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.