Health Service Support in a Nuclear, Biological, and Chemical Environment Tactics, Techniques, and Procedures

CHAPTER 5

Chapter 526,039 wordsPublic domain

OTHER HEALTH SERVICE SUPPORT

Section I. PREVENTIVE MEDICINE SERVICES

5-1. General

On the integrated battlefield, PVNTMED services will be in greater demand than at any other time, especially under BW conditions. Preventive medicine personnel will be called upon to assist the commander in determining the health hazards associated with nuclear fallout; the safety of drinking water in an NBC environment; as well as determining when to use prophylaxis, pretreatments, immunizations, and other PVNTMED measures (PMM) associated with NBC warfare. Preventive medicine personnel must be aware of the medical threat in the AO. They must continually update their medical surveillance activities to identify disease trends (endemic and epidemic), potential disease vectors, and the susceptibility of troops to these diseases. Under NBC conditions, diseases may manifest that exist in the area, but were not being transmitted to personnel. However, due to the reduced health status of personnel from exposures to or from stress-related NBC conditions, the troops begin to suffer their effects. The appearance of diseases or arthropods not known to exist in the AO are indicators that BW agents have been used. For details on PVNTMED operations, see FM 4-02.17.

5-2. Disease Incidence Following the Use of Nuclear, Biological, and Chemical Weapons

_a._ _Determining Factors._ Factors of prime importance in determining the nature and severity of the disease effects are--

· Immunization status of personnel.

· Population density.

· Degree of industrialization in the operational area.

· Availability of food supplies.

· Availability of water.

· Climate.

Finally, the manner and situation in which nuclear weapons are used are of importance. A single weapon detonated in a socially stable area will have far less serious effects than a detonation in an area where combat has already disrupted the social stability. At Hiroshima and Nagasaki, Japan (excellent examples of the first type of situation), the survivors who could get away were able to obtain food, shelter, and care from surrounding intact areas. With prolonged combat operations, such intact areas would not be available, resulting in no food, shelter, or care for survivors. There will be a breakdown in social order and there will be a lack of effective medical support; including PVNTMED functions and facilities.

_b._ _Disease Incidence._ Without PVNTMED capabilities, increased incidence and morbidity from diseases will follow. Some diseases will predominate in incidence, depending upon the geographical areas involved and the endemic diseases present.

(1) In urban areas in temperate climates, several diseases are epidemic threats. These epidemic threats may include--

· Dysentery (due to a variety of pathogens).

· Rickettsial diseases, particularly typhus and scrub typhus.

· Hepatitis.

· Tuberculosis.

· Sexually transmitted diseases.

· Malaria and cholera (in many parts of the world).

(2) There are several reasons for the increased risk of disease including, but not limited to--

· Crowding of surviving populations with limited sanitary facilities, such as was seen in Europe at the end of World War II.

· A lack of prophylaxis and immunizations with resultant increases in the susceptible faction of a given population.

· A lack of pest management.

· The effect of irradiation on susceptibility to infection. With the high levels of fallout covering wide areas, a large number of people will sustain sublethal whole-body doses of irradiation. The interaction of irradiation with infections is not clear; but it may be the result of latent infections manifesting and decreased resistance to infection. The result is an increased incidence of disease.

· The ecological imbalance and host-parasite relationship following the use of nuclear weapons. Each class and order of animals has marked differences in sensitivity to irradiation. Arthropods, for example, are much more resistant than are vertebrates. The normal balance between arthropods and birds that prey upon them in a given area may be severely upset, producing a marked overgrowth of the arthropods. If the arthropods include vectors of disease there would be a serious increase in disease hazards. If there is an increase in arthropods that destroy vegetation there would be a serious destruction of food crops.

· The introduction of a BW agent in an AO in which the disease organism is endemic or epidemic can increase the risk level for exposed personnel.

5-3. Preventive Medicine Section

The PVNTMED sections of the brigade, divisional, and nondivisional medical companies perform analysis on water sources and supplies to determine the presence or absence of NBC/TIM contamination; see Appendix I for additional information. Based upon their findings, the water is released for consumption, or is restricted from use until it is treated (usually by water production personnel using the reverse osmosis water purification unit [ROWPU]). They also collect water samples for suspect biological agent contamination for supporting medical laboratory analysis (see Appendix B). They conduct medical surveillance activities, to include occupational and environmental health threat surveillance. They conduct limited entomological surveys to determine the existence of disease-vectoring arthropods in the AO. They inspect food service facilities to determine the extent, if any, of NBC contamination. They evaluate the unit's--

· Immunization status.

· Use of prophylaxis for specific diseases (such as antimalarial tablets) (see FM 4-02.33), for nuclear radiation exposure (such as granisetron for nausea and vomiting) (see FM 4-02.283), and for BW agents (such as Ciprofloxacin for postexposure chemoprophylaxis for Anthrax) (see FM 8-284).

· Use of nerve agent pyridostigmine pretreatment tablets (see FM 8-285), if warranted.

· Application of personal hygiene and field sanitation procedures (FM 21-10/MCRP 4-11.1D).

Based upon their findings, they provide recommendations for corrective actions to the commanders. They assist in training US Army unit field sanitation teams (FM 4-25.12); they are not members of the unit field sanitation team. They conduct medical surveillance activities for their command (FM 4-02.17).

5-4. Preventive Medicine Detachment

The PVNTMED detachment provides PVNTMED services on an area support basis to units within their assigned AO. These services include, but are not limited to--

· Conducting water surveillance, including NBC contamination. Collecting water samples suspected of NBC/TIM contamination for analysis by supporting medical laboratory (see Appendix B).

· Performing food service sanitary inspections.

· Conducting medical surveillance and providing epidemiological consultation.

· Conducting pest (arthropod and rodent) surveys and surveillance.

· Conducting arthropod control operations. The aerial spraying missions are dependent upon availability of helicopter support.

· Conducting occupational and industrial hygiene surveys.

· Advising commanders on the application of PMM.

· Training the supported units' field sanitation teams.

Section II. VETERINARY SERVICES

5-5. General

The US Army Veterinary Service is the Executive Agent for veterinary services to all Services within the DOD. They ensure that food and bottled water supplies are safe and provide veterinary medical and surgical care for government-owned animals throughout the AO. On the integrated battlefield, their role is particularly important; the potential for food supplies becoming contaminated with NBC agents is high. For detailed information on provision of veterinary services see FM 8-10-18.

