERSE IN     |WASH WITH SOAP AND    |WASH WITH SOAP
  OR PROTECTED BY |BOILING,       |WATER, THEN IMMERSE   |AND WATER, RINSE.
  IMPERMEABLE     |SOAPY WATER    |IN DISINFECTANT       |
  CONTAINER.      |FOR 30 MINUTES |SOLUTION. (IMMERSE IN |BRUSH, WIPE
                  |AND RINSE.     |BOILING WATER FOR 30  |CHLORINE, FOOD
                  |               |MINUTES. FOOD DIS-    |CONTAMINATION
                  |               |INFECTANT, OR 1/3     |FROM SURFACE OF
                  |               |CANTEEN CUP OF HOUSE- |CONTAINER.
                  |               |HOLD BLEACH IN 10 GAL |
                  |               |OF WATER).            |
                  |               |                      |
                  |SPRAY WITH     |                      |
                  |DS2 AND RINSE  |                      |
                  |               |                      |
                  |WASH IN HOT,   |BOIL IN WATER 15      |
                  |SOAPY WATER,   |MINUTES; NOT EFFECTIVE|
                  |RINSE, AND     |ON TOXINS AND SOME    |
                  |AERATE.        |SPORES.               |
                  |               |                       \
                  |               |IMMERSE IN 5% SODIUM    \
                  |               |CARBONATE (4 LB WASHING  |
                  |               |SODA IN 10 GAL WATER),   |
                  |               |RINSE WITH POTABLE WATER.|
                  |               |                         |
                  |               |IMMERSE IN HOUSEHOLD     |
                  |               |BLEACH SOLUTION (1/2 GAL |
                  |               |BLEACH IN 25 GAL WATER)  |
                  |               |FOR 30 MINUTES THEN RINSE|
                  |               |AND AERATE FOR 10        |
                  |               |MINUTES.                 |
                  |               |                         |
                  |               |IMMERSE IN HTH SOLUTION  |
                  |               |(1/2 LB IN 25 GAL WATER) |
                  |               |20 MINUTES, THEN RINSE.  |
                  |               |                         |
                  |               |IMMERSE IN STB SOLUTION  |
                  |               |(1 LB IN 25 GAL WATER)   |
                  |               |30 MINUTES, THEN RINSE.  |
                  |               |                         |
                  |               |IMMERSE IN 2% PERACETIC  |
                  |               |ACID FOR 10 MINUTES,     |
                  |               |RINSE, AND AERATE FOR    |
                  |               |10 MINUTES.              |
                  |               |                         |
  NOT CANNED OR   |FOOD KNOWN OR  |BOIL IN WATER 15 MINUTES.|WASH OR TRIM
  IMPERMEABLE     |SUSPECTED TO   |COOK.                    |CONTAMINATION
  CONTAINER.      |BE CONTAMINATED|                         |FROM UNPACK-
                  |SHOULD NOT BE  |IMMERSE IN OR SPRAY WITH |AGED FOOD.
                  |CONSUMED UNTIL |2% HOUSEHOLD BLEACH      |
                  |APPROVED BY    |SOLUTION. PACKAGED,      |
                  |VETERINARY     |PEELED, OR PARED FOOD MAY|
                  |PERSONNEL.     |BE IMMERSED OR SPRAYED.  |
  =========================================================================

      · Decontaminate hard cheeses, margarine, and butter by cutting
      off the outer layer to a depth of 2.5 to 3 cm.

      · Let cooking oils stand for 3 to 5 days, then pour off the
      contaminated layer; use a funnel to control spillage.

      · Nonperishable items that are hard to decontaminate, such
      as flour, sugar, and salt, can be set aside allowing natural
      radioactive decay. When supplies are short, dilute the
      contamination by mixing with uncontaminated food. This will
      reduce the total amount of radioactive exposure in foods
      prepared using these contaminated items.

      · Decontaminate air permeable, double-sacked goods by removing
      the outer sack. If the inner sack is free of radiation, double
      sack the food again to restore protection. However, when
      contamination is present on the inside bag, the food in contact
      with the bag is likely to be contaminated. Three methods can be
      used to handle this type of contaminated product. The easiest
      method involves spraying the bag of dry goods (except sugar
      or salt) with water. This will wet a layer of the food inside
      the bag. The wet layer can be removed when the bag contents
      are emptied. The uncontaminated contents are scooped back
      into clean packaging. Another method involves using melted
      paraffin to uniformly coat the outside of the bag. The paraffin
      solidifies after 30 to 40 minutes, and then the bag with the
      radioactive contamination can be removed from the contents.
      Although this method will seal the radioactive substance in
      the wax, it probably will not remove the layer of contaminated
      food product inside the bag. For the third method, form a piece
      of sheet metal into a cylinder the same height as the bag
      and 4 to 6 cm smaller in diameter. Insert the cylinder into
      the bag, then remove the top 3 to 4 cm of the contaminated
      product. Carefully scoop the remaining product out into a
      clean sack. With the cylinder still in place, fold the bag
      down catching the contaminated product on plastic sheeting, or
      a tarpaulin. When using this method, mixing the contaminated
      portion with the uncontaminated portion is a problem. Check for
      contamination remaining in the product.

      · Boiling or cooking has no effect on radioactive contamination.

    (4) Group IV--Food contaminated through the food chain. It is
    not practical to decontaminate this food. Meat and milk are the
    two most common foodstuffs contaminated in this way.

      · Milk may be decontaminated to a safe level by a complicated
      ion exchange process. The I-131 activity will decline rapidly
      during storage of milk and milk-products, although the Cesium
      and Strontium activity will remain almost constant for years.
      In an area with high-level fallout, milk is withdrawn from
      human consumption. The duration of withdrawal will be dependent
      upon the type of fallout and levels.

      · Meat may be decontaminated to a safe level by soaking in
      water or brine. Cesium is loosely bound in the meat. By
      repeated soaking of meat cut in small pieces, most of the
      Cesium activity will be removed. Traditional meat preserving,
      such as salting with brine, will remove up to 60 to 70 percent
      of the Cesium activity. See Table J-2.

      · Fruits, vegetables, root crops, and grain products may also
      contain hazardous amounts of radioactivity if ingested.

    (5) Food animals. Food animals that have been exposed
    to fallout should be considered fit for consumption and
    slaughtered using routine inspection and slaughter procedures.
    In those cases where the animal has been exposed to fallout,
    but is not scheduled for immediate slaughter, the radiation
    burden can be reduced by moving the animal to an uncontaminated
    area (barn if available) and washing it with soap and water.
    Mild radiation sickness does not necessarily mean that the
    animals cannot be used for food. If the animals have been
    exposed to an internal radiation hazard, the meat can be eaten
    if the internal organs are discarded. Chickens that have eaten
    radioactive material may lay contaminated eggs, but most of the
    radioactivity will be concentrated in the shells. The white
    and yolk will be free of harmful amounts of radiation and can
    be eaten. Chickens will not lay eggs if the radioactive body
    burden is large enough that their eggs are unfit to eat.


_Table J-2. Traditional Salt Preserving Brine_

  ======================================================================
   MEAT, WHOLE 4-5 KG

   25% NaCl (SALT) BRINE 5-LITER BRINE PER KG.
   KEEP MEAT IN BRINE FOR 3 WEEKS, TEMPERATURE BELOW 10°C.
   SOAK IN WATER FOR 1-2 DAYS.
   65-70% OF CS ACTIVITY WILL BE REMOVED.
  ----------------------------------------------------------------------
   MEAT, CUT 1-2 KG

   25% NaCl BRINE 5-LITER BRINE PER KG.
   KEEP MEAT IN BRINE FOR 4 DAYS.
   SOAK IN WATER FOR 4 HOURS.
   65-70% OF CS ACTIVITY WILL BE REMOVED.
  ----------------------------------------------------------------------
   MUTTON/LAMB RIB

   PIECE OF RIB 1-5 KG.
   25% NaCl BRINE 5-LITER BRINE PER KG.
   KEEP IN BRINE FOR 2 DAYS.
   SOAK IN WATER FOR 2 HOURS.
   AIR-DRYING FOR 10 DAYS.
   SOAK IN WATER FOR 2 HOURS.
   BOIL IN WATER FOR 3 HOURS.
   85-90% CS ACTIVITY WILL BE REMOVED.
  ----------------------------------------------------------------------

   DECONTAMINATION OF COARSELY CHOPPED MEAT

   0.9% NaCl SOLUTION. 2-LITER SOLUTION PER KG.
   SOAK IN NaCl SOLUTION FOR 10 MIN.
   60-70% CS ACTIVITY WILL BE REMOVED.
   REPEATED PROCEDURES WILL REMOVE THE SAME PERCENTAGE OF CS ACTIVITY.
   SIX TIMES REPEATED TREATMENT WILL REMOVE NEARLY 100% OF CS ACTIVITY.
  ======================================================================

_d._ _Considerations When Decontamination is Not Possible._ When
food cannot be decontaminated, sealing the product in a wrapping
material or container may be needed. Sealing the product can
reduce or shield the emanation of the contamination and/or fix the
contamination in place. The hazard from contaminated food is small
compared with that from external gamma radiation. Hungry people
or animals should not be denied food because of possible fallout
contamination. 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 used. Common sense must be
applied in establishing priorities for distribution of available
food. For example, use the least contaminated and the most
protected food first; hold milk products for 1 to 2 weeks before
use.


J-4. Biological

_a. Contamination._ Biological warfare agents exist in the form
of toxins and microorganisms. The normal packaging and packing of
food (to protect against moisture, dust, and bacterial or other
contamination) provides protection against most biological agents.
The exception may be toxins and biologically derived substances.
However, the protective methods used for chemical agents will also
protect against toxins and derived substances. Food in freezers,
refrigerators, and in refrigerated trucks or rail cars will be safe
if these containers remain sealed until the outer surfaces are
decontaminated.

    (1) It is unlikely that a biological agent will affect the
    appearance, taste, or smell of the food enough for the change
    to be apparent.

    (2) Packaging and packing materials are not life supportive to
    pathogenic agents and are, therefore, self-decontaminating with
    the exception of spore-forming organisms.

    (3) Most operational rations are packaged in metal containers,
    or encased in heavy aluminum laminated plastics that can
    withstand boiling water; also, they are impervious to arthropod
    penetration. This food is highly resistant to biological agents.

    (4) The use of unpackaged items (unwrapped meats, fresh fruits,
    and vegetables) should be restricted; use only operational
    rations. Unprotected fresh food stored in the open and close to
    the source of dissemination will become contaminated.

_b. Detection._

    (1) Rapid identification of agents used is absolutely essential
    to implement effective countermeasures. Agent identification
    must be achieved quickly; it is the first step in answering
    critical management questions. What adjustments must be made
    in food preparation and distribution? What are the essential
    countermeasures? What is the expected outcome of the incident?

    (2) Samples of food that are suspected of being contaminated
    are transported to the designated supporting laboratory.
    Samples must be accompanied by a description of the samples,
    the sample collection procedures, and the circumstances, which
    prompted the collection. The designated medical laboratory in
    the TO will provide a field confirmation identification of the
    agent(s). Designated CONUS laboratories accomplish definitive
    identification. See Appendix B for sampling procedures.

        NOTE

        New biological detection equipment is under development that
        will enable units to conduct presumptive identification of
        biological warfare agents. However, samples must also be
        collected and processed as described in Appendix B.

_c. Decontamination._

    (1) Food contaminated with toxins is handled in the same manner
    as food contaminated with chemical agents. Food contaminated
    with microorganisms is handled in the same manner as when
    contaminated with the more common foodborne disease-producing
    microorganisms.

