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

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

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

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

3-13. Medical Triage

3-14. Biological Environment

• 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

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

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.

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.

CHAPTER 4

LEVELS III AND IV HOSPITALIZATION

4-1. General

• 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

• 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.