5-6. Food Protection

Food may become contaminated from enemy employment of NBC weapons/agents or from terroristic contamination of food procurement facilities and food supplies. The NBC agents may be introduced during production or in the storage area of the procurement facility; while the product is in transit; at the military storage facility; or at the unit food service facility. Regardless of where the agent is used, the effect is the same; personnel will become ill or die if they consume the contaminated food. To ensure food safety, veterinary personnel inspect and monitor food from its procurement until it is issued to the consumer. Throughout the AO, all Services (Army, Navy, Marine, and Air Force) logistics and food service personnel must take precautions to protect subsistence from contamination.

5-7. Food Decontamination

Veterinary personnel are involved in the detection and monitoring of NBC contaminated rations; before use, they must inspect all food suspected of being contaminated with NBC agents. Appendix J provides guidance on food decontamination procedures. Veterinary personnel provide advice on the decontamination of food to unit personnel owning the food, or personnel performing the food decontamination. Depending on the type of contamination and packaging, the food may be--

· Consumed without being decontaminated.

· Decontaminated and then consumed.

· Destroyed.

Some items may be held to allow time for natural decay of nuclear or chemical contamination before consumption. The commander, with advice from veterinary personnel, makes the decision on the disposition of the food. However, veterinary personnel make the final determination of food safety.

5-8. Animal Care

Veterinary personnel are concerned with the protection of government-owned animals and animals being procured for consumption. Animals must be protected from NBC contamination, whenever possible. Animals should be moved into enclosures to protect them as much as possible from contamination. Protective equipment is not available for military working dogs; however, protection of the animal's feet and body must be considered. When military working dogs must cross a contaminated area, protect their feet by using butyl rubber material to improvise booties. Since CPS systems are not available, animal treatment facilities must be established in contamination free areas. Veterinary treatment personnel must remain in MOPP Level 4 when caring for NBC animal casualties until the animals have been decontaminated. The treatment of military working dog NBC casualties is outlined in FM 8-10-18.

Section III. LABORATORY SERVICES

5-9. General

Laboratory services must continue their support role even under NBC conditions. For the provision of clinical and diagnostic support, the facility must be located in a contamination-free area or be inside collective protection. Designated laboratories within the theater will analyze NBC samples/specimens (including in theater field confirmation identification of biological agents by evaluating specimens from symptomatic patients and animals and environmental samples collected from the AO). See Appendix B for procedures in collecting biological samples/specimens, handling/packaging, maintaining chain of custody, transporting samples/specimens, and analysis.

5-10. Level II

Laboratory support at this level is extremely limited; it consists of laboratory procedures in direct support of MTF and FST activities. Laboratory personnel prepare collected suspect NBC specimens for submission to the supporting laboratory for analysis; the specimens are forwarded to supporting medical laboratories (Appendix B).

5-11. Level III

Laboratory support in a CSH is intended for providing clinical laboratory support and is primarily in support of acute surgical cases, blood services, and statim (STAT) services required for intensive care operations. Only extremely limited microbiology services (parasitological exams and gram stains) are provided. In a mature theater, the microbiology services may be augmented to include limited cultures and sensitivity testing. Patients with documented or suspected exposure to NBC weapons/agents will be medically evaluated, specimens will be collected, packaged, and have chain of custody established. The specimens will be forwarded through technical channels to the supporting medical laboratory (such as the theater Army medical laboratory [TAML]) for analysis. See Appendix B for specimen collection, packaging, chain of custody, and processing requirements.

5-12. Level IV

_a._ _Clinical Laboratories._ The clinical laboratories in the combat support, field, and general hospitals have the ability to perform a general, but limited, array of analytical procedures in hematology, urinalysis, chemistry, microbiology, serology, and blood bank. Patient specimens of suspected biological or chemical agent exposures are forwarded through technical channels to the supporting medical laboratory. See Appendix B for sample/specimen collection, packaging, chain of custody, processing, and transporting requirements.

_b._ _Field Laboratories._

(1) _Theater Army Medical Laboratory._ The TAML is the specialized echelons above corps (EAC) laboratory that provides clinical and nonclinical medical laboratory support. When equipped and staffed, the TAML provides in-theater field confirmation identification of NBC samples or specimens. Using sophisticated equipment and methods, the TAML has the capability to detect and identify NBC agents in a variety of specimens/samples (such as human, air, soil, water, animals, vegetation, and food). Direct support from continental United States (CONUS)-based laboratories aids the TAML with identification of NBC agents. Command decision on use of protective/preventive measures and patient care may be based on the TAML findings. Proper collection, packaging, and rapid shipment of specimens by MTFs and samples from other sources will ensure effective, timely, and accurate laboratory analyses.

(2) _Area Medical Laboratory._ The Area Medical Laboratory (AML) is the specialized laboratory within the theater that provides nonclinical medical laboratory support. The AML can be deployed in the corps or to EAC for support missions. When fielded, the AML will replace the TAML in the force structure. The AML provides in-theater field confirmation identification of NBC samples or specimens. Using sophisticated equipment and methods, the AML has the capability to detect and identify NBC agents in a variety of specimens/samples (such as human, air, soil, water, animals, vegetation, and food). Direct support from CONUS-based laboratories aids the AML with identification of NBC agents. Command decision on use of protective/preventive measures and patient care may be based on the AML findings. Proper collection, packaging, and rapid shipment of specimens by MTFs and samples from other sources will ensure effective, timely, and accurate laboratory analyses.

5-13. Level V (Continental United States)

Designated Level V medical laboratories perform analyses to provide definitive identification of suspect biological agents for the President and Secretary of Defense purposes. The definitive identification of suspect biological agents also aids commanders in the AO in maintaining the health of their command.

5-14. Field Samples

Chemical corps personnel collect environmental, air, soil, and vegetation samples. Preventive medicine personnel collect samples from drinking water sources and supplies. Veterinary personnel collect samples from food supplies and medical specimens from animals. All other units collect soil, vegetation, and small animal samples for laboratory analysis. Samples are subjected to initial screening with rapid test kits and in-theater confirmatory identification at the supporting medical laboratory. The President- and Secretary of Defense-required definitive identification is performed at the designated Level V medical laboratory. Comprehensive databases will be maintained to provide historical testing results and will aid in the AO commander's decisions to conduct operations in an NBC environment. See Appendix B for specific procedures for sample collection, packaging, transporting, maintaining chain of custody, and analysis.