    (2) Several methods are available to decontaminate food
    items contaminated with biological agents. The following
    decontamination methods are considered to be the minimum. See
    Table J-1.

    (3) 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 decontaminated.
    Decontamination of these items is as follows:

      (_a_) For containers made of metal, glass, plastic, or
      porcelain:

        _1._ Thoroughly wash the container in potable water and soap,
        or in a disinfectant solution. If the water used for washing is
        contaminated, the soap and water wash may increase, not reduce,
        the contamination hazard. After which, the food containers are
        immersed in a disinfectant solution for 30 minutes (see Table
        J-3); then rinsed with potable water, if available and time
        permits. Chlorine solutions are not as reactive or corrosive as
        DS2.

        _2._ Place the containers in boiling soapy water for 15
        minutes; then rinse with potable water.

            NOTES

            1. The chemical field decontamination kits do not meet the
            requirements to decontaminate food supplies exposed to
            biological agents.

            2. The same procedures should be followed even if there is
            only suspicion of a biological warfare attack.

      (_b_) Thoroughly wipe containers that will not withstand
      soaking with a cloth soaked in a chlorine detergent solution.
      Remove the food from the container and place it in Group III.

      (_c_) Metal or glass containers determined to have
      trichothecenes (Yellow Rain) present can be decontaminated
      using DS2. Allow a contact time of 5 to 30 minutes for the DS2
      to neutralize the toxin. Then rinse the container with potable
      water.

    (4) Group III food items that are not protected by the
    packaging material are decontaminated or disposed of as follows:

      (_a_) Decontaminate foods that can be peeled or pared by
      immersing them in a disinfectant solution for 30 minutes, and
      then rinsing them with potable water (see Table J-3). Peel
      or pare the items after decontamination, then wash and, if
      appropriate, cook before eating.

      (_b_) With the exception of certain heat-stable toxins, heat
      is the most practical means of decontaminating food. Several
      heating methods may be used, but the method chosen depends upon
      the type of food to be decontaminated. The key is to apply as
      much heat as possible without rendering the food unfit.

        _1._ Cook in a pressure-type cooker with 15 pounds of pressure
        at 250°F (121°C) for 15 minutes.

        _2._ Cook in a low-pressure cooker at 228°F (109°C) for 1 hour.

        _3._ Bake bread or related items at 400°F (204°C) for 40
        minutes.

            +------------------------------------------------------+
            |                        CAUTION                       |
            |                                                      |
            | Bread made with toxin-contaminated flour (especially |
            | with trichothecenes) is still toxic.                 |
            +------------------------------------------------------+

        _4._ Bake or roast meat at 325°F (163°C) for 2 hours.

        _5._ Boil for at least 15 minutes when no other method is
        available.

      (_c_) Although decontamination methods are provided above,
      vegetables such as lettuce, broccoli, and cauliflower, or
      unwrapped meats that have been exposed to biological agents
      should not be eaten.

      (_d_) Foods, such as butter, ice cream, and bread that will not
      withstand any of the above treatments must be destroyed.

    (5) Established meat inspection procedures are followed when
    animals exposed to biological agents must be used for food. The
    meat must be thoroughly cooked.


_Table J-3. Chlorine Solutions for Decontamination of Biological
Warfare Agents_

    ============================================================
             CHLORINE        |   MIXTURE TO PRODUCE 200 PPM
             SOURCE          |   SOLUTION OF AVAILABLE CHLORINE
    -------------------------+----------------------------------
     HOUSEHOLD BLEACH        |   1/2 GAL/25 GAL WATER
                             |
     HIGH-TEST HYPOCHLORITE  |   1/2 LB/25 GAL WATER
     (CALCIUM HYPOCHLORITE)  |
                             |
     SUPERTROPICAL BLEACH    |   1 LB/25 GAL WATER
    ============================================================


J-5. Chemical

_a. Contamination._

    (1) Contamination of foodstuffs by a chemical agent may occur
    at any point on the battlefield. This contact may render
    the food unpalatable also. In many cases, decontamination
    is difficult, thus, emphasis must be placed on protection.
    Keep food supplies covered at all times. Take special
    precautions to protect food that is not packed in protective
    packages. Unprotected food, forage, and grain supplies may
    be so contaminated that their consumption will produce
    gastrointestinal irritation, or systemic poisoning. Nerve
    agents, vesicants, and arsenicals are the most dangerous.
    Field concentrations of phosgene, hydrocyanic acid, irritants,
    and smokes will seldom be high enough to cause serious food
    contamination. The effect of CK on food is not known. As a
    precaution, foods exposed to CK should be considered toxic.

    (2) The effects of chemical agents on food depend on the nature
    of the agent and the type of the food. The extent to which
    chemical agents penetrate food also depends on the amount, form
    of dispersal (liquid [droplet size], or vapor) and duration of
    exposure. Nerve agents and mustard will penetrate deeply into
    unprotected fatty foods and will readily penetrate granular
    products such as grain and sugar. Liquid food products can
    be completely contaminated. Arsenicals readily hydrolyze to
    poisonous arsenical oxides in some foods. Foods can be divided
    into three categories based on their water content, fat
    content, and crystalline structure:

      (_a_) Foods having a high water content, a low fat content,
      and/or a crystalline structure (fresh vegetables, fruits,
      sugar, salt, and eggs) will absorb mustard and nerve agents,
      either as a liquid or as a vapor. Nerve agents will be
      hydrolyzed slowly.

      (_b_) Foods having a low fat content and an irregular
      (amorphous) structure (flour, bread, grain, rice, cereals,
      dried fruits, dried vegetables, tea, coffee, peas, and beans)
      readily absorb mustard and nerve agents in liquid form. As a
      vapor, these agents are absorbed to some extent, but are easily
      removed by airing.

      (_c_) Foods having a low water content and a high fat content,
      such as butter, fat, fatty oils, ham, cheese, milk, bacon,
      fatty meat, and fish, absorb mustard and nerve agents such that
      removal of the agents is virtually impossible.

    (3) Chemical agents can be physically and chemically absorbed
    into food. In addition to the toxic effect, they often
    adversely affect taste, smell, and the appearance of the food.
    However, chemical agents can cause the food to become very
    toxic without causing any other changes in the food. Table
    J-4 shows the effects of a number of chemical agents on food.
    Since food can be contaminated without any outward change in
    appearance, the possibility of contamination must be assumed
    in a chemical agent environment. Treat the food with the same
    precautions as established for known contaminated items.

    (4) The protective properties of packaging materials are
    dependent upon a number of factors. The factors include the
    form of the agent (liquid versus vapor); concentration and
    exposure time; weather (temperature, wind speed, and humidity);
    and packaging material (the type of material, thickness, and
    the presence of folds, tears, and small holes). Even the
    thinnest material will offer some protection and is better
    than nothing at all. Therefore, always cover food supplies
    with whatever material is available. Table J-5 summarizes the
    protection values of various packaging materials against vapors
    and liquids.

      (_a_) 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 fiberboard,
      shrink wrap, or film wrap. The worst case is pallets of
      subsistence contaminated by liquid droplets during an attack.
      After the attack, high vapor concentrations will exist in the
      vicinity of the palletized loads. If the outer barrier is
      permeable such as fiberboard, it is possible that a liquid
      agent can seep through the overlay fiberboard and contact the
      shipping containers in liquid form. Normally, with seepage
      resistant materials, such as shrink wrap as the outer barriers,
      only the vapors of the agent are found within the pallet.

      (_b_) While MREs are stored, the food is protected by up to six
      layers of material. Multilayer barriers result in a complex
      diffusion process of the agent from the outside towards the
      interior. Vapor penetration into nonhermetically sealed spaces
      is a simple gaseous diffusion process. Permeation through
      packaging is a much more complex process regardless of whether
      the challenge is a liquid or a vapor.

        _1._ Liquid is adsorbed into permeable materials such as
        fiberboard or chipboard. With permeation-resistant materials
        (such as shrink wrap), the agent dissolves into, seeps through,
        and then desorbs from the barrier material. Shrink wrap
        provides adequate protection. Fiberboard sheathing provides
        adequate protection against mustard agents, but not against
        nerve agents.

        _2._ The low-density polyethylene used to construct the menu
        bag can absorb chemical agents and possibly toxins. If the menu
        bag is removed from the shipping container and is exposed to
        liquid contamination, enough agent may pass through the bag to
        create a health hazard. Keep MREs in the shipping container
        until issued to the soldier. The menu bags should then be kept
        under the same degree of protection as the soldier.

        _3._ The aluminum-laminated materials used to construct the
        MRE (retort and nonretort) pouches protect food from chemical
        contamination if hermetically sealed. The only item in the MRE
        meal bag that is not adequately protected is the spoon.

    (5) Mylar and cellophane are resistant to chemical agents.


_Table J-4. 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    | +, ARSENIC
                  |        |       |   VEGETABLES          |
  NERVE AGENTS    | BAD    | NONE  | NONE                  | +
  PHOSGENE        | ACID   | NONE  | ?                     | - AFTER
                  |        |       |                       |   WEATHERING
  CYANOGEN AGENTS | BITTER | BAD   | NONE                  | - AFTER
                  |        |       |                       |   WEATHERING
  IRRITANTS       | ACID   | BAD   | NONE                  | +
  SMOKE           | ACID   | BAD   | ?                     | -
  WHITE           | ?      | ?     | ?                     | +
    PHOSPHOROUS   |        |       |                       |
  ----------------+--------+-------+-----------------------+-------------

  + INDICATES THE PRESENCE OF RESIDUAL TOXICITY.
  - DENOTES THAT RESIDUAL TOXICITY IS NOT PRESENT.
  ? THE INFLUENCE HAS NOT BEEN DETERMINED.
  =======================================================================


_Table J-5. 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
    CELLOPHANE, WET       |  NONE           | NONE
    CANVAS                |  POOR           | POOR
    ======================+=================+=============


_b. Detection._

    (1) Currently, a field method for detecting chemical agent
    contamination in food does not exist. Contamination is not
    always spread evenly throughout food; this makes it impossible
    to take a single sample and determine the presence or
    absence of chemical agents in the entire lot. Additionally,
    standardized laboratory tests have not been developed for
    determining levels of chemical agents in food. Until a specific
    method to detect chemical agents in food is available, reliance
    will have to be made upon determination of contamination, or
    lack thereof, on the packaging material; the integrity of the
    packaging material; the protective qualities of the packaging
    material; and the penetration characteristics of the suspected
    chemical agents.

    (2) Food may become toxic without any change in outward
    appearance. Never taste or smell food to determine if
    contamination is present in food.

    (3) Veterinary and subsistence units have the following
    equipment available to detect chemical agents in the field:

      (_a_) The M8 Automatic Chemical Agent Alarm System consists
      of the M43 detector unit and the M42 alarm unit. The detector
      unit is a portable, automatic, point-monitoring device that is
      designed to be hand carried from point to point. The M8 is used
      to provide early warning of a toxic agent position and detects
      the presence of chemical vapors and aerosols. The M43 detects
      all nerve, blood, and choking agents, and some blister agents.
      The M43A1 (the replacement for the M43) only detects nerve
      agents.

      (_b_) The M256 Chemical Agent Detector Kit detects and
      identifies nerve, blood, and blister agents. The M256 is the
      most sensitive of the chemical agent vapor detectors available.
      However, it is not a continuous, real-time monitoring system.
      It requires 15 to 20 minutes for sampling and analysis.

