CHAPTER 4

=LEVELS III AND IV HOSPITALIZATION=

4-1. General

_a._ Many factors must be considered when planning for Levels III and IV hospital support on the integrated battlefield. The hospital staff must be able to defend against threats by individuals or small groups (two or three) of infiltrators and survive NBC strikes or TIM incidents while continuing their mission. This threat may include the introduction of NBC or TIM in the hospital area, the water or food supplies; and the destruction of equipment and/or supplies. On the larger scale of surviving NBC strikes and continuing to support the mission, operating in a contaminated environment will present many problems for hospital personnel. The use of NBC weapons or TIM release can compromise both the quality and quantity of health care delivered by medical personnel due to the contamination at the MTF; constrain mobility and evacuation; and contaminate the logistical supply base. While providing hospital support, consider the following assumptions:

(1) Their location, close to other support assets, makes them vulnerable to NBC strikes and release/dispersion of TIMs.

· Command, control, communications, computers, and intelligence (C4I) infrastructure, logistical nodes, and base clusters are high value targets.

· Most NBC weapons are designed for wide-area coverage. Chemical and biological agents may present a hazard some distance downwind from the area of attack; also, residual radiation may extend for hundreds of kilometers (km) from ground zero.

· The large signature (size, heat, infrared) of a hospital makes it easy to find and target (the assumption is that the hospital is very near the intended targets).

· Hospitals located near road networks and airfields for access to evacuation routes increase their exposure to tactical strikes of NBC weapons and exposure to TIM releases.

· There are ever-increasing numbers of countries and individuals with the ability to manufacture and deliver NBC weapons/agents. This activity increases their use potential at all levels of conflict.

NOTE

When using existing civilian hospitals, the materials for an RDD may be at these hospitals. Exploding the material in place is very practical for a small team of terrorists.

(2) Large numbers of casualties are produced in a short period of time. Many of these casualties may have injuries that are unfamiliar to hospital personnel. These injuries may include--

· 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

_a._ Protection of hospital assets requires intensive use of intelligence information and careful planning. The limited mobility of hospitals makes their site selection vital to minimize collateral damage from attacks on other units.

· 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.

NOTE

Patients with injuries that prevent their assuming a protective posture must be placed in a PPW or immediately evacuated to a clean MTF.

_(b) Environmental protection._ As noted previously, hospital complexes without CPS offer some protection against liquid or fallout contamination, but little protection against vapor hazards.

· When MOPP Level 1 must be assumed, close and secure all tent flaps, vents, and doors to prevent the entrance of liquids or particles. All hospital personnel outside of shelters assume MOPP Level 4. Cover or move all equipment and supplies into shelters (tents, hard-walled shipping containers), if possible. Placement under thick foliage trees is better than left out in the open. The best policy is to keep all equipment and supplies not immediately needed covered or in closed containers.

· When MOPP Level 3 or mask-only posture is assumed, shut down the hospital's ventilation system to prevent drawing vapors or fallout contamination into the hospital. This measure also provides some protection of the internal environment during the time required for the vapor to penetrate the tentage.

_(c) Patient protection._

· Patient protection depends upon prior planning and timely warning of the chemical threat. Each patient's protective mask must be available and serviceable. If the patient came from a contaminated area, the mask must be decontaminated and the filters changed. The mask decontamination and filter change may have to be performed by hospital personnel. If ambulatory patients' medical conditions permit (minimal care ward), they may be able to perform this task. The hospital supply staff must ensure that mask filters are available at the supporting logistics support facility and can be requisitioned to meet this requirement. Check all masks for serviceability as soon as the mission permits, but always before they are needed. Do not wait until the warning has been received to begin checking the mask. Each area must have an established plan for operations (to include assisting patients assuming MOPP or other protective posture) in the NBC environment. Appendix F provides additional information on patient protection.