Section IV. DENTAL SERVICES

5-15. General

Dental service support is provided in the AO at Levels II, III, and IV. Because of their location close to main supply routes and other support assets, dental units are vulnerable to an NBC strike. Nuclear, biological, and chemical operations have an impact at all levels; thus, dental units must be prepared to survive on the integrated battlefield. Defense against NBC weapons must be included in the dental unit's TSOP. Individual and collective tasks must be intensely trained on a regular basis; survival depends on the ability of personnel to use basic survival skills against an NBC attack. For details on provision of dental services, see FM 4-02.19.

5-16. Mission in a Nuclear, Biological, or Chemical Environment

The overall mission of dental units to provide dental services is greatly affected in the aftermath of an NBC attack. First, the unit must survive the attack and rapidly recover from its effects. Secondly, in the event of mass casualties, the dental patient care effort must be redirected from dental treatment to the alternate wartime role of augmenting the adjacent MTF. Dental units do not possess CPS; therefore, providing dental services in an NBC environment will be limited to the treatment of maxillofacial emergencies requiring immediate attention. This care will be provided at an MTF with a CPS.

5-17. Dental Treatment Operations

As a general rule, in the aftermath of an NBC attack, dental treatment operations cease until deliberate decontamination of the unit and its equipment has been accomplished. Only maxillofacial injuries of an immediate life-threatening nature should be considered for treatment. After an attack, the resources of the dental treatment facility (DTF) are redirected toward support of any mass casualty situation that may have been generated at an adjacent MTF, or toward decontamination and relocation to a noncontaminated area.

5-18. Patient Treatment Considerations

The only category of dental treatment appropriate in an NBC environment is emergency; and then, only those emergencies of an extreme nature which demand immediate attention. The most likely condition requiring such attention would be maxillofacial trauma and would most likely be treated at an MTF rather than a DTF. Although the likelihood of a requirement to treat dental patients in an NBC environment is extremely low, DTFs must have a plan in the event that such patients do present.

_a._ _Patient Decontamination._ Decontamination of patients, dental patients included, is an absolute requirement before admission into a clean MTF. Contaminated patients are triaged and decontaminated before treatment (except for life- or limb-saving care). Both triage and decontamination should be accomplished as far forward as possible. Specific details on patient decontamination are in Appendix G. It is important to note that normally patient decontamination is not performed by medical or dental personnel. Initial decontamination at the basic skill level is accomplished at the casualty's unit. Detailed patient decontamination is accomplished by the patient decontamination teams (made up of nonmedical personnel from the supported units) that are supervised by medical personnel at the MTF.

_b._ _Patient Decontamination at Dental Treatment Facilities._ Neither dental units nor their DTFs are equipped for patient decontamination. Any contaminated patients arriving at a DTF requiring urgent attention must be directed or evacuated to the nearest MTF with a patient decontamination capability.

5-19. Patient Protection

Dental treatment facilities must also consider the need to protect patients in their care in the event of an NBC attack, or when the threat of an attack is high. Special consideration must be made for maxillofacial patients whose condition prevents them from wearing their protective mask.

_a._ _Immediate Response._ In the event of an attack or when the alarm sounds, dental treatment providers immediately cease work and mask. The patients should do likewise. Only after putting on their own masks, do the dental treatment providers assist the patient, if necessary, by removing materials that impede the patient's masking. Only those materials that impede masking or may compromise the airway (such as rubber dam frames or impressions) are removed, the rest are left in place until the all clear is sounded. Special attention must be given to patients who may have been medicated into a less than fully conscious state, or are otherwise incapacitated.

_b._ _Mission-Oriented Protective Posture Considerations._ The MOPP level should be taken into account when determining the category and extent of dental treatment to be provided. Patients, including those seated in the dental chair, should be at the MOPP level prescribed for the DTF by its parent headquarters. Dental treatment at MOPP Levels 3 and 4 is, of course, impossible because of the requirement to wear the protective mask; however, treatment is still possible at MOPP Levels 0, 1, and 2. Treatment at MOPP Level 2 should be limited only to emergency care requiring urgent attention. At MOPP Level 1, most types of dental emergencies can be accommodated; however, only minimal essential treatment should be undertaken in order to reduce risk of the patient being caught in a compromised state. At MOPP Level 0, the provision of dental treatment generally is not limited. However, the degree of the NBC threat forecast for the area should be considered before undertaking extensive treatment.

_c._ _Maxillofacial Injuries._ Patients with maxillofacial injuries that prevent proper fit and seal of the individual protective mask must be placed in a PPW. Though patients with these types of injuries are most likely to be found only in MTF channels, DTFs should nevertheless be prepared in the event a patient presents to the DTF. Since the DTF does not have any PPWs; these patients should be immediately evacuated to the adjacent MTF for treatment.

Section V. COMBAT OPERATIONAL STRESS CONTROL

5-20. General

When operating under the threat of or under actual NBC conditions, soldiers will be at a high risk of suffering combat operational stress-related conditions. The invisible, pervasive nature of these weapons creates a higher degree of uncertainty and ambiguity, presenting fertile opportunities for false alarms, mass panic, and other maladaptive stress reactions. Therefore, commanders and leaders must take actions to prevent and reduce the numbers of combat operational stress cases in this environment. The symptoms and physical signs caused by excessive stress are similar to some signs of true NBC agent injury. In World War I, inexperienced units initially evacuated two stress cases for every one true chemical casualty. Some minor chemical casualties also had major stress symptoms. Therefore, far forward triage is essential to prevent over evacuation and loss of the individual to the unit. For details on provision of COSC see FM 8-51 and FM 22-51.

5-21. Leadership Actions

_a._ _Keep Personnel Informed of the Situation._ Keep information flowing, dispel myths, and control rumors by--

· Discussing the situation and its possible long-term implications honestly.

· Maintaining the perspective that the best chance for mission accomplishment is assured when the unit and the Army stays mission focused.

_b._ _Train Soldiers to Survive._ Use training procedures that--

· Tell the lessons of history on NBC weapons employment. Show that the enemy's use of NBC weapons/agents will not give him enough advantage to justify the risk to his forces.

· Increase the chance of surviving and winning should the enemy use NBC weapons/agents.

· Emphasize the buddy system as a means of keeping watch for each other. Personnel must always seek buddy aid before taking additional antidotes. This will reduce the numbers of individuals using their antidotes when not needed; and prevent the increased heat stress caused by the effects of atropine on the body's cooling capabilities.

