CHAPTER 3

LEVELS I AND II HEALTH SERVICE SUPPORT

3-1. General

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

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

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

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

· Contamination avoidance techniques.

· Alarms and detection equipment.

· Unit dispersion techniques.

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

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

· Chemical agent resistant coatings on equipment.

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

3-2. Level I Health Service Support

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

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

3-3. Level II Health Service Support

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

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

· Providing area support Level I medical treatment.

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

· Providing limited dental service.

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

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

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

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

3-4. Forward Surgical Team

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

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

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

· Survive the attack individually and as a unit.

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

· Effectively care for NBC patients.

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

_c._ Other tasks include:

· Verifying NBC defense HSS inventories are complete.

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

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

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

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

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

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

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

· Massive hemorrhage.

· Respiratory distress.

· Severe shock.

3-8. Logistical Considerations

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

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

NOTE

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

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

3-9. Personnel Considerations

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

3-10. Disposition and Employment of Treatment Elements

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

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

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

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

3-11. Civilian Casualties

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

3-12. Nuclear Environment

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

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

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

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

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

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

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

· The contaminated environment hinders MEDEVAC.

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

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

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

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

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

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

3-13. Medical Triage

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

3-14. Biological Environment

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

· Increases in disease incidence or fatality rates.

· Sudden presentation of an exotic disease.

· Other sequential epidemiological events.

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

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

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

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

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

3-15. Chemical Environment

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

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

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

3-16. Operations in Extreme Environments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NOTE

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

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

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

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