+--------------------------------------------------------+ | CAUTION | | | | Remember, personnel must assume MOPP Level 4 before | | beginning any decontamination process or risk becoming | | a casualty themselves. | +--------------------------------------------------------+

· Hospital staff always mask themselves first, then assist patients in masking. On minimal care wards, most patients can put on their masks. For those who cannot, other patients can assist them after putting on their own masks. On the intermediate care wards, some patients will be able to put on their masks, but many will require assistance. Intensive care and emergency room staff will have to assist their patients in masking.

· Many patients with head and neck wounds or who are on life-support devices will be unable to wear their individual protective masks; these patients must be placed in a PPW. While the PPW has two ports for intravenous or blood infusion lines, the staff may have to adapt for other devices (Foley catheters, traction devices, and cardiac monitor) by using tape and other means to seal the gaps created in the seal around the edge of the PPW. Patients requiring assisted ventilation are at extreme risk, unless their air supply is protected. The sequence of protecting everyone is mask yourself first; assist those patients who can wear their protective masks; and then place patients in the PPW.

_(d) Materiel protection._ Protection of materiel, especially expendable supplies, requires covers and barriers. All materiel not required for immediate use is kept in shipping containers, medical chests, or under cover (tentage, plastic sheeting, and tarpaulin) for protection against particulate or liquid hazard. Protection against vapor hazard may require multiple barriers through which the vapor must penetrate. For example, intravenous solutions are in their individual plastic bags, in the cardboard shipping box, on a covered pallet, in a hard-walled shelter; such as a military-owned demountable container (MILVAN). This presents four barriers against the vapor hazard. These principles should be used to the maximum extent practical.

4-3. Decontamination

_a._ Decontamination of nuclear-contaminated personnel, equipment, and the operational site is as follows:

(1) Monitoring equipment is used to detect contamination; the contamination is then removed by brushing or scraping with brooms, brushes, or tree branches. Flushing hard surface contaminated areas with water is also effective in removing nuclear contamination. However, there remains a problem of containing and removing the contaminated water. The best method of containment is to trench the area into a sump for collection of the contamination. This will reduce the area of contamination; however, the level of concentrated radiation may be such that there is an increased hazard to personnel. The collection area must be clearly marked using the standard nuclear hazard signs.

(2) Nuclear contamination of the site may require relocating the hospital. Scraping 1 or 2 inches of topsoil from the area, or covering the area with 1 or 2 inches of uncontaminated dirt will not be practical. 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. If the hospital is immersed in a high level of radioactivity, the best option may be to abandon it for 48 to 72 hours. After this period the area should be checked and if the radioactivity has decayed sufficiently the hospital may be reoccupied and continue operations or moved to a clean area. The command OEG must be followed if reoccupying or moving the facility.

_b._ Suspect biological agents should be removed from equipment as quickly as possible, In the absence of agent-specific guidance, clean exposed surfaces using a 5 percent hypochlorite solution or copious quantities of soap and water (preferably hot). Liberally apply the hot, soapy water and scrub all surfaces with a brush. Then rinse the surfaces with hot water. As previously discussed, the soapy water used is contaminated and must be controlled and removed to a safe area. Supertropical bleach (STB) and decontaminating solution Number 2 (DS2, US Army) are effective against most known biological agents because of their caustic nature. If anthrax (or other spore formers) is suspected, repeat the entire decontamination process again to remove the spores. Other standard biological decontamination agents are described in FM 3-5.

+------------------------------------------------------------------+ | CAUTION | | | | 1. Keep liquid decontaminants out of equipment with electronic | | or electrical circuits. Unplug electrical devices before | | attempting to decontaminate them; prevent electric shock. Some | | electronic devices maintain an electric charge, even after being | | unplugged, use extreme care to prevent shock. | | | | 2. Soap and water only mechanically remove BW agents. The | | soap and water solution must be contained to prevent spreading | | the agent to other personnel, thus causing more casualties. | +------------------------------------------------------------------+

_c._ Decontamination of chemical contamination is as follows:

(1) Personnel use their soldier skills and their M295 Individual Equipment Decontamination Kit to decontaminate their personal equipment. The M13, decontamination apparatus, portable, is used to decontaminate vehicles, trailers, and International Organization for Standardization (ISO) shelters. This apparatus uses DS2 (a highly caustic, flammable solution that cannot be used to decontaminate tentage). The DS2 must be washed off after sufficient time has passed for decontamination (see FM 3-5 for details). Water used for NBC decontamination purposes becomes contaminated; therefore, it must be contained in sumps. Dig shallow trenches to channel the water into sumps. This will be difficult in hospital areas because relatively flat sites are needed for hospital complexing, but must be accomplished to reduce the contamination levels in the hospital area.