      (_c_) The ABC-M8 VGH Chemical Agent Detector Paper can detect
      and differentiate between nerve and blister agents by color
      change. It is intended to be used by blotting and wiping
      surfaces suspected of contamination. The M8 paper will respond
      with a visual color change in 10 seconds or less.

      (_d_) The M9 Chemical Agent Detector Paper will detect liquid
      nerve (G & V) and blister agents (H & L), but will not identify
      the specific agent or differentiate between nerve and blister
      agents. The M9 tape is sensitive to droplets as small as 100 μ,
      and will respond with a visual color change in 10 seconds or
      less.

    (4) All subsistence in a chemical attack area are considered
    contaminated until a survey can be conducted, preferably by
    veterinary and chemical personnel. Personnel must be at MOPP
    Level 4 while conducting the survey. 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 items. The area surrounding the
    storage facility is examined for the presence of animals,
    rodents, birds, and arthropods acting unusual, or dead in
    unusual numbers. If animals are present and assistance is
    required in identifying the NBC agent, specimens can be
    collected and submitted to the area medical laboratory. Damage
    such as broken windows, holes, or loss of structural integrity
    of the storage facility is noted. This information combined
    with knowledge of the agent form (liquid or vapor), type of
    agent (which will indicate the degree of persistency), and
    approximate time of attack will provide a risk assessment.
    Liquid agents should not significantly penetrate an intact
    facility, but may produce vapor contamination by off-gassing.

      (_a_) Upon entering the storage facility, the M8 can be used to
      determine the presence of chemical vapors. However, precautions
      must be taken. The M42 alarm is not to be used inside shelters,
      vehicles, vans, or other interior modes. Therefore, when
      checking food storage facilities, the alarm unit must be
      left outside, turned off, or disconnected. Do not tilt the
      M43 detector more than 45 degrees (because of the liquids it
      contains). This is not a problem with the improved M43A1, but
      the M43A1 requires attachment of an exit port filter when used
      indoors. The M256 Chemical Agent Detector Kit can be used to
      sample the air.

      (_b_) Pre-position M9 chemical agent detector paper in food
      storage areas; especially on the least protected pallets and in
      areas where droplets may enter, such as near doors or windows.
      Examine the M9 paper for indications of liquid chemical agents.
      If the M9 paper is positive, or if the packaging materials show
      the presence of liquids or stains, use the M8 detector paper to
      determine the type of the agent. If an agent is not indicated
      by the detector paper, then the amount of agent present will be
      insufficient to cause secondary contamination when the outer
      package is removed.

    (5) Detection procedures become more complicated if a chemical
    agent has penetrated or permeated through the packaging and
    packing materials. Unless liquid has seeped through the
    cardboard, any agent in the interior of the shipping case will
    be in a vapor form. Liquid seeping should be obvious. The
    sampler-detectors in the M256 Chemical Agent Detector Kit do
    not have an aspirator for sampling the interior of the case.
    However, there are several procedures that can be used. One is
    to open the case, place the activated sampler-detectors inside
    the case, and then reclose the case. Another is to punch holes
    in the case, place the activated sampler-detector over the
    holes, and cover the sampler-detector with an empty box or can
    (open end down) to concentrate the vapors escaping from the
    case. Alternatively, remove the food from the case and place
    it in a plastic bag with the sampler-detectors to concentrate
    the vapors. These procedures require two sampler-detectors; one
    for blood agents and one for nerve and blister agents. Neither
    method is very sensitive in low concentrations of vapor as is
    expected to be present inside shipping containers. A better
    method is to modify the M43 detector with a field expedient
    probe of Teflon tubing attached to the detector's air inlet.
    Insert the open end of the tubing into a hole in the case
    or package to sample the interior air. When available, the
    improved chemical agent monitor (ICAM) can be used; its design
    will allow aspiration of air from inside shipping cases. The
    ICAM can also be used to detect and identify liquid agents
    on a surface provided the agent is vaporizing in sufficient
    quantity. The ICAM gives a visual representation of a hazard
    evaluation.


_c. Decontamination._

    (1) Decontamination is only required for contamination
    remaining 10 minutes or longer. Decontamination efforts on
    subsistence items will normally be limited to removal of the
    containers and carton overwrap material.

    (2) The need for decontamination is primarily dictated by the
    type of chemical agent used. The method of decontamination
    selected will depend upon the type of packaging material used
    and the urgency with which the food is required.

    (3) Food supplies in storage are not likely to be seriously
    contaminated if reasonable protection precautions are taken.
    For this reason, large supplies of food are not to be
    condemned as a whole simply because they have been exposed to
    possible chemical contamination. A prompt and careful survey
    of the supplies may reveal that only a few items have been
    contaminated to a level that decontamination is required.
    Prompt segregation of the heavily contaminated portions will
    prevent, or minimize, contamination of the remainder. Foods
    without protective packages constitute the major difficulty.

    (4) Individual decontamination is performed by each soldier on
    those subsistence items in his possession at the time of the
    attack. Individual decontamination is limited to operational
    rations that are in original, intact containers. Unit-level
    decontamination is performed by unit personnel under the
    supervision of unit NBC personnel. Support decontamination
    is attempted at major subsistence storage facilities. Again,
    decontamination is limited to packing material. Decontamination
    of food itself is only attempted in emergency situations when
    alternative supplies are not available.

    (5) Start decontamination operations with the easiest method
    and proceed to the most difficult. This allows for the removal
    of a relatively large portion of the contamination in a minimum
    of time. The simplest procedure is to allow the materials to
    age and air ("weather"). Substantial self-decontamination will
    occur with most agents. Exceptions are thickened mustard,
    thickened GD, and VX. Table J-6 provides the length of time for
    which contaminated subsistence supplies may present a contact
    hazard. Weather elements that affect decontamination are--

      (_a_) Warm temperatures speed liquid agent off-gassing and
      hasten the dispersion of chemical agents into the air.

      (_b_) High winds rapidly disperse chemical agent vapors and
      speed off-gassing from surfaces.

      (_c_) Moisture causes chemical agents to react with water to
      form nontoxic or less toxic chemicals. Heavy rain or rain of
      long duration can aid decontamination by mechanically removing
      chemical agents.

      (_d_) Even in cold weather, direct sunrays warm surfaces
      above the air temperature and hasten the off-gassing and
      decomposition of chemical agents.


_Table J-6. Persistency of Selected Liquid Chemical Agents_

    ================================================================
                 |               WEATHER CONDITIONS
                 +---------------+----------------+-----------------
                 |               |                |
        AGENT    |     SUNNY,    | WET AND WINDY, |   CALM, SUNNY,
                 |  AROUND 20°C, |   AROUND 10°C  |   LYING SNOW,
                 |  LIGHT BREEZE |                |   AROUND -10°C
                 |               |                |
     MUSTARD(HD) |    2-7 DAYS   |  1/2-2 DAYS    |    2-8 WEEKS
      TABUN(GA)  |    1-4 DAYS   |  1/2-6 HOURS   |  1 DAY-2 WEEKS
      SARIN(GB)  |  1/4-4 HOURS  |  1/4-1 HOUR    |    1-2 DAYS
      SOMAN(GD)  | 2-1/2 -5 DAYS |    3-36 HOURS  |    1-6 WEEKS
      NERVE(VX)  |    3-21 DAYS  |    1-12 DAYS   |    1-16 WEEKS
    =============+===============+================+=================

    (6) Active decontamination is attempted only when weathering
    will not decontaminate the packaging material in sufficient
    time. Decontamination procedures can be enhanced by using
    heat to vaporize the chemical agent; by reaction with
    decontaminants; or by removing with hot soapy water.

      (_a_) The simplest (standard) decontamination materials
      are water and detergents. An effective decontaminant is
      hot water used with the addition of soap or detergent and
      scrubbing. Commercial abrasive powdered cleansers are effective
      decontaminants for many surfaces (metal, glass, Formica), but
      not wood or soft plastics.

      (_b_) Water can be used to flush chemical agents from surfaces.
      High-pressure application produces a better cleansing action
      than low pressure. If the surface has absorbed the agent,
      flushing will remove the surface contamination, but will not
      affect the agent that is absorbed.

      (_c_) Soaking contaminated items in boiling water is an
      excellent decontamination method for some agents. Water alone
      will not be sufficient to decontaminate all chemical agents.
      Soaking in warm or cold water may reduce the contamination
      slightly; however, the hazard may not be reduced sufficiently
      even after prolonged soaking. If hot water is not available,
      or if it might cause damage to the item, other methods of
      decontamination should be considered, such as decontaminating
      solutions or a caustic solution followed by thorough rinsing.

      (_d_) Fibrous materials such as cloth and canvas are best
      decontaminated by washing and scrubbing.

      (_e_) Glass, metal, porcelain, and plastic surfaces are best
      decontaminated by using hot water or hot soapy water. Some
      toxic materials are readily removed with no more than slight
      abrasion or brushing.

      (_f_) Painted, varnished, and waxed surfaces are generally
      smooth and nonporous. Dust and liquids are readily removed by
      wiping, brushing, or vacuuming. Absorbed materials are removed
      by hot water, detergent, or complexing agents. None of these
      surfaces stand up well to heavy abrasive techniques. Agents
      can be attacked and removed by caustics, acids, and organic
      chemicals. Some of these surfaces readily absorb agents, so
      weathering following decontamination is advisable.

      (_g_) Rubber is a porous material that can absorb agents. It is
      not easily decontaminated by abrasive techniques. Warm, soapy
      water used with brushing is effective since it removes some
      absorbed contamination. Strong acids, alkalies, and organic
      solvents may deteriorate and decompose rubber articles.

    (7) Operational rations are the primary rations issued;
    always issue uncontaminated stocks first. This allows for
    decontamination of contaminated stocks without interrupting
    supply support. Normally, contaminated stocks are not issued.
    The decision to issue contaminated items is based on the
    tactical situation, criticality of the items, type and extent
    of contamination, and the time and resources available for
    decontamination. Decontamination efforts on subsistence items
    are limited to the containers and carton overwrap material.

      (_a_) The MRE retort and nonretort food pouch may be
      decontaminated with soap and water wash. The chemical agents
      will be removed by the solutions.

      (_b_) Semipermeable materials (polyethylene menu bag, shrink
      wrap, and film wrap) may have chemicals deposited not only
      on the surface, but also dissolved into the matrix of the
      material. The chemicals can be removed from the surface by
      washing with hot soapy water, but contaminant dissolved in
      the material is not removed. The remaining agent can only be
      removed by weathering which can be accelerated through the use
      of heat and sweeping the surface with air.

      (_c_) Fiberboard is both sorbent and permeable and acts like
      a blotter. Liquid decontaminants can force the contaminant
      further into the fiberboard. Any attempt to decontaminate
      fiberboard would be futile. The only alternatives are to remove
      the fiberboard, or to allow it to weather.

      (_d_) Palletized unit loads of MRE and UGR outerwraps can be
      decontaminated through the aid of a forced clean air sweep in 4
      to 5 days, compared to 3 weeks or more under natural conditions
      without a forced air sweep.

    (8) Contaminated food supplies are only handled by personnel
    trained in decontamination methods and in MOPP Level 4.
    Contaminated food items are divided into three groups as
    described below (see Table J-1 for additional information).

      (_a_) Group 1 consists of canned and unopened packaged items
      which have been exposed only to agent vapors. Most items in
      this group will be safe to issue after a brief period of
      outdoor airing to remove clinging vapors. Table J-7 lists the
      decontamination procedures for packaging materials contaminated
      with nerve agents, mustards, and arsenicals.