_c._ _Put Nuclear, Biological, and Chemical Defense in Realistic Perspective._ Continuously strive to maintain a realistic perspective in the unit by--

· Comparing the risks of the threat with the increased risk of facing the conventional threat in varying levels of MOPP. The decision to initiate a MOPP level should be like deciding how much cover is needed to protect a unit from conventional weapons.

· Choosing the lowest MOPP level that protects the unit, yet permits accomplishment of the mission. Do not try to be 100 percent safe from chemical attack if it means that there is--

· Only a small chance of mission accomplishment.

· A high probability of being killed by the enemy.

· A high personnel loss due to heat injury.

_d._ _Train in the Protective Mask._ Train in the protective mask often. It takes repeated wear and time to acclimate and get over the claustrophobic feeling of wearing the mask. The training can be conducted during a variety of activities.

· Have personnel wear the mask often in garrison or during lulls in other activities, even at desk jobs. If on average, one person in five wears the mask, on a rotational basis, at any given time, everyone will quickly become accustomed to wearing it.

· Periodic prolonged wear (8 hours or more) helps soldiers gain confidence and realize that they can tolerate the discomfort.

· Have personnel wear the mask while performing combat-related (mission essential) tasks.

_e._ _Train in Mission-Oriented Protective Posture Level 4._ Training in MOPP Level 4 (or simulated MOPP 4, which is to overdress while wearing the protective mask, overboots, and gloves) will increase personnel confidence in their ability to wear the ensemble.

_f._ _Ensure Sleep Plans are Safely Practiced._ Have everyone practice wearing the mask while sleeping. Ensure personnel only sleep in safe places; do not allow personnel to sleep under or near vehicles or other motorized machinery. Require ground guides for all vehicles in the unit bivouac area. Ensure that each individual get at least 4 hours of uninterrupted sleep during every 24-hour period, mission permitting (See FM 21-10).

5-22. Individual Responsibilities

_a._ _Follow Orders._ By following orders, individuals can increase their ability to cope with and prevent combat operational stress-related conditions. Coping with the stresses of an NBC environment requires extra individual action. Concentrate on the positive aspects of survival, not the negatives of illness or death.

_b._ _Train._ Use every opportunity to wear the protective mask or the entire MOPP ensemble during training, when permitted. You build self-confidence and endurance by frequently training with your protective mask, or at MOPP Level 4. Perform refresher training in basic NBC survival skills.

_c._ _Use Buddy System._ Use the buddy system to increase your ability to survive. Service members looking out for each other give a sense of security that relieves stress. Looking out for each other improves every individual's ability to perform his duties.

5-23. Mental Health Personnel Responsibilities

_a._ _Staffing for Combat Operational Stress Control._ Combat operational stress control is provided by the following activities or units:

· Brigade mental health section.

· Division mental health section.

· Area support medical battalion mental health section.

· Neuropsychiatric ward and consultation service of each CSH, field hospital, and general hospital.

· Medical detachment, COSC.

· Medical company, COSC.

_b._ _Conduct Preventive Activities._ In an NBC environment, prevention is the most economical means of controlling combat operational stress reactions. Mental health personnel must begin consultation services before NBC weapons/agents have been employed.

_c._ _Control Stress Reactions._ Individuals with combat operational stress reactions require prompt intervention. The evaluation of over-stressed personnel is difficult but not impossible when both the soldier and the evaluator are in MOPP. The primary method of mental health evaluation is the interview and mental status examination. For details on controlling stress reactions, see FM 8-51.

Section VI. HEALTH SERVICE LOGISTICS

5-24. General

As in all combat situations, the protection of medical supplies and equipment on the integrated battlefield is a must. Without medical supplies and equipment, HSS will be greatly diminished. Thus, the flow of supplies must continue to forward units as they are requested, including during NBC operations. For detailed information on providing health service logistics see FM 4-02.1 and FM 8-10-9.

5-25. Protecting Supplies in Storage

Protecting supplies can be accomplished by placing them under tents, using plastic wraps, or providing storage warehouses with CB filtered-conditioned (heated or cooled) air systems. Wrapping supplies in two layers of plastic material provides protection from most agents for a short period of time; the thicker the plastic material, the longer the protection. Effectiveness of protective procedures can be checked by placing M9 tape on supplies and between layers of the covering. Protection from the thermal and blast effects of nuclear detonations requires much more elaborate measures. Placing the supplies in trenches, inside earthen berms, behind stonewalls, or in other field expedient facilities will enhance the protective posture of supplies from the nuclear effects. Even when taking these protective measures, a quantity of supplies will become contaminated and must be replaced. Plans should be in place for replacement of lost items.

5-26. Protecting Supplies During Shipment

During shipment, supplies are protected by placement inside MILVANs, in covered enclosed vehicles, or by wrapping them in several layers of plastic, in tarpaulins, or in other protective material. To monitor exposure of supplies to chemical agents during shipment, place M9 detector paper between the wrappings. If exposure is limited to the outer layer, simple removal of this layer may be all that is required to eliminate the contamination. Decontamination is much easier when the supplies and equipment have been protected by multilayers of over-wraps.

5-27. Organizational Maintenance

Maintenance on vehicles, equipment, and medical equipment will become much more complex under NBC conditions. Most chemical agents are soluble in organic solvents such as gasoline, motor oils, and lubricants. The agent may be removed from the equipment by these solvents, but exposure to the contaminated solvents will produce the same effects as exposure to the agent on the equipment. The agents may seep down around the threads of bolts, in cracks and crevices of the equipment, and inside the cabinets or enclosures of equipment. These potential contamination sources produce an increased hazard to maintenance personnel. Decontamination of some items, especially medical equipment, may be a problem for maintenance personnel. The use of standard decontamination agents will cause damage beyond repair to most medical equipment and electronic equipment. In some instances, removal of chemical agents will require aging (off-gassing) of the agent. Turning the equipment on and running it, or just exposing the equipment to warm air will speed the off-gassing process. Maintenance personnel must perform all procedures in MOPP Level 4 until decontamination is completed. Radiation will penetrate the metal structures of vehicles and other equipment; radioactive material will be absorbed into the lubricants and fuels. Decontamination of this type of contamination is very difficult, if not impossible. Personnel must use radiation detection equipment to determine the extent of contamination and decontaminate the items as much as possible. Dusting or washing with water can remove any fallout on the surface of vehicles and nonelectrical/electronic components of equipment. Removal of radioactivity absorbed into metals or mixed in lubricants and fuels is beyond the capabilities of unit personnel. See FM 3-5 for decontamination procedures.