(2) When hospital tentage becomes contaminated, decontamination operations must be considered immediately. Spot decontamination may be effective for small areas; however, gross contamination of TEMPER and GP tentage is best decontaminated by aging. Without CPS and with persistent agent contamination that absorbs into the tentage and presents a continuing vapor hazard, the hospital stops receiving patients and evacuates all patients as quickly as possible. When large portions of the hospital are contaminated, personnel decontaminate all equipment possible and relocate to a new site, leaving the contaminated equipment to age or to be decontaminated by a specialized unit. When small portions of the hospital are contaminated, the contaminated portions are removed to another location for decontamination; hospital operations are continued, but at a lower operational level. For detailed equipment decontamination procedures, see FM 3-5.

NOTE

Liquid decontamination material must not be used on electrical or electronic components of equipment. Liquid decontaminants can damage the equipment; thus making it inoperable and not available for patient care or transport. The use of liquids to decontaminate electronic equipment could also potentially result in injury or electrocution of personnel.

(3) Each US Army hospital is issued =five= chemical agent patient treatment MES and =three= chemical agent patient decontamination MES, Chemical Agents Patient Decontamination, for use in decontaminating patients. Each hospital must decontaminate and treat its own personnel who become casualties; chemical casualties from units in its general area; or contaminated patients received from lower level MTFs. See Appendix G for patient decontamination procedures and for establishment of a patient decontamination and treatment station.

4-4. Emergency Services

_a._ Providing emergency services will be complicated by several factors:

· Varying levels of treatment received prior to arrival at the hospital.

· Caring for combined conventional wounds and NBC agent effects.

· Managing heat-related complications associated with MOPP/PPW use.

· Controlling psychological effects caused by biological and chemical agents, the impact of NBC weapons, or the isolation of MOPP gear or PPWs.

· Having EMT personnel working at the arrival point, decontamination site, and in the hospital EMT area.

· Conducting triage and providing patient care while in MOPP gear.

· Supervising supported units decontamination augmentation personnel. These personnel will most likely be of any military occupational specially (MOS), except medical. They will use hospital equipment and supplies to decontaminate patients.

_b._ Contaminated patients must be triaged in the decontamination area that is established at the hospital. Contaminated patients =WILL NOT= be brought into the clean EMT area until decontaminated. All patients are screened for contamination. Based on the findings, the patient is routed to the contaminated triage station, or to the clean triage station. Contaminated patients are triaged, then routed to the decontamination area, or to the contaminated treatment area. Patient admission to the clean treatment area may be delayed; however, life- or limb-saving care is provided in the contaminated treatment area before decontamination.

4-5. General Medical Services

The provision of general medical services in the hospital will be continued with minimal interruptions in the NBC environment. The noninvasive nature of these services allows their continuation at most MOPP levels. However, some general medical services will be constrained by MOPP Levels 3 and 4 and the mask-only posture. These constraints may include, but not be limited to--

· Communication limitations.

· Loss of the oral route for administering medications to patients.

· Limited ability to accurately evaluate the eyes, nose, and mouth of patients wearing a protective mask.

· Reduced ability to perform examination/assessment of patients in PPW or MOPP Levels 3 and 4.

· Inability to provide oxygen therapy or ventilator support to a patient in a vapor hazard environment, unless a CB filter-supported respirator is available.

· Logistical constraints based upon the fact that key areas such as dietetics, supply, and laundry are not in the CPS. These services may be reduced or delayed in the NBC environment. See Appendix F for Information on patient feeding under NBC conditions.