_Table J-7. Chemical Decontamination of Packaged Material_

  ======================================================================
  PACKAGING MATERIAL       CONTAMINATION    DECONTAMINATION PROCEDURES
  ----------------------------------------------------------------------
  AIRTIGHT METAL           VAPOR AND        AIR FOR 24 HOURS. WASH
  CONTAINERS, GLASS        LIQUID           WITH HOT SOAPY WATER,
  BOTTLES, FOIL                             SODA, OR BLEACH SOLUTION.
  ALUMINATED LAMINATED                      RINSE WITH WATER.
  MATERIALS.

  POLYESTER, PVF.          VAPOR            REMOVE CONTAMINATED
  WOODEN BOXES, CRATES,                     PACKAGE. AIR CONTENTS FOR
  BOARD, MULTILAYER                         24 HOURS.
  BAGS.

  CARDBOARD,               LIQUID           CONTAMINATED CONTENTS--TREAT
  POLYETHYLENE.                             AS UNPACKAGED FOOD.
  =======================================================================

      (_b_) Group II consists of canned and unopened packaged items
      which have been contaminated with a liquid chemical agent.

        _1._ Attempts to decontaminate porous packaging materials,
        such as cardboard or wood, are likely to be unsuccessful and
        may result in spreading the contamination. 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 occurred. If it has, continue stripping off
        layers until an uncontaminated layer is reached and place it in
        Group I. If the agent has penetrated to the food, place it in
        Group III.

        _2._ Food in cans or in other sealed, impermeable containers is
        not in danger of chemical contamination. Because contamination
        is confined to the outer surface of the sealed container,
        decontamination is accomplished by: immersion in boiling, soapy
        water for 30 minutes and rinse; immersion in boiling water for
        30 minutes; spray with DS2; or to wash in hot soapy water,
        rinse, and aerate. Under no conditions should contaminated
        containers be opened before they have been decontaminated and
        monitored.

        _3._ Supertropical bleach and DS2 can be used on the
        polyethylene menu bag for up to 24 hours without a significant
        change in appearance, tensile properties, and size of the
        plastic. The use of DS2 will cause significant degradative
        changes to most other plastics, while STB will cause little
        or no change. Also, DS2 may cause false positive readings
        when using M8 or M9 paper, or the M256 Detector Kit to check
        completeness of decontamination.

      (_c_) Group III will consist of unpackaged or poorly packaged
      items which have been exposed to an agent in either vapor or
      liquid form. Foodstuffs in this group should be decontaminated
      only when absolutely necessary. =The decision to use foods
      that have been contaminated is to be made by the commander.=
      Decontamination procedure to be followed, in order, is: trim
      surface fat and grossly contaminated areas; wash with water or
      2-percent sodium bicarbonate solution; then boil in water.

        _1._ Boiling in water may be eliminated when the contamination
        has been only with the vapors of irritant agents. When such an
        exposure has been light, aeration for a short time may be used
        for decontamination.

        _2._ Frying, roasting, or broiling will not remove traces of
        blister agents from meats. In general, salvage of foods heavily
        contaminated with droplets of the blister agents, especially
        the arsenical blister agents, is not practical. 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 mustard.

        _3._ When foods have been exposed to blister agent vapor, they
        can be reclaimed by washing with sodium bicarbonate solutions
        and rinsing with clear water, by intensive cooking, or in
        the case of dry provisions, by 24 to 48 hours of aeration.
        Lean meat contaminated with mustard vapor can be reclaimed by
        boiling in water for 30 minutes or more. With nitrogen mustard
        vapor contamination, the meat should be boiled in a 2-percent
        sodium bicarbonate solution. Discard the water used to boil the
        meat.

        _4._ Nerve agent contamination is treated the same as blister
        agent contamination.

        _5._ Foods, such as potatoes and hard-skinned fruits and
        vegetables, can be decontaminated by washing or scrubbing,
        followed by peeling or scraping, then washing again.

        _6._ Prepared food in open containers will be contaminated;
        it must be temporarily isolated, or disposed of (bury or as
        directed by commander).

        _7._ A food Item that is contaminated with irritants can be
        decontaminated by airing. Consumability is determined by taste
        rather than toxicity.

        _8._ Phosgene is rapidly hydrolyzed, therefore, washing the
        food with water or airing it will usually suffice.

        _9._ Food contaminated with white phosphorous should be
        destroyed.

        _10._ Normally, hydrocyanic acid will have little effect on
        food supplies. The exposures will most likely be as a vapor.
        However, foods with a high water content may become unfit for
        consumption after exposure to high concentrations.

        _11._ The effect of CK on foods is not known. Foods exposed to
        CK vapors are considered toxic.

        _12._ Table J-8 lists the decontamination procedures for
        unpackaged food contaminated with a chemical agent.

    (9) Decontaminating cattle, poultry, and other livestock is
    only attempted when other sources of food are not available.
    Heavily contaminated animals should be destroyed. Livestock
    contaminated lightly by phosgene, nerve agents, mustards, and
    arsenicals (such as vapor or liquid) may be slaughtered in the
    early stages of poisoning before the full effects of exposure
    are shown. If these animals are slaughtered in the preliminary
    stages of poisoning and all tissues exposed to the agent (the
    head, blood, lungs, organs, and local areas) are discarded,
    there is no danger in consumption of the meat, provided the
    animal passes a pre-slaughter and slaughter inspection.
    This is true even of animals poisoned by arsenical agents
    since the edible tissue will contain amounts of arsenic too
    small to be toxic. Organs (liver, brain, heart, kidney, and
    lungs) will contain more arsenic than the musculature and are
    discarded. The meat must be well cooked. Personnel involved in
    slaughtering procedures must be careful to prevent spreading
    contamination to the meat and to themselves.

    (10) Decontaminating forage and grain exposed to only chemical
    agent vapors is by aeration. Aerated supplies, especially if
    mixed with larger amounts of uncontaminated supplies, produces
    no ill effects when fed to animals. Forage or grain heavily
    contaminated by liquid vesicants, especially arsenicals, should
    not be used.


_Table J-8. Chemical Decontamination of Unpackaged Food_

  ========================================================================
                  FATTY FOODS      NONFATTY FOODS,      NONFATTY FOODS,
                  (BUTTER, BACON,  High WATER CONTENT   LOW WATER CONTENT,
  CHEMICAL AGENT  MILK, CHEESE,    CRYSTALLINE (FRUITS, AMORPHOUS (FLOUR,
                  HAM).            VEGETABLES, SALT,    CEREALS, BREAD,
                                   SUGAR).              PEAS).
  ------------------------------------------------------------------------
  =NERVE AGENTS=

   VAPOR, HEAVY   DESTROY          DESTROY, UNLESS       AIR FOR 48 HOURS,
                                   POSSIBLE TO BOIL      THEN BOIL.
                                   AFTER AIRING 48
                                   HOURS.

   VAPOR, LIGHT   DESTROY          AIR FOR 48 HOURS,     AIR FOR 48 HOURS,
                                   THEN BOIL.            THEN BOIL.

   LIQUID         DESTROY          DESTROY               DESTROY

  =MUSTARDS=

   VAPOR          REMOVE 1-3 cm    WASH WITH WATER.      WASH WITH WATER.
                  OF OUTER LAYER   AIR FOR 48 HOURS.     AIR FOR 48 HOURS.
                  AND WASH WITH 2%
                  SODIUM BICARB-
                  ONATE SOLUTION.
                  BOIL FOR AT
                  LEAST 30 MINUTES.
                  DESTROY MILK.

   LIQUID         DESTROY          DESTROY               DESTROY

  =ARSENICALS=
                  DESTROY          DESTROY               DESTROY
  ========================================================================




GLOSSARY

ABBREVIATION, ACRONYMS, AND DEFINITIONS


=ABCA= American, British, Canadian, 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

=AMedP= Allied Medical Publication

=AML= area medical laboratory

=AN/PDR27= radiac meter

=AN/PDR77= radiac meter

=AN/VDR2= 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 results.
Examples might include the findings of the presumptive biomarker
identification with the addition of a positive PCR, ELISA, or
electrochemiluminescence (ECL) results, using specific target
nucleic acid sequences for the organism and antibody recognition
of agent-specific antigen sites, respectively. (Field sample/
specimen identification by forward deployed or forward positioned
laboratories [such as the US Air Force Biological Augmentation
Team (BAT), theater army medical laboratory, or forward deployed
preventive medicine unit (US Navy) and homeland security Laboratory
Response Network (LRN) Level B or C, US Army Community Hospitals or
Medical Centers].)

=Biological Warfare Agent Definitive Identification And
Confirmation= The specific identification of a suspect
biological agent as to genus and species, serological type,
or toxin. This level of identification is by means of
devices/materials/technologies that are based on two or more
independent biomarker results and using different methodologies.
This level of identification is performed in a reference laboratory
with a broader variety of methodologies available and highly
skilled testing personnel, thus providing the highest levels of
accuracy. (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 Prevention.)

=Biological Marker= Characteristics of a biological agent
(organism, virus, toxin, or product) that are specific to the
agent. This includes (1) recognition of specific nucleic add
sequences (DNA or ribonucleic acid [RNA]) unique to the bacteria
or virus by a technique such as PCR; (2) identification of
specific ECL assay; (3) specific growth properties as seen on
selective media such as characteristic colony morphology on culture
along with phage inhibition; (4) Identification using specific
microscopic characteristics such as Gram stain, fluorescent
antibody stain, immunohistochemical stain, or cytopathic effects.

=Biological Warfare Agent Presumptive Identification=
Identification of a suspect biological warfare agent by means of
devices/materials/technologies that are based detecting biological
markers (biomarkers) using a single methodology. The biomarkers
and/or methodologies used at this level of testing have significant
limits to their accuracy. Agent identification to species level,
or differentiation among a family of similar agents, may not be
possible. This is equivalent to the LRN Level A and the US Army
BIDS. (EXAMPLES: Identification by sensor triggering, hand-held
devices [hand-held assays] or initial systems, or laboratory
analysis employing one screening methodology [such as microscopic
morphology, antibody/protein, or nucleic acid-based test].)

=bot/pkg= bottle/package

=BSA= brigade support area

=BW= biological warfare

=BZ= an incapacitating chemical warfare agent


=C= Centigrade/Celsius

=C2= command and control

=C4I= Command, Control, Communications, Computers, and Intelligence

=CaCl= calcium hypochlorite

=cal/cm^2= calories per square centimeter

=cal/cm^2/sec= calories per square centimeter per second

=CAM= chemical agent monitor

=CANA= convulsant antidote for nerve agent (diazepam)

=CB= chemical/biological

=CBDA= Chemical Biological Defense Agency

=CBPS= chemically biologically protected shelter

=CBRNE= chemical, biological, radiological, nuclear, and high-yield
explosive

=CBSCC= Chemical-Biological Sampling Control Center

=CBSCE= Chemical-Biological Sampling Control Element

=cc= cubic centimeter

=CG= phosgene

=cGy= centigray

=CIS= Commonwealth of Independent States (Russia)

=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^2= square centimeter

=CNS= central nervous system

=CO_{2}= 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-137= Cesium 137

=CSF= cerebrospinal fluid

=CSH= combat support hospital

=CSS= combat service support

=CW= chemical warfare

=CX= phosgene oxime


=DA= Department of the Army

=DAP= decontamination apparatus, 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

DS2 decontaminating solution Number 2

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-1 Fraction-1

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

G1 Assistant Chief of Staff (Adjutant)

G2 Assistant Chief of Staff (Intelligence)

G3 Assistant Chief of Staff (Operations and Training)

G4 Assistant Chief of Staff (Logistics)

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 (100 cGy)


=H= heparin

=HD= sulfur mustard (a blister agent)

=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 (70% available chlorine)


=I-131= Iodine-131

=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

=IgG= immunoglobulin class G

=IgM= immunoglobulin class M

=IMA= installation medical authority

=ISO= International Organization for Standardization

=IV= intravenous


=J2= Joint Intelligence Directorate

=J3= Joint Operations Directorate


=kg= kilogram

=km= kilometer(s)

=kph= kilometers per hour

=KT= kiloton


=L= Lewisite

=LAB= laboratory

=lb= pound

=LCE= load-carrying equipment

=LD= lethal dose

=LD 50/60= lethal dose for 50 percent of exposed persons within a
period of 60 days

=LRN= Laboratory Response Network

=LSD= d-lysergic acid diethylamide

=LZ= landing zone


=µ= micron

=m= meters

=m3= 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 hazards; and following injury those measures
taken to treat NBC casualties and improve medical capability for
diagnosis, physiological resuscitation and continued medical
management of NBC casualties.