Section VII. HOMELAND SECURITY RESPONSE

5-28. Chemical, Biological, Radiological, Nuclear, and High-Yield Explosive Response

Although, homeland security is not a specific military mission, commanders must plan for and be prepared to support a lead federal agency (such as the Federal Bureau of Investigation or Federal Emergency Management Agency) in response to CBRNE event. When the CBRNE event occurs on a military installation, the Weapons of Mass Destruction--Incident Support Team (WMD-IST) is the lead federal agency in charge of responding and establishes an incident command center (ICC). The installation medical authority (IMA) provides the HSS initial response to the event site. Request for assistance from deployable HSS organizations and staffs are initiated by the IMA through military channels. The incident commander will submit a request for HSS assistance to a CBRNE event off the military installation through the appropriate federal channels. The President will direct any DOD response in support of a lead federal agency to a CBRNE event. The Presidential direction to assist will be passed down through military channels to the appropriate HSS organization for response. The HSS response may be in the form of special medical augmentation teams (SMART) support from US Army Medical Command resources or HSS (table of organization and equipment [TOE]) units may be directed to respond. Normally, responding TOE units will provide HSS to nonmedical military responders. However, the HSS mission may be to provide support to the lead federal agency or civilian public health organizations, emergency medical services (ambulance crews), or hospitals. The HSS response will include, but not be limited to--

· Providing medical care to casualties at the incident casualty decontamination site and supervising the casualty decontamination process to ensure that no further injury is caused to the casualty.

· Providing en route care for casualties from the incident site to an MTF or designated location for further care. Normally, TOE MEDEVAC assets are not used, but HSS personnel provide the en route care on locally provided transport vehicles.

· Providing guidance to local responders in the management of CBRNE casualties. The guidance may be on the correct use of antidotes, chemoprophylaxis, prevention of contamination spread in the MTF, patient decontamination at the MTF, and other related medical management procedures.

· Identifying suspect chemical, biological, or radiological materials used in the event.

· Providing guidance on application of standard precautions for CBRNE, especially preventive measures to prevent spread of contagious agents.

· Managing, triaging, and treating mass casualties.

5-29. Capabilities of Response Elements

For detailed Information on capabilities of SMARTs see FM 4-02 and FM 8-42. For detailed information on capabilities and functions of TOE HSS units see FM 4-02- and 8-series publications.

APPENDIX A

MEDICAL EFFECTS OF NUCLEAR, BIOLOGICAL, AND CHEMICAL WEAPONS AND TOXIC INDUSTRIAL MATERIAL

A-1. General

Biological and chemical weapons/agents may be employed by assassins, terrorists, rebels, and insurgents, as well as well-formed battle organizations, across the continuum of operations. In addition, nuclear weapons will remain a threat on the future battlefield. Another weapon that may be used is the RDD. The RDD can cause significant damage and present health hazards to fighting forces by exposing them to radiation without the thermal and full blast effects of nuclear weapons. The RDD can disperse radioactive material over an area of the battlefield; the area covered is dependent upon the amount of radioactive and explosive material used. In order to detonate a nuclear weapon, an adversary must first obtain access to the appropriate weapons-grade material. However, an RDD can be produced and used by anyone with access to industrial or medical radioisotopes and explosives. Biological agents are easy to disperse on the battlefield without immediate detection; however, their effects on exposed troops can change the course of the battle. Some nations consider chemical weapons as a component of their munitions for the battlefield. As more nations enter the arena of developing biological and chemical weapons, their potential effects on our troops will increase. The enemy's use of TIMs as weapons or collateral damage to TIM storage faculties can severely affect the unit personnel's ability to continue the mission. The signs and symptoms of some TIM exposure can be the same as those presented from exposure to NBC weapons. Considerations of both the physical and biological effects of these weapons are required for HSS operations. Field Manual 4-02.283 provides additional information on nuclear and radiological effects; FM 8-284 provides additional information on biological agent effects; FM 8-285 provides additional information on CW effects; FM 8-500 provides detailed information on hazardous material (TIM) effects.

A-2. Physical Effects of Nuclear Weapons

_a._ The principal physical effects of nuclear weapons are blast, thermal radiation (heat), and nuclear radiation. These effects are dependent upon the yield (or size) of the weapon expressed in kilotons (KT), the physical design of the weapon (such as conventional and enhanced), and the method of employment. The distribution of energy (Figure A-1) from the detonation of a moderate-sized (3 to 10 KT) weapon is as follows:

(1) Fifty percent as blast.

(2) Thirty-five percent as thermal radiation; made up of a wide spectrum of electromagnetic radiation, including infrared, visible, and ultraviolet light and some soft x-ray radiation.

(3) Fourteen percent as nuclear radiation, 4 percent as initial ionizing radiation composed of neutrons and gamma rays emitted within the first minute after detonation, and 10 percent as residual nuclear radiation (fallout).

(4) One percent as EMP.

_b._ Larger weapons are more destructive than smaller weapons, but the destructive effect is not linear. Table A-1 presents a comparison of three aspects of nuclear weapons effects with yield.

_c._ The altitude at which the weapon is detonated determines the blast, thermal, and nuclear radiation effects. Nuclear blasts are classified as air, surface, or subsurface bursts.

(1) An airburst is a detonation in air at an altitude below 30,000 meters, but high enough that the fireball does not touch the land or water surface. The altitude is varied to obtain the desired tactical effects. Initial radiation will be a significant hazard, but there is essentially no local fallout. However, the ground immediately below the airburst may have a small area of neutron-induced radioactivity. This may pose a hazard to troops passing through the area.

(2) A surface burst is a detonation in which the fireball actually touches and vaporizes the land or water surface. In this case, the area affected by blast, thermal radiation, and initial nuclear radiation will be smaller than for an airburst of comparable yield. However, in the region around ground zero, the destruction will be much greater and a crater is often produced. Additionally, all the material that was within the fireball becomes fallout and will be a hazard downwind. A surface burst is the most likely type of terrorist detonation.