4-6. Surgical Services

_a._ Surgical services will be severely limited in the NBC environment. At any level above MOPP Level 0, without a CPS system surgical services are halted except for life- or limb-saving expedient procedures. Surgery cannot be safely performed outside a CPS due to a variety of factors including--

· Lack of protected ventilation for patients during and after surgery.

· Inability to maintain a sterile field while using MOPP gear.

· Direct access for agents through open wounds to the circulatory and respiratory systems.

· Decreased dexterity and vision resulting from MOPP gear use.

· Inability to quickly place the patient in a PPW should the need arise.

_b._ Due to the relatively high number of trauma cases, hospital services may be severely constrained by NBC contamination. The hospital location and the possible need for relocation are two major planning considerations for the command staff.

_c._ Patient accounting and medical regulating are critical factors in the transfer of patients from a hospital without a CPS that must move out of an NBC environment. Hospitals without CPS stop receiving patients when a persistent hazard is identified; patients on hand are protected and transferred to a clean MTF.

4-7. Nursing Services

Providing nursing care in a hospital without CPS is influenced by the amount of protective gear worn by the nursing staff and the patients. The patients may be in their MOPP gear, in a PPW, or wearing only their protective mask; any of which will interfere with care. The nursing staff will wear the same level of protection as the patients.

_a._ Direct assessment of a patient's vital signs is extremely limited at MOPP Levels 3 or 4; however, a carotid artery pulse can be taken by palpating the neck area. The patient's respiratory rate and level of consciousness may be assessed visually. Palpitation of the blood pressure through a PPW may be possible if it is relatively strong, or at least in the normal range. The patient's temperature cannot be monitored; this is an area of concern due to the possibility of heat stress.

_b._ Only gross neurological signs can be assessed through the PPW or when the patient is in MOPP Levels 3 or 4. However, even this assessment is complicated by the presence of miosis and by the health care provider's mask. Urinary output and cardiac monitoring is continued uninterrupted for patients wearing a mask only and for patients in the PPW.

_c._ Oral hygiene and bathing are postponed until a safe environment is available (MOPP Level 2 or less). All toileting will occur within the hospital complex using ISO contained latrines, chemical toilets, bedpans, urinals, buckets, or containers with plastic liners. Waste from improvised containers must be placed in containers with covers or in plastic bags and sealed to control odors and prevent spread of infectious material within the facility.

_d._ At MOPP Levels 3 and 4, feeding must be postponed. A nutritional assessment is needed to determine how long each patient can tolerate a fasting state when MOPP Level 3 or Level 4 remains in effect for over 24 hours.

_e._ Intravenous (IV) medications are mixed in a clean area and then transported in a protective wrap (multilayers of plastic, medical chest, or layered cardboard) to the user. However, IV solutions, blood, and injections can be given to patients on an unprotected ward. Normally, oral medications are only given at MOPP Level 2 or lower.

_f._ Treatment procedures that have the potential of contaminating the patient's pulmonary or circulatory systems are conducted only at MOPP Level 2 or below. However, EMT procedures may have to be performed in the contaminated treatment area, or the patient decontamination area.

_g._ Continuous oxygen therapy requires a collective protection environment or a CB filter supported respirator.

_h._ Delivery of nursing care at MOPP Level 3 or Level 4 is limited due to the sensory restrictions of MOPP gear. Time is taken to reassure the patients on a personal basis, as much as possible, and by routinely monitoring the ward environment. Communications are difficult and identities are masked. Maintain the identity of personnel by using handwritten name tags for staff and patients (including patients in PPW).

_i._ As with all procedures, the time required for record-keeping rises markedly at MOPP Level 3 or Level 4. Contaminated paperwork cannot be evacuated with the patient. Transcribe essential information onto uncontaminated documents for evacuation with the patient. A record of patient exposure time to a contaminated area is prepared to assess the cumulative risk to the patient.

4-8. Conventional Operations

For conventional operations of hospitals in a field environment see FM 4-02.10, FM 8-10-14, and FM 8-10-15.