=MES= medical equipment set

=MF2K= Medical Force 2000 (Army of Excellence Organizations)

=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

=NaCl= sodium chloride (salt)

=NATO= North Atlantic Treaty Organization

=NAVMED P= Naval Medical Publication

=NBC= nuclear, biological, and chemical

=NBCC= nuclear, biological, and chemical control

=NBCWRS= nuclear, biological, and chemical warning and reporting
system

=NCO= noncommissioned officer

=NL= no limit

=NTTP= Navy Tactics Techniques and Procedures

=O_{2}= oxygen

=OEG= operational exposure guide

=OPLAN= operation plan

=OPSEC= operations security

=Patient Decontamination=--The removal and/or the neutralization of
hazardous levels of nuclear, biological, and chemical contamination
from patients at a medical treatment facility. 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 process.
Patient decontamination serves multiple purposes; it protects the
patient from further injury, it prevents exposing medical personnel
to the contamination, and it prevents contamination of the medical
treatment facility.

=PCR= polymerase chain reaction

=PDS= patient decontamination station

=pH= 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 0 to 14 with 7 representing neutrality.
Numbers less than 7 indicate increasing acidity, and numbers
greater than 7 indicate increasing alkalinity.

=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

=S1= Adjutant (US Army)

=S2= Intelligence Officer (U.S. Army)

=S3= Operations and Training Officer (U.S. Army)

=S4= Supply Officer (U.S. Army)

=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-89= Strontium-89

=Sr-90= Strontium-90

=STANAG= Standardization Agreement (NATO)

=STAT= statim

=STB= supertropical bleach

=Sv= Sievert


=T2= trichothecene

=TAML= theater Army medical laboratory

=TC= training circular

=TEU= technical escort unit

=TEMPER= tent, expandable, modular, personnel

=Toxic Industrial Biological (TIB)= Biological materials (bacteria,
viruses, and toxins) found in medical research, pharmaceutical, and
other manufacturing processes that are toxic to humans and animals,
or cause damage to plants.

=Toxic Industrial Chemical (TIC)= Chemical compounds used or
produced in industrial processes that are toxic to humans and
animals, or cause damage to plants. EXAMPLES include fuels,
solvents, heavy metals, and chemicals used in manufacturing
processes.

=Toxic Industrial Material (TIM)= Toxic industrial materials may be
toxic industrial chemical (TIC), toxic industrial biological (TIB)
and toxic industrial radiological (TIR) materials.

=Toxic Industrial Radiological (TIR)= Radiation-emitting materials
used in research, power generation, medical treatment, and other
non-weapon developmental activities that are harmful to humans and
animals if released outside their controlled environment.

=TIR= toxic industrial radiological

=TM= technical manual

^{=TM=} trademark

=TOE= table of organization and equipment (US Army organizational
structure document)

=TO= theater of operations

=trmt= treatment

=TSOP= tactical standing operating procedures

=TT= tiger top


=µ= 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 Handbook._ 1988.


=NATO STANAGs=

These agreements are available on request (using DD Form 1425)
from the Standardization Documents Order Desk, 700 Robins Avenue,
Building 4, Section D, Philadelphia, Pennsylvania 19111-5094.

    2002. _Warning Signs for the Marking of Contaminated or
    Dangerous Land Areas, Complete Equipments, Supplies and Stores.
    Edition 8._ 29 January 1999.

    2047. _Emergency Alarms of Hazard or Attack (NBC and Air Attack
    Only). Edition 7._ 24 July 1998. (Latest Amendment, 7 February
    2000.)

    2068. _Emergency War Surgery. Edition 4._ 28 October 1986.
    (Latest Amendment, 17 October 1991.)

    2083. _Commander's Guide on Nuclear Radiation Exposure of
    Groups. Edition 5._ 19 September 1986. (Latest Amendment, 26
    June 1994.)

    2103. _Reporting Nuclear Detonations, Biological and Chemical
    Attacks, and Predicting and Warning of Associated Hazards and
    Hazard Areas--ATP 45(A). Edition 8._ 31 August 2000.

    2104. _Friendly Nuclear Strike Warning. Edition 7._ 28 June
    1994. (Latest Amendment, 28 June 1995.)

    2112. _Nuclear, Biological, and Chemical Reconnaissance.
    Edition 4._ 6 March 1998.

    2475. _Medical Planning Guide for the Estimation of NBC Battle
    Casualties (Nuclear)--AmedP-8(A), Volume I._ December 2000.

    2476. _Medical Planning Guide of NBC Battle Casualties
    (Biological)--AmedP-8(A), Volume II._ March 2001.

    2477. _Planning Guide for the Estimation of NBC Battle
    Casualties (Chemical)--AmedP-8(A), Volume III._ March 2001.

    2500. _NATO Handbook on the Medical Aspects of NBC Defensive
    Operations--AMedP-6(B). Edition 4._ 11 February 1997.

    2873. _Concept of Operations of Medical Support in Nuclear,
    Biological, and Chemical Environments--AmedP-7(A). Edition 3._
    16 October 1996.

    2879. _Principles of Medical Policy in the Management of a Mass
    Casualty Situation. Edition 3._ 7 September 1998.

    2941. _Guidelines for Air and Ground Personnel Using Fixed and
    Transportable Collective Protection Facilities on Land. Edition
    2._ 19 June 1992. (Latest Amendment, 30 October 1995.)

    2954. _Training of Medical Personnel for NBC Operations.
    Edition 1._ 28 December 1987. (Latest Amendment, 6 June 1995.)


=ABCA QSTAGs=

These agreements are available on request (using DD Form 1425)
from the Standardization Documents Order Desk, 700 Robins Avenue,
Building 4, Section D, Philadelphia, Pennsylvania 19111-5094.

    183. _Emergency Warning Signals and Alarms for NBCD Hazards or
    Attacks (NBC and Air Attacks Only). Edition 3._ 12 August 1991.

    187. _Reporting Nuclear Detonations Biological and Chemical
    Attacks and Predicting and Warning of Associated Hazards and
    Hazard Areas. Edition 5._ 21 May 1998.

    189. _Friendly Nuclear Strike Warning. Edition 3._ 12 August
    1991.

    501. _Warning Signs for the Marking of Contaminated or
    Dangerous Land Areas, Complete Equipment, Supplies and Stores.
    Edition 2._ 11 May 1982.

    608. _Interoperable Chemical Agent Detector Kits. Edition 3._
    13 December 2000.

    816. _Medical Aspects of Mass Casualty Situations. Edition 1._
    August 1990.

    1330. _Medical Aspects of NBC Defensive Operations._ Draft.

    2000. _Guidelines on Entry and Exit Procedures for Using
    Collective Protection Facilities._ 17 December 1996.


=JOINT OR MULTISERVICE PUBLICATIONS=

    AR 40-535. _Worldwide Aeromedical Evacuation._ AFR 164-5;
    OPNAVINST 4630.9C; MCO P4630.9A. 1 December 1975. (Reprinted
    with basic including Change 1, 10 May 1979.)

    AR 40-562. _Immunizations and Chemoprophylaxis._ AFJI 48-110;
    BUMEDINST 6230.15; CG COMDTINST M6230.4E. 1 November 1995.

    AR 40-656. _Veterinary Surveillance Inspection of Subsistence._
    NAVSUPINST 4355.10; MCO 10110.45. 15 October 1986.

    AR 40-657. _Veterinary/Medical Food Inspection and Laboratory
    Service._ NAVSUPINST 4355.4F; MCO P10110.31G. 6 November 1997.

    FM 3-3. _Chemical and Biological Contamination Avoidance._ FMFM
    11-17. 16 November 1992. (Change 1, 29 September 1994.)

    FM 3-4. _NBC Protection._ FMFM 11-9. 29 May 1992. (Reprinted
    with basic including Changes 1-2, 21 February 1996.)

    FM 3-5. _NBC Decontamination._ MCWP 3-37.3. 28 July 2000.

    FM 3-6. _Field Behavior of NBC Agents (Including Smoke and
    Incendiaries)._ AMF 105-7; FMFM 7-11 H. 3 November 1986.

    FM 3-9. _Potential Military Chemical/Biological Agents and
    Compounds._ NAVFAC P-467, AFR 355-7. 12 December 1990.

    FM 3-11.34. _Multiservice Procedures for Nuclear, Biological,
    and Chemical (NBC) Defense of Theater Fixed Sites, Ports, and
    Airfields._ MCWP 3.37.5; NTTP 3-11.23; AFTTP(I) 3-2.33. 29
    September 2000.

    FM 3-19. _Nuclear, Biological and Chemical Reconnaissance._
    FMFM 11-20. 19 November 1993.

    FM 3-100. _Chemical Operations, Principles and Fundamentals._
    MCWP 3-3.7.1. 8 May 1996.

    FM 4-02.33. _Control of Communicable Diseases Manual._ 17th
    Edition. NAVMED P-5038. 31 December 1999.

    FM 4-02.283. _Treatment of Nuclear and Radiological
    Casualties._ NTRP 4-02.21; AFMAN 44-161(I); MCRP 4-11.1B. 20
    December 2001.

    FM 6-22.5. _Combat Stress._ MCRP 6-11C; NTTP 1-15M. 23 June
    2000.

    FM 8-9. _NATO Handbook on the Medical Aspects of NBC Defensive
    Operations AMedP-6(B), Part I--Nuclear, Part II--Biological,
    Part III--Chemical._ NAVMED P-5059; AFJMAN 44-151V1V2V3. 1
    February 1996.

    FM 8-284. _Treatment of Biological Warfare Agent Casualties._
    NAVMED P-5042; AFMAN(I) 44-156; MCRP 4-11.1C. 17 July 2000.
    (Change 1, 8 July 2002.)

    FM 8-285. _Treatment of Chemical Agent Casualties and
    Conventional Military Chemical Injuries._ NAVMED P-5041; AFJMAN
    44-149; FMFM 11-11. 22 December 1995.

    FM 21-10. _Field Hygiene and Sanitation._ MCRP 4-11.1D. 21 June
    2000.


=DEPARTMENT OF DEFENSE=

    DOD 5100.52-M. _Nuclear Weapon Accident Response Procedures
    (NARP)._ September 1990.

    DOD Directive 3150.8. _DOD Response to Radiological Accidents._
    13 June 1996.

    DD Form 1380. _US Field Medical Card._ December 1991.

    DD Form 1911. _Material Courier Receipt._ May 1982.


=DEPARTMENT OF THE ARMY FORM=

    DA Form 4137. _Evidence/Property Custody Document._ 1 July 1976.


=ARMY PUBLICATIONS=

    AR 40-5. _Preventive Medicine._ 15 October 1990.