(3) A subsurface burst is an explosion in which the detonation is below the surface of land or water. Cratering usually results. If the burst does not penetrate the surface, the only hazard is from the ground or water shock. If the burst penetrates the surface, blast, thermal, and initial nuclear radiation will be present, though less than for a surface burst of comparable yield. Local fallout will be heavy over a small area.

(4) A high altitude burst occurs above 30,000 meters. Radiation and physical effects do not reach the ground and there is no local fallout. This is the only detonation where the effects of the EMP are significant. Nonhardened electronic equipment including many medical devices may become inoperative. The EMP damage is a moot point with other types of detonations, as its range is primarily limited to the area of intense physical destruction.

_Table A-1. Comparison of Weapons Effects (Radii of Effects in Kilometers--Airburst)_

============================================================== 1 KT 20 KT 100 KT 1 MT 10 MT -------------------------------------------------------------- NUCLEAR RADIATION 0.71 1.3 1.6 2.3 3.7 (1,000 cGy) -------------------------------------------------------------- BLAST (50% INCIDENCE OF TRANSLATION WITH SUBSEQUENT IMPACT 0.28 1.0 1.4 3.8 11.7 WITH A NON-YIELDING SURFACE) -------------------------------------------------------------- THERMAL (50% INCIDENCE OF 2ND-DEGREE BURNS TO 0.77 1.8 3.2 4.8 14.5 BARE SKIN, 10 KM VISIBILITY) ==============================================================

A-3. Physiological Effects of Nuclear Weapons

The physiological effects of nuclear weapons are the result of exposure to the blast; thermal radiation; ionizing radiation (initial or residual) effects; or a combination of these. For smaller weapons (less than 10 KT), ionizing radiation is the primary creator of casualties requiring medical care, while for larger weapons (greater than 10 KT), thermal radiation is the primary creator of casualties.

_a._ The rapid compression and decompression of blast waves on the human body results in transmission of pressure waves through the tissues. Resulting damage is primarily at junctions between tissues of different densities (bone and muscle), or at the interface between tissue and airspace. Lung tissue and the gastrointestinal system (both contain air) are particularly susceptible to injury. The tissue disruptions can lead to severe hemorrhage or to an air embolism; either can be rapidly fatal. Direct overpressure effects do not extend out as far from the point of detonation as the drag force and are often masked by the drag force effects. A typical range of probability of lethality, with variations in overpressure for a 1 KT weapon, is shown in Table A-2.

_Table A-2. Range of Lethality of Peak Overpressure_

============================================================== LETHALITY PEAK OVERPRESSURE DISTANCE FROM (APPROXIMATE %) (ATMOSPHERES) GROUND ZERO; METERS -------------------------------------------------------------- 1 2.3-2.9 150 50 2.9-4.1 123 100 4.1+ 110 ==============================================================

(1) The significance of the data is that the human body is relatively resistant to static overpressure compared to rigid structures such as buildings. For example, an unreinforced cinder block panel will shatter at 0.1 to 0.2 atmospheres.

(2) Overpressure lower than those in Table A-2 can cause nonlethal injuries such as lung damage and eardrum rupture. Lung damage is a relatively serious injury, usually requiring hospitalization, even if not fatal; whereas eardrum rupture is a minor injury, often requiring no treatment at all.

(_a_) The threshold level of overpressure for an unreinforced unreflected blast wave that can cause lung-damage is about 1.0 atmosphere.

(_b_) The threshold level for eardrum rupture is around 0.2 atmospheres; the overpressure associated with a 50 percent probability of eardrum rupture is about 1.1 atmospheres.

(3) Casualties requiring medical treatment from direct blast effects are produced by overpressure between 1.0 and 3.5 atmospheres. However, other effects (such as indirect blast injuries and thermal injuries) are so predominate that patients with only direct blast injuries make up a small part of the patient workload.

_b._ The drag forces (indirect blast) of the blast winds are proportional to the velocities and duration of the winds. The winds are relatively short in duration, but can reach velocities of several hundred km per hour. Injury can result from missiles impacting on the body or from the physical displacement of the body against objects and structures.

(1) The distance from the point of detonation at which severe indirect injury occurs is greater than that for equally serious direct blast injuries. A high probability of serious indirect injury can occur when the peak overpressure is about 0.2 atmospheres. This range will increase with the increased size of the weapon; for a 1 KT weapon, the range is 0.22 km, whereas for a 20 KT weapon, the range is 0.76 km. At greater ranges injuries will occur and casualties will be generated, but not consistently.

(2) The drag forces of the blast winds produced by a nuclear detonation are so great that almost any form of vegetation or structure will be broken up or fragmented into missiles. Thus, multiple, varied missile injuries will be common, increasing their overall severity and significance. Table A-3 lists ranges at which significant missile injuries can be expected.

_Table A-3. Ranges for Probabilities of Serious Injury from Small Missiles_

================================================================= RANGES (km) ----------------------------------------------------------------- YIELD 1% PROBABILITY OF 50% PROBABILITY OF 99% PROBABILITY OF (KT) SERIOUS INJURY SERIOUS INJURY SERIOUS INJURY ----------------------------------------------------------------- 1 0.28 0.22 0.17 10 0.73 0.57 0.44 20 0.98 0.76 0.58 50 1.4 1.1 0.84 100 1.9 1.5 1.1 200 2.5 1.9 1.5 500 3.6 2.7 2.1 1,000 4.8 3.6 2.7 ----------------------------------------------------------------- 1 INCIDENCE OF INJURY BASED ON SKIN AND TISSUE PERFORATION. 2 MISSILES USED WERE 10 GRAM (gm) IN WEIGHT. =================================================================

(3) The velocity to which missiles are accelerated is the major factor in causing injury. The probability of a penetration injury increases with increasing velocity, particularly for small, sharp missiles such as glass fragments. Small, light objects are accelerated to speeds approaching the maximum (wind) velocity. Table A-4 shows data for probability of penetration related to size and velocity of glass fragments.

_Table A-4. Probability of Glass Fragments Penetrating the Abdominal Cavity_

======================================================= MASS OF GLASS 1% 50% 99% FRAGMENTS (gm) IMPACT VELOCITY (METERS PER SECOND) ------------------------------------------------------- 0.1 78 136 243 0.6 53 91 161 1.0 46 82 143 10.0 38 60 118 =======================================================

(4) Heavy, blunt missiles may not penetrate, but can result in significant injury, particularly fractures. The threshold velocity for skull fractures from a 4.5 milligram (mg) missile is about 4.6 meters per second (m/sec).

