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.

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

• 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.

Table B-4. Standard Sizes of CB Samples/Specimens to be Collected

B-15. Reporting, Packaging, and 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

• 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.

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).

Figure B-2. Sample/specimen background document.

Figure B-3. Chemical/biological incident interview.

APPENDIX C

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

C-1. General

C-2. Predeployment

• 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

C-4. Establish a Medical Treatment Facility

• 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

• 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

C-7. Veterinary Services

C-8. Dental Services

C-9. Combat Operational Stress Control

C-10. Medical Laboratory Services

• 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

• 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.