    AR 40-61. _Medical Logistics Policies and Procedures._ 25
    January 1995.

    AR 40-66. _Medical Records Administration and Health Care
    Documentation._ 3 May 1999.

    AR 40-400. _Patient Administration._ 12 March 2001.

    FM 3-06.11. _Combined Arms Operations in Urban Terrain._ 28
    February 2002.

    FM 3-7. _NBC Field Handbook._ 29 September 1994.

    FM 3-50. _Smoke Operations._ 4 December 1990. (Change 1, 11
    September 1996).

    FM 3-101. _Chemical Staffs and Units._ 19 November 1993.

    FM 3-101-4. _Biological Detection Platoon Operations--Tactics,
    Techniques, and Procedures._ 9 June 1997. (Reprinted with basic
    including Changes 1-2, 1 September 2000.)

    FM 4-02.1. _Combat Health Logistics._ 28 September 2001.

    FM 4-02.4. _Medical Platoon Leaders' Handbook--Tactics,
    Techniques, and Procedures._ 24 August 2001.

    FM 4-02.6. _The Medical Company--Tactics, Techniques, and
    Procedures._ 1 August 2002.

    FM 4-02.10. _Theater Hospitalization._ 29 December 2000.

    FM 4-02.17. _Preventive Medicine Services._ 28 August 2000.

    FM 4-02.19. _Dental Service Support in a Theater of
    Operations._ 1 March 2001.

    FM 4-25.12. _Unit Field Sanitation Team._ 25 January 2002.

    FM 8-10. _Health Service Support in a Theater of Operations._ 1
    March 1991.

    FM 8-10-1. _The Medical Company--Tactics, Techniques, and
    Procedures._ 29 December 1994.

    FM 8-10-6. _Medical Evacuation in a Theater of
    Operations--Tactics, Techniques, and Procedures._ 14 April 2000.

    FM 8-10-8. _Medical Intelligence in a Theater of Operations._ 7
    July 1989.

    FM 8-10-9. _Combat Health Logistics in a Theater of
    Operations--Tactics, Techniques, and Procedures._ 3 October
    1995.

    FM 8-10-14. _Employment of the Combat Support
    Hospital--Tactics, Techniques, and Procedures._ 29 December
    1994.

    FM 8-10-15. _Employment of the Field and General
    Hospitals--Tactics, Techniques, and Procedures._ 26 March 1997.

    FM 8-10-18. _Veterinary Service--Tactics, Techniques, and
    Procedures._ 22 August 1997.

    FM 8-10-24. _Area Support Medical Battalion--Tactics,
    Techniques, and Procedures._ 13 October 1993.

    FM 8-10-25. _Employment of Forward Surgical Teams--Tactics,
    Techniques, and Procedures._ 30 September 1997.

    FM 8-10-26. _Employment of the Medical Company (Air
    Ambulance)._ 16 February 1999. (Change 1, 20 May 2002.)

    FM 8-30. _Veterinary Food Inspection Specialist._ 12 August
    1986.

    FM 8-42. _Combat Health Support in Stability Operations and
    Support Operations._ 27 October 1997.

    FM 8-50. _Prevention and Medical Management of Laser Injuries._
    8 August 1990.

    FM 8-51. _Combat Stress Control in a Theater of
    Operations--Tactics, Techniques, and Procedures._ 29 September
    1994.

    FM 8-55. _Planning for Health Service Support._ 9 September
    1994.

    FM 8-250. _Preventive Medicine Specialist._ 27 January 1986.
    (Reprinted with basic including Change 1, 12 September 1986.)

    FM 8-500. _Hazardous Materials Injuries: A Manual for
    Pre-Hospital Care. Edition 4._ 17 January 1997.

    FM 10-52. _Water Supply in Theaters of Operations._ 11 July
    1990.

    FM 21-11. _First Aid for Soldiers._ 27 October 1988. (Reprinted
    with basic including Changes 1-2, 4 December 1991.)

    FM 22-51. _Leaders' Manual for Combat Stress Control._ 29
    September 1994.

    FM 31-71. _Northern Operations._ 21 June 1971.

    FM 90-3. _Desert Operations._ FMFM 7-27. 24 August 1993.

    FM 90-5. _Jungle Operations._ 16 August 1982.

    FM 90-10. _Military Operations on Urbanized Terrain (MOUT)._ 15
    August 1979.

    STP 8-91 W15-SM-TG. _Soldier's Manual, Skill Levels 1/2/3/4/5
    and Trainer's Guide, MOS 91W, Health Care Specialist._ 10
    October 2001.

    TC 8-13. _Deployable Medical Systems--Tactics, Techniques, and
    Procedures._ 7 December 1990.

    TM 3-4240-288-12&P. _Operator's and Unit Maintenance
    Manual including Repair Parts and Special Tool List for
    Collective Protection Equipment NBC, Simplified M20 (NSN
    4240-01-166-2254)._ NAVFAC P-475. 20 August 1987. (Reprinted
    with basic including Changes 1-2, 3 May 1989.)

    TM 10-5410-228-10. _Operator's Manual for Chemical Biological
    Protective Shelter System._ 31 August 2001.

    TM 10-5410-283-14&P. _Operator's Unit, Direct Support,
    and General Support Maintenance Manual (Including Repair
    Parts and Special Tools Lists) for Chemically Protected
    Deployable Medical System (CP DEPMEDS) (NSN 5410-01-479-9730)
    (5410-01-479-9727) and CP DEPMEDS Training Set
    (6910-01-479-2464)._ 30 November 2001.




INDEX

References are to paragraph numbers unless otherwise indicated.


advanced trauma management, 3-1_e_, 3-9

Allied medical publications, viii, D-1, D-3_d_, D-11_b_, D-19_e_

animals
  consumption, for, 5-8, J-3_a_(5), J-3_b_(5), J-5_c_(9)
  contamination of, J-3
  decontamination of, 5-8, J-3_d_, J-4_d_, J-5_d_(9)
  government-owned, 5-5, 5-8, C-7
  protection of, 5-8, J-3_a_(5)
  specimens, from, 5-9, 5-14, J-5_b_(4)
  treatment of, 5-5, 5-8

area of operations, 1-3_b_(4)

attack, nuclear, biological, or chemical actions
  after, 2-6_a_, 3-1_c_, 3-7
  before, 3-5
  detection of, 5-7, A-1, F-14, I-2, J-1, J-3_b_, J-4_b_, J-5_b_
  during, 2-6a, 3-6, 3-9, 3-10b
  monitoring, 3-10_d_, 4-2_d_(2)(_a_), 4-7_h_, 5-7, A-6_a_, C-4--5,
      Appendix E, F-4, F-15_b_, G-10_f_, J-3_b_, J-4_b_, J-5_b_
  personnel considerations, 3-9
  prediction for, D-3_d_, D-26_b_
  responsibilities, 2-3, 2-6_a_, 5-22, 5-23
  supplies, 3-5_b_, 3-8_b_, 4-1--2, 5-2_a_, 5-3, 5-5--6, 5-14, 5-24--26,
      C-2--3, C-5--12
  survey, 3-7, 3-14_c_, C-4, D-4_c_, G-11_j_(4), J-3_b_, J-5_b_(4)
  treatment, 3-7, 4-1_a_(3), 4-4, 4-7_g_
    disposition, 3-10, 3-15b
    elements, 2-1_b_(3), 3-10
    operations, 2-2_a_

battlefield, 1-3_a_, 2-1, 2-2_a_, 2-3, 2-5_a_, 2-6, 3-1, 3-9, 3-12, 4-1,
      5-1, 5-5, 5-15, 5-24, A-1, D-3, D-19, G-3, H-2
  contaminated, 1-3_a_, 2-1, 2-6_a_, 3-1_e_, 3-9, 3-12_d_, 4-1, 5-1,
      5-5, 5-15, 5-24, A-1, D-3, D-19f, D-25, G-8, J-5_a_
  conventional, 3-1_a_ and _e_, 3-10


care, in unit, D-7, D-15, D-23

casualties
  biological, C-2, C-5, D-1, D-20
  chemical, D-1
  civilian, 3-11
  estimates, D-3_b_, D-11
  mass casualties, 2-1
  nuclear, 3-7, A-6, D-1, D-6_b_, D-8
  requirements estimation tool, D-2

chemical, biological, radiological, nuclear, and high-yield explosive,
      5-28, C-1

collective protection systems
  advanced simplified, F-2_c_, F-10
  alternate facilities, 2-5_b_(4)
  available, 2-5_b_
  decontamination of entrance area, F-13
  employment
    battalion aid station, 3-2_b_, F-2_a_, F-3
    division clearing station, 3-3_c_, F-2_a_, F-4
    forward surgical team, 3-4, F-2_a_, F-5
    in DEPMEDS hospital, 4-1_a_, F-2_b_, F-6--9
    operation, entry, and exit guidelines, 3-2_b_, F-12
    procedures, 3-2_b_, 3-3_c_, 3-4
  entry/exit, F-14--15
    ambulatory patients, 3-2_b_, F-15
    litter patient, 3-2_b_, F-15_b_
  establish, 2-5_b_(1), F-3--6
  radiation exposure, 3-12_b_ and _d_, 5-3, A-6_a_
  resupply of protected areas, F-16
  shielding, 4-2_b_(2)(_b_)
  water supply, in, F-6_b_

combat operational stress control, 3-3_a_, 5-20, C-9
  effects of, 3-1_a_, 5-20
  leadership actions, 3-1_b_, 3-3_a_, 5-21
  preventive, 5-23_b_
  reactions, 5-23_c_
  responsibilities, 5-20, 5-22, 5-23
  sleep plans, 5-21_f_

command and control, 2-1, 2-5_a_, 4-1_a_
  appraisal of the support mission, 2-3
  health service support units, 2-4
  homeland security, 2-7
  leadership, 2-6, 3-1_b_
  operations, 2-2_a_, 2-4--5, 2-6_b_
  planning considerations, 2-2

communications, 2-4, 3-1_c_

contaminated
  environment, 4-1_a_
  facility, 2-5_c_
  patients, A-6

contamination, 3-1_d_, 5-3
  avoidance, 2-5_c_, 3-1_d_, 3-17_e_
  control, 2-5_c_, 3-14_c_
  detection, 3-1_d_, I-2
  food, 4-1_a_, A-9_c_, J-1
  free area, 3-2_b_, 3-3_b_, 3-10_d_, 3-15
  hinder HSS operations, 3-1_d_
  persistency, 2-1_b_(2)
  water, 4-1_a_, A-9_c_, I-1