(5) The drag forces of the blast winds are strong enough to displace large objects (such as vehicles), or cause large structures to collapse (such as buildings) resulting in serious crushing injuries. Man himself can become a missile resulting in injuries (called translational injuries). The velocity at which the body is displaced will determine the probability and the severity of injury. Assuming a displacement of 3.0 meters, the impact velocity associated with various degrees of injury is shown in Table A-5. The velocities in Table A-5 can be correlated against yield. The ranges at which such velocities can occur and the probability of injury are given in Table A-6.

_Table A-5. Translational Injuries_

================================================ A. BLUNT INJURIES AND FRACTURES PROBABILITY OF INJURY VELOCITY (m/sec) ------------------------------------------------ 1% 2.6 50% 6.6 99% 16.5 ------------------------------------------------ B. FATAL INJURIES PROBABILITY OF FATALITY VELOCITY (m/sec) ------------------------------------------------ 1% 6.6 50% 17.0 99% 39.7 ================================================

_Table A-6. Ranges for Selected Impact Velocities of a 70-Kilogram Human Body Displaced by Blast Wind Drag Forces for Different Yield Weapons_

============================================== WEAPON YIELD VELOCITIES (m/sec) (KT) 2.6 6.6 17.0 ---------------------------------------------- RANGES (km) ---------------------------------------------- 1 0.38 0.27 0.19 10 1.0 0.75 0.53 20 1.3 0.99 0.71 50 1.9 1.4 1.0 100 2.5 1.9 1.4 200 3.2 2.5 1.9 500 4.6 3.6 2.7 1,000 5.9 4.8 3.6 ===============================================

A-4. Biological Effects of Thermal Radiation

The thermal radiation emitted by a nuclear detonation causes burns in two ways--by direct absorption of the thermal energy through exposed surfaces (flash burns); or by the indirect action of fires in the environment (flame burns). Indirect flame burns can easily outnumber all other types of injury.

_a._ Thermal radiation travels outward from the fireball in a straight line; therefore, the amount of energy available to cause flash burns decreases rapidly with distance. Close to the fireball all objects will be incinerated. The range for 100 percent lethality will vary with yield, height of burst, weather, environment, and immediacy of treatment. The critical factors determining the degree of burn injury are the flux (calories per square centimeter/second [cal/cm^2/sec]) and the duration of the thermal pulse. The total amount of thermal radiation needed to cause a flash partial thickness burn on exposed skin will vary with the yield of the weapon and the nature of the pulse (Table A-7). Most burn patients will come from the zones where partial thickness burns occur. In areas where radiation, blast, and thermal intensity are highest, burn victims surviving long enough to reach medical care will be rare.

NOTE

The battle dress uniform (BDU), MOPP gear, or any other clothing will provide additional protection against flash burns. The airspace between the clothing significantly impedes heat transfer and may prevent or reduce the severity of burns, depending on the magnitude of the thermal flux.

_Table A-7. Factors for Determining the Probability of Partial Thickness Burns_

================================================================== YIELD OF WEAPON 1 KT 10 KT 100 KT 1 MT 10 MT ------------------------------------------------------------------ RANGE (km) FOR PRODUCTION OF PARTIAL THICKNESS BURNS 0.78 2.1 4.8 9.1 14.5 ON EXPOSED SKIN ------------------------------------------------------------------ DURATION OF THERMAL PULSE IN SECONDS 0.12 0.32 0.9 2.4 6.4 ------------------------------------------------------------------ Cal/cm^2/sec REQUIRED TO PRODUCE PARTIAL THICKNESS 4.0 4.5 5.3 6.3 7.0 BURNS ON EXPOSED SKIN ==================================================================

_b._ Indirect (flame) burns result from exposure to fires caused by the thermal effects in the environment, particularly from ignition of clothing. The larger-yield weapons are more likely to cause firestorms over extensive areas. There are too many variables in the environment to predict either incidence or severity of casualties. Expect the burns to be far less uniform (in degree) and not limited to exposed surfaces. For example, the respiratory system may be exposed to the effects of hot gases produced by extensive fires. Respiratory system burns cause high morbidity and high mortality rates.

_c._ The initial pulse of radiation in the optical and thermal bands can cause injuries in the forms of flash blindness and retinal scarring. The initial brilliant flash of light produced by the nuclear detonation causes flash blindness. This flash swamps the retina, bleaching out the visual pigments and producing temporary blindness. During daylight hours, this temporary effect may last for about 2 minutes. At night, with the pupil dilated for dark adaptation, flash blindness will affect personnel at greater ranges and for greater durations. Partial recovery can be expected in 3 to 10 minutes, though it may require 15 to 35 minutes for full night adaptation recovery. Retinal scarring is the permanent damage from a retinal burn. It will occur only when the fireball is actually in the individual's field of view and should be a relatively uncommon injury. The location of the scar will determine the degree of interference with vision. Because night vision apparatus electronically amplifies an image, it cannot transmit the flash intensity and will not cause eye injury.

A-5. Physiological Effects of Ionizing Radiation

A nuclear burst results in four types of ionizing radiation: neutrons, gamma rays, beta, and alpha radiation. The initial burst is characterized by neutrons and gamma rays while the residual radiation is primarily alpha, beta, and gamma rays. The effect of radiation on a living organism varies greatly by the type of radiation to which the organism is exposed. See Table A-8 for characteristics of nuclear radiation.

_a._ Alpha particles are extremely massive, charged particles (four times the mass of a neutron); they are a fallout hazard. Because of their size, alpha particles cannot travel far and are fully stopped by the dead layers of the skin or by the uniform. Alpha particles are a negligible external hazard, but if inhaled or ingested, can cause significant internal damage.

_Table A-8. Characteristics of Nuclear Radiation_

_b._ Beta particles are very light, charged particles that are found primarily in fallout radiation. These particles can travel a short distance in tissue; if large quantities are involved, they can produce damage to the basal stratum of the skin. The lesion produced is similar to a thermal burn (called a beta burn).

_c._ Gamma rays, emitted during the nuclear detonation and in fallout, are uncharged radiation similar to X rays. They are highly energetic and pass through matter easily. Because of its high penetrability, radiation can be distributed throughout the body, resulting in whole body exposure.

_d._ Neutrons, like gamma rays, are uncharged, are only emitted during the nuclear detonation, and are not a fallout hazard. However, neutrons have significant mass and interact with the nuclei of atoms, severely disrupting atomic structures. Compared to gamma rays, they can cause 20 times more damage to tissue.

