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):

CHAPTER 1

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

1-1. General

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

(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

Table 1-3. The Future of Biological Warfare Agents

(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

Table 1-5. Chemical Warfare Agents

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

• 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.

Figure 2-1. Sample triage and emergency medical treatment decision matrix.

2-5. Movement/Management of 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

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

• 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

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

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

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

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 (T₂) 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