decontamination
  augmentation, 3-5_c_, 4-1_a_(3), 4-4_a_, C-4, G-3_b_, G-4_b_, G-5, G-6
  biological, A-10_c_, D-12_a_, D-13_b_, G-12
    ambulatory patients, G-14
    litter patient, G-13
  chemical
    ambulatory patients, G-11
    litter patients, G-10
  clothing removal, G-1O_c_, G-11_a_ and _i_, G-13_c_, G-14_b_, G-17_b_
  collocation with thorough decontamination, G-3
  complicating factors, 4-4_a_
  dental, 3-3_a_, 3-15, C-8
  facility, 2-5_b_(9), 3-1_c_, 4-1_a_(2), 4-3--4, G-3_f_
  Field Medical Card, G-2, G-10_a_(4), G-11_f_, G-13_b_, G-14_b_
  food, 5-7
  gross contamination removal, G-10_a_, G-11_h_
  heat injury prevention, during, G-8
  immediate, G-2
  litter, G-10_e_
  mask, 4-2_b_(4), G-10_a_(1), G-11_e_
  materials needed, 2-5_d_, 4-3, G-1_c_
  medical treatment facility, at, G-4--6
  monitor for completeness, G-10_g_, G-11_j_, G-15
  nuclear, 4-4_a_-_c_, A-6_c_, G-15
    ambulatory patients, G-17
    litter patients, G-16
  operations, G-1, G-3_a_, J-5_c_(5)
  patient protective wrap, G-11_c_
  patients, 2-5_b_(2) and (4), 2-5_d_, 3-2_b_, 3-14_d_, 3-15_c_,
      4-1_a_(2), F-11, G-1_a_, G-8, G-13
  personal effects, G-10_c_, G-13_a_, G-14_a_, G-16_a_, G-17_a_
  personnel/equipment, 2-5_b_(2), 3-2_b_, 3-9, 4-3, G-11_d_, G-14_a_
  shuffle pit, G-10_g_, G-11_l_, G-13_e_, G-14_e_, G-16_d_, G-17_d_
  skin, G-10_a_ and _f_, G-11, G-13_d_, G-14_d_, G-16_c_, G-17_c_
  solution preparation, G-1_c_, G-7
  spot, 3-2b, 4-3c, G-10_f_, G-11_g_
  treatment during, G-10, G-11_a_ and _k_(2)
    bandages, G-10_c_(2) and f(2), G-11_k_(2)
    splints, G-10_c_(2) and f(2), G-11_k_(2)
    tourniquet, G-10_c_(2) and _f_(2), G-11_k_(2)
  unit, G-2
waste, dispose of, G-10f(4), G-11_k_
water, G-7

defense, 3-14_b_

dental services, 3-3_a_, 5-15, C-8
  decontamination, 5-17--18, C-8
  mission, 5-16
  operations, 5-17
  patient protection, 5-19
  treatment, 3-3_a_, 5-16, 5-17, 5-18

detection, 3-1_d_

diseases, 1-3_b_(4), 5-1, 5-2_b_, 5-3, A-8_b_(5), D-12_c_, D-17_b_

emergency medical treatment, 3-1_e_, 3-2_b_, 3-3_c_, 3-4, 3-7, 3-9,
      3-15_b_, 4-1_a_(3), D-4_a_, D-12_a_

enemy prisoners of war, 2-2_a_

environment
  biological, 3-14
  chemical, 3-15
  nuclear, 3-12
  operations in extreme environments, 3-16
    desert, 3-16_d_
    jungle, 3-16_c_
    mountain, 3-16_a_
    NBC, 3-16
    snow and extreme cold, 3-16_b_
    urban terrain, 3-16

evacuation, 3-17, D-6, D-9, D-12_a_, D-14, D-22
  aircraft, 3-17_b_ and _e_
  contaminated areas, in, 3-17_b_
  ground vehicles, 3-17_b_
  nonmedical vehicles, 3-17_b_(1), 4-1_a_(3)
  personnel, 3-17_b_

facilities, 2-5_b_(9), 3-1_c_
  clean, 3-1--3, 3-10, 3-15, 3-17b(4)
  contamination, 3-2, 3-3_c_, 3-15_a_(4)
  move
    alternate facilities, 2-1_b_(4), 3-1_d_
    decision to, 2-1_b_(3)
    mobility, 4-1_a_, 4-2_a_, D-6_a_, D-14_a_, D-23_a_, F-1
    patients, 2-1_b_(3)
    protection available, 2-1_b_(1) and (4)
  principles, 4-2_b_(4)(_d_)

field expedient protective systems, H-1, H-4
  foxholes and trenches, H-3
  protection
    biological agent, against, H-4_a_
    chemical agent, against, H-4_a_
    factors, H-2
    radiation, against, H-2
    shielding, H-2
  shelters, expedient, H-1, H-3--4
    building of opportunity, 2-1_b_(1), H-3
    cave, 2-1_b_(1), H-3
    culverts, H-3
    ditches, H-3
    dozer trenches, H-3
    dug-in tents, H-3_d_
    engineer support, H-3_c_
    overpasses, H-3
    sandbagging, H-3_e_
    tents, H-3_e_
    tunnels, 2-1_b_(1), H-3

Field Medical Card, G-2, G-10_a_(4), G-11_f_, G-13_b_, G-14_b_

first aid, 3-1_a_, 3-2_a_, 3-9, D-7_b_
  buddy aid, 3-1_a_, 3-2_a_, D-4_a_, D-7_b_, D-12_a_, D-20_c_
  combat lifesaver, 3-1_a_, 3-2_a_
  self-aid, 3-1_a_, 3-2_a_, D-4_a_, D-7_b_, D-12_a_, D-20_c_

food
  animal, J-3_c_(5)
  considerations, J-3_d_
  contamination avoidance, J-1_c_(1)
  contamination of, 4-1_a_, J-3_a_, J-4_a_, J-5_a_
  countermeasures, J-1_b_
  decontamination of, J-1_a_, _c_(3), and _d_, J-3_c_, J-4_d_, J-5_c_
  detection in, J-1_a_, J-4_b_, J-5_b_
  disposition of, J-1_a_, J-5_d_(9)
  monitoring, J-3_b_
  operational rations, J-2_a_
  priorities, J-1_c_
  protection of, J-1_a_, J-2
  storage
    bulk, J-2_b_
    expedient, J-2_b_
    fresh food, J-2_b_
  susceptibility of, J-1_a_

forward surgical team, 3-4

guidelines
  chemical, biological, radiological, nuclear, and high-yield explosives,
      C-1
  conduct operations, A-2
  evacuation, A-7
  health service support planning, C-1
  mobilization, for, A-2
  operational exposure, 3-12_d_
  planning, A-1
  predeployment, A-2

health service logistics, 5-24, A-11
  organizational maintenance, 5-27
  protection of supplies
    shipment, during, 5-26
    storage, in, 5-25, A-11

health service support, D-9, D-12_a_
  appraisal, 2-3
  casualty collection point, 3-1_c_
  conventional operations, 2-4
  evacuation, 2-2_b_, 2-5_b_(5), 3-2--3, 3-16_a_, 3-17, 4-1, 4-2b(_2_),
      4-7_i_, A-7, A-14_b_, A-15_b_, D-1--2, D-4_a_, D-6, D-7_b_, D-8,
      D-12_a_, D-13_b_, D-14, D-16, D-19_a_, D-20_c_, D-22, D-24,
      D-26_d_, Appendix E, F-2_a_, F-3, F-5, G-2, G-10, G-11_c_, G-14_e_,
      G-17_d_
  factors, medical planning, 2-3
  levels of, 3-2, 3-3, 4-1_a_
  operations in NBC, 2-2_g_, 2-5, 2-6_b_, 3-1--4, 3-17_d_, 4-1_a_
  personnel protection, 2-6_a_, 3-8
  planning, 3-8
  proximity, 3-1_c_
  replacements, 3-1_c_
  survival, 3-5a, 3-16_c_, 5-15, 5-22_a_, D-7_b_
  technical channels, 3-1_c_
  treatment, 3-7, 4-1_a_(3)

heat stress, 2-6_a_

homeland security, 2-7, 5-28, C-12

hospitalization
  bed requirements, D-8, D-16, D-24
  blood services, 5-11
  conventional operations, 4-8
  decontamination, 4-1_a_(5)
  defensive measures, 4-1_b_
  emergency services, 4-4
  general medical services, 4-5
  integrated battlefield, on, 4-1_a_
  intensive care, 5-11
  locations, 4-1_a_(1)
  logistics support, 4-1_b_(2), A-11
  nursing services, 4-7
  protection, 4-1_a_(5) and _b_(2), 4-2_b_(2)(_b_), 4-4
    protective procedures, 4-1_a_(5) and _b_(1)
    biological, 4-1_b_(3)
    chemical, 4-2_b_(4)
    MOPP levels, 4-1_b_
    nuclear, 4-2_b_(2)
  response, 4-2_a_
  surgical services, 4-6, 5-11
  warning system, 4-1_b_(4)

initial effects
  alternate operational sites, 3-10
  detection, 3-1_d_, 5-7, 5-27, A-1, C-2, C-4, C-6--7, C-11, Appendix E,
      F-12_c_, F-14, I-2, J-1, J-2_a_, J-4_b_

installation medical authority, 5-28

International Standardization Agreements, D-1
  STANAG 2475, p. viii, D-3
  STANAG 2476, p. viii, D-11
  STANAG 2477, p. viii, D-19

laboratory services, 5-9--11, A-1O_a_, Appendix E
  biological specimens, 5-11, 5-14
  chain of custody, 5-14
  clinical, 5-11
  levels, 5-11
  samples, 5-10
    animals, small, 5-14
    environmental, 5-14
    field, 5-14
    food, 5-14
    soil, 5-14
    vegetation, 5-14
  support, 5-11
  theater Army medical laboratory, 5-11

leadership

logistics, 2-6, 3-8, 4-2b(4)(_c_), 5-6, D-9, D-12_a_, D-17, D-25,
      Appendix E

main supply routes, 3-5_c_

mass casualties, 2-1, 5-15--16, 5-29, A-10_b_, A-14_b_, A-15_b_, D-4_a_,
      D-12_a_, D-20_b_

medical equipment sets
  chemical agent patient decontamination, 3-8_b_, 4-3_c_(3), C-2, C-4
  chemical agent patient treatment, 3-8_b_, 4-3_c_(3), C-2, C-4

medical evacuation, 2-5_b_(3) and (5), 3-1_c_ and _e_, 3-2_a_, 3-3_a_,
      3-10_b_, 3-12_b_, 3-17, 4-1, 5-28

medical surveillance, 3-3_a_, 3-14_f_

medical treatment facility, 2-1, 2-2_a_, 2-5_b_, 3-3_c_

mission-oriented protective posture
  clothing, 2-5_b_, 3-1_a_--_b_, 3-9--10, 3-15_a_, 5-19_b_, 5-21_e_, C-3,
      F-2_a_
  equipment, 2-5_b_
  performance degradation, 2-6

movement and management of contaminated facilities, 2-5_b_, 3-10_d_

nuclear, biological, and chemical battlefield
  considerations, C-1
  defense, 3-1b, 5-21
  leadership, 2-6, 3-1, 3-6, 3-17_a_, 5-21, Appendix E
  operational exposure guide, nuclear, 2-5_a_, 3-1_b_
  operations in, 1-3_b_(4), 2-2_a_, 2-4--5, 3-5_a_, 3-9, 3-12_d_, 3-16,
      4-2b(1)(_c_), (2), and (4)(_c_), 4-3_a_, 5-14--15, 5-17, A-7, C-2,
      C-11, Appendix E, F-4--5
  strikes, 4-1_a_
  warning and reporting system, 4-1_b_

nursing services, 4-7, A-10

operational
  exposure guide, nuclear, 2-5_a_, 3-1_b_, 3-12_d_, 3-17_b_
  plans, 2-5_a_, 3-1_a_

operations, 4-2_b_(1)(_c_) and (2)(_a_), 4-3_a_(2), A-1, A-7, C-1, C-5,
      C-11, D-3_d_, F-3--5, F-11--12, G-1_a_, J-1_d_, J-5_c_(5)
  security, 4-1_b_(1), 4-2_b_

passive defense measures, 3-14_b_

patient
  chemical agent, A-14
  contaminated, 3-10_c_, 3-12, 4-1_a_(3), C-5
  decontamination, 3-3_b_, 3-10, 4-1_a_(3) and _b_, A-14_c_, A-15_c_
  externally contaminated, 3-12_a_
  holding, 3-3_a_
  internally contaminated, 3-12_a_
  irradiated, 3-12_a_
  management of, A-10_c_
  number of, 2-1_b_(3)
  protective wrap, 3-17_f_, F-15_b_(2)(_a_), G-11_c_
  stability operations and support operations, in, A-7
  types of, 2-1_b_(3), 3-12_b_, C-4

personnel
  protection of, 2-1_b_(9), 2-6_a_
  replacement of, 3-1_c_

planning
  considerations for, D-4, D-20_a_
  estimates, D-2, D-4, D-11_c_, D-17, D-19
  health service support, 3-9
  medical force, for, D-10, D-18, D-20, D-26
  medical NBC staff officer, Appendix E
  mobilization, C-2--3
  NBC, 3-5_c_, p. D-1
  predeployment, C-2
  tool, medical, D-2

plans
  establish a medical treatment facility, C-1
  HSS, 3-17_d_
  load, C-3
  movement, C-3
  operation, 2-5_a_, 3-1_a_
  tactical, 3-17_d_

preventive medicine
  arthropods, 5-2_b_, 5-3
  climate, 5-2_a_
  detachments, 5-4
  determining factors, 5-1, 5-2_a_
  disease, 5-1
  divisional, 3-3_a_, 5-3
  field hygiene and sanitation, 5-3
  field sanitation team, unit, 5-3--4
  immunizations, 5-3, D-11_f_
  incidents and morbidity, 5-2_b_
  measures, 3-1e, 5-1, 5-4, 5-11--12
  medical surveillance, 5-4
  occupational and environmental health threat, 5-3--4
  operations, 5-1--2, 5-4
  pest management, 5-2_b_, 5-4
  prophylaxis, D-11_f_
  services, 3-3_a_, 5-1, 5-14, C-6, Appendix E
  water and food, 5-2_a_, 5-3--4

protection
  buildings of opportunity, use of, 3-1_d_, 3-5_b_, 3-12
  collective, 3-1_d_, 3-2_b_, 3-3_b_, 3-4, 3-10_a_, 3-15, 4-7, C-2, C-4
  covers, 3-1_d_, 3-12
  environmental, 4-2_b_(2), 4-5, 4-6_a_ and _c_, 4-7_c_
    hospital, 4-2_a_
    individual, 4-2_b_, 5-21_d_
    mask-only, 4-2_b_(4)(_a_), 4-7_b_
    materiel, 3-1_d_, 4-2_b_(4)(_d_)
    overhead, 3-1_d_, 3-12
    patient, 3-5d, 4-2b(4)(_c_), A-6
    personnel, 3-5_b_, 4-2b(4)(a)
    proximity, 3-1_c_
    shielding, 3-5_b_, 4-2_b_(2)
    site selection, 3-12
    supplies, 3-5_b_
    types of, 3-1_d_
    warning system, 4-2_b_(4)
  expedient, 2-5_b_(1), 3-5_b_, 3-12
  shielding, 4-2_b_(2)(_b_)3

radiation exposure status, 3-12_d_, 3-17_b_

radiological dispersal devices, 1-1_a_, 4-1_a_, A-1

rations, F-6_b_, J-5_a_(4)

reporting, Appendix E

return to duty, 3-1_e_

samples, 5-3--4, 5-9, C-6--7, C-10, Appendix E
  analysis of, B-1--2
  chain of custody, 5-9, 5-14_a_ and _b_(1), C-6--7
    documentation, 5-9
  collection, 5-9, B-1--2, B-4_b_
  description of, B-2
  environmental, 5-9, 5-14, B-1, B-3_b_, B-5
    air, 5-12_b_(1), 5-14, B-1, B-8
    soil, 5-12_b_(1), 5-14, B-1, B-10
    vapor, B-8
    vegetation, 5-12_b_(1), 5-14, B-1, B-4
    water, 5-12_b_(1), 5-14, B-1, B-3_c_, B-9
  food, 5-9_b_(1), 5-14, J-4_b_(1), B-1, B-3_d_
  handling, 5-9
  history of, B-2
  identification, 5-9_b_(1), 5-13
  labeling, 5-9, 5-13, B-4_b_
  preservation, 5-9_b_(1), B-2, B-4_b_, C-6--7
  transportation, 5-9_b_(1)

sleep loss, 2-6_a_

special medical response teams, 5-28--29

specimens, Appendix E
  analysis, 5-10--11, 5-12_b_, A-10, B-1--3
  ante mortem, B-3_a_
  background documents, B-18
  biological, 5-3--4, 5-9, A-10, B-1, B-5, B-12--13, p. C-6--7
  chain of custody, 5-9_a_, 5-11--12, 5-14_b_(1), B-4, B-17, C-6--7,
      C-10--11
  civilians, from, B-1_b_, B-13
  collection of, 5-3--4, 5-9_b_(1), 5-10--12, 5-14, B-1, B-4_b_,
      B-12--13, C-7, C-10--11
  description of, B-2
  documentation of, B-2
  field, 5-14
  history of, B-2, B-15
  identification, 5-9b(1), 5-12_b_, 5-13, A-10_a_
  post mortem and forensic, B-3_b_, B-14
  preservation, 5-9_b_(1), 5-11--12, B-2--3, B-4_b_, B-15--16, C-6--7,
      C-10--11
  reporting, 5-12_b_, B-15, B-17
  transportation, 5-9_a_ and _b_(1), 5-12
  types of, B-3

stability operations and support operations, A-7

Standardization Agreement (STANAG). See International Standardization
      Agreements.

stress, 2-6_a_

supply, Class VIII

tactical standing operating procedures, C-2

threat, 1-1_a_
  biological warfare, 1-2, 1-3_b_, 3-14
  chemical, biological, radiological, nuclear, and high-yield explosive,
      1-2
  chemical warfare, 1-2, 1-3_c_
  directed energy, 1-2
  medical, 1-2
  nuclear, 1-2, 1-3_a_
  radiological dispersal device, 1-2, 1-3_a_
  toxic industrial material, 1-1_b_, 1-3_d_

toxic industrial material, 1-1_b_, 1-2, 3-1_a_ and _d_, 4-1_a_, 5-3, A-1,
      A-15, Appendix E

training, 3-1_b_, C-3

treatment, 3-1--2, 3-7, 3-9--10, 3-13--16, 5-29, A-3_a_(3), A-6_e_,
      A-10_d_, A-14_d_, A-15_d_, Appendix E
  advanced trauma management, 3-1_e_, 3-9
  clean area, 3-1--3, 3-10, 3-15, 3-17_b_(4)
  emergency medical treatment, 3-1_e_, 3-3_b_, 3-7, 3-9, 3-15_b_,
      4-1_a_(3), D-4_a_, D-12_a_

triage, 2-3, 3-13, 4-1_a_(3) and _b_, 4-4_b_, 5-20, 5-29, C-2, C-5,
      D-4_a_, D-5, D-12_a_, D-13, D-21

veterinary services, 5-5, 5-14, C-7, Appendix E
  animal care, 5-8
  food protection, 5-6

waste disposal, F-6_b_

water supply, 4-1_a_, C-2, F-6_b_, I-1--4
  actions to protect, I-3
  detection in, I-2
  treatment of, I-4

weapons, 1-3, 3-1_b_ and _c_, 4-1_a_, A-1
  biological, 4-2_b_(3), 5-2_b_, A-8, D-11_e_, D-12_b_
    agents, A-8
    behavior, A-9
    dispersion, A-8--9
    effects, 3-7, A-7, A-10, D-11_c_
    incubation period, A-8_a_(3)
    individual, F-14
    infection, A-8_a_(2)
    live agents, A-8_a_
    spore-forming, A-8_b_
    toxins, A-8_c_
  categories
    nonpersistent, A-12_a_(2)
    persistent, A-12_b_(1)
    protection against, 3-10
    vapor hazard, 3-10_d_
  chemical, 4-2_b_(4)
    agents, 3-7, A-11_b_
    attacks types of, A-11_b_
    behavior, A-12
    blister, Table A-12, A-13_b_, D-20_e_
    blood, Table A-12, A-13_d_
    characteristics, A-12--13
    incapacitating, A-12_a_, Table A-12
    lung damaging, Table A-12, A-13_c_
    nerve, Table A-12, A-13_a_
  effects, 3-5_b_, A-11
  employment of, A-1
  nuclear, 4-2_b_(2)
    biological effects, A-4
    blast, 3-7, 3-12_a_, A-2_c_, A-3_a_
    burns, A-4
    detonation of, D-3_e_
    effects of, D-3_d_
    electromagnetic pulse, A-2_a_, D-4_d_
    eye injuries, A-4_c_
    fallout, 3-12_b_
    overpressure, A-3_a_(2)
    physical effects, A-2
    physiological effects, A-3, A-5
    radiation injury, 3-7, 3-12_a_
    thermal injury, 3-7, 3-12_a_, D-4_a_
  radiological dispersal device, 1-1_b_, 1-3, A-1, A-3
  threat, 1-1, 3-1_a_, 3-2_b_

work/rest cycles, 2-6_a_




    FM 4-02.7 (FM 8-10-7)
    1 OCTOBER 2002

By Order of the Secretary of the Army:

    ERIC K. SHINSEKI
    _General, United States Army_
    _Chief of Staff_

Official:

[Illustration: (signature)]

    JOEL B. HUDSON
    _Administrative Assistant to the
    Secretary of the Army_
    0225424


DISTRIBUTION:

_Active Army, U.S. Army Reserve and Army National Guard_: To be
distributed in accordance with the initial distribution Number,
114899, requirements for FM 4-02.7.




    TRANSCRIBER'S NOTE

    Italic text is denoted by _underscores_. Blank space in some sample
    documents in the text is also denoted by ____.

    Bold text is denoted by =equal signs=.

    Superscripts are denoted by ^  eg abc^{TM}.

    Subscripts in chemical formulae are denoted by _  eg CO_{2}.

    Footnotes are all within a specific Table, including the Table of
    Contents. They are positioned at the bottom of that Table, as in the
    original text, and are denoted by [*] or [**].

    Obvious punctuation errors have been corrected after careful
    comparison with other occurrences within the text and consultation
    of external sources.

    Column headings in Tables, all bolded in the original text, are
    unbolded here for clarity.

    Fractions in the original text are mostly full-height format, eg 1/2,
    and have been left in that form. Some are half-height and have been
    converted to Unicode fractions eg ½ ¾ whenever possible.


    Except for those changes noted below, all misspelling in the text, and
    inconsistent or archaic usage, have been retained.

    Chapter-Paragraph:
      2-1. 'thermoberic' replaced by 'thermobaric'.
      3-3. 'proves' replaced by 'provides'.
      3-8. 'company's' replaced by 'companies'.
      4-3. 'are also' replaced by 'is also'.

    Appendix:
      Table A-1. 'RADIATON' replaced by 'RADIATION'.
      Table A-7. 'Cal/cm2/sec' replaced by 'Cal/cm^2/sec'.
      Table A-10. '0.8%-2% CANCER.' replaced by '0.8%-2%'.
      Table A-13. 'Characteristics' replaced by 'Characteristics of'.
      Para B-11. 'handsful' replaced by 'handful'.
      Para B-18. 'BLUFFED VISION' replaced by 'BLURRED VISION'.
      Para J-5. 'modify to M43' replaced by 'modify the M43'.

    Index:
      heat injury prevention. '6-10_g_(4)' replaced by 'G-8'.
      monitor for completeness. '6-10_f_' replaced by 'G-10_g_'.





End of the Project Gutenberg EBook of Health Service Support in a Nuclear,
Biological, and Chemical Environment, by Anonymous

*** END OF THE PROJECT GUTENBERG EBOOK 49037 ***