_e._ When radiation interacts with atoms, energy is deposited resulting in ionization (electron excitation). This ionization may involve certain critical molecules or structures in a cell, producing its characteristic damage. Two modes of action in the cell are direct and indirect action. The radiation may directly hit a particularly sensitive atom or molecule in the cell. The damage from this is irreparable; the cell either dies or is caused to malfunction. The radiation can also damage a cell indirectly by interacting with water molecules in the body. The energy deposited in the water leads to the creation of toxic molecules; the damage is transferred to and affects sensitive molecules through this toxicity.

_f._ The most radiosensitive organ systems in the body are the male reproductive, the hematopoietic, and the gastrointestinal systems. The relative sensitivity of an organ to direct radiation injury depends upon its component tissue sensitivities. Cellular effects of radiation, whether due to direct or indirect damage, are basically the same for the different kinds and doses of radiation. The simplest effect is cell death. With this effect, the cell is no longer present to reproduce and perform its primary function. Changes in cellular function can occur at lower radiation doses than those that cause cell death. Changes can include delays in phases of the mitotic cycle, disrupted cell growth, permeability changes, and changes in motility. In general, actively dividing cells are most sensitive to radiation. Additionally, radiosensitivity tends to vary inversely with the degree of differentiation of the cell.

_g._ Predicting radiation effects is difficult because often it is unknown which organs were exposed. Thus, most predictions are based on whole body irradiation. Partial body and specific organ irradiation will occur due to shielding by equipment, from fallout particles, or from internal deposition. Depending upon the organ system, the irradiation can be severe. The severe radiation sickness resulting from external, whole body irradiation and its consequent organ effects is a primary medical concern. The median lethal dose (LD) of radiation that will kill 50 percent of the exposed persons within a period of 60 days (designated as LD50/60) is estimated to be approximately 4.5 gray (Gy) if appropriate medical care is not provided to the casualties. Medical intervention should raise this figure to approximately 10 Gy. This larger figure includes most of the casualties who would be actually capable of reaching medical care following a nuclear detonation, and nearly all those who could be exposed to a RDD. For acute effects of single high dose rate exposures of whole-body irradiation to healthy adults see Table A-9.

_h._ Recovery of a particular cell system will occur if a sufficient fraction of a given stem cell population remains after radiation injury and appropriate stimulation and protection are received. Complete recovery may appear to occur; however, the immune system may repair incompletely with consequent greater susceptibility to future insult from a variety of agents. It is possible for late somatic effects to have a higher probability of occurring because of the radiation damage. Efficacy of both prior and future immunization in this group is not adequately understood.

_i._ Interactions between radiological injury and chemical or biological agents appear to be synergistic. Insult by these agents in radiologically injured personnel, even in individually subclinical dosages, may result in significant clinical illness.

A-6. Handling and Managing Radiologically Contaminated Patients

_a._ _Radiologically Contaminated Patients._ Personnel from contaminated areas may have fallout on their skin and clothing. Although the individual will not be radioactive, he may suffer radiation injury from the contamination. Removal of the contamination should be accomplished as soon as possible; definitely before admission into a clean treatment area. The distinction must be made between a radiation-injured soldier and one who is radiologically contaminated. Although personnel may have received substantial radiation exposure, this exposure alone does not result in the individual being contaminated. Contaminated personnel do not pose a short-term hazard to the medical staff, rather the contamination is a hazard to the individuals' health. However, without patient decontamination, medical personnel may receive sufficient exposure to create beta burns, especially with extended exposure.

_b._ _Handling Radiologically Contaminated Patients._ To properly handle radiologically contaminated personnel, medical personnel must first detect the contamination. Detectors that may be used are the AN/PDR27 and AN/VDR2 to monitor patients for contamination. Generally, a reading on the meter twice the current background reading indicates that the patient is contaminated. Monitoring is conducted when potentially contaminated personnel arrive at the MTF. This monitoring is conducted at the MTF's receiving point before admitting the patient. Contaminated patients must be decontaminated before admission. Removal of radiological contamination is less important than immediate lifesaving treatment and providing the best possible medical care. Lifesaving care before decontamination is provided outside the MTF.

_c._ _Decontamination._ Removing all outer clothing and a brief washing or brushing of exposed skin will reduce 95 percent of contamination; vigorous bathing or showering is unnecessary. See Appendix G for patient decontamination procedures.

_d._ _Internal Contamination._ Internalization of radioactive isotopes will primarily occur via inhalation, ingestion, and contaminated wounds. Extensive internal decontamination should only be undertaken when individual dose estimates indicate that the individual will benefit from the procedures. Soldiers who wear their protective mask will be adequately protected from inhalation and ingestion of radioactive particulate matter. Internal contamination is considered a delayed problem and does not influence triage categories, as does irradiation injury.

_e._ _Treatment._ Treatment procedures for radiation injuries are described in FM 4-02.283, FM 8-9, and the NATO Handbook, _Emergency War Surgery_. Appropriate medical intervention and bone marrow resuscitation will prevent most deaths secondary to irradiation and infection.

_Table A-9. Acute Clinical Effects of Single High Dose Rate Exposures of Whole-body Irradiation of Healthy Adults_

[Part 1] -----------------------++-----------+------------+ || 0-100 cGy |100-1000 cGy| DOSE (RANGE) || (SUB- | (SUBLETHAL | || CLINICAL | RANGE) | || RANGE) |------------+ || |100-200 cGy | ----------+------------++-----------+------------+ |INCIDENCE || | | |OF NAUSEA || NONE | 5-50% | |& VOMITING || | | +------------++-----------+------------+ |TIME OF || ---- | APPROX | INITIAL |ONSET || | 3-6 HRS | PHASE +------------++-----------+------------+ |DURATION || ---- | LESS THAN | | || | 24 HRS | +------------++-----------+------------+ | || | | |COMBAT || | | |EFFECT- || 100% | 100% | | IVENESS || | | | || | | ----------+------------++-----------+------------+ LATENT |DURATION || ---- | MORE THAN | PHASE | || | 2 WEEKS | ----------+------------++-----------+------------+ |SIGNS & || | MODERATE | |SYMPTOMS || NONE |LEUKOPENIA | +------------++-----------+------------+ |TIME OF || | | |ONSET POST || ---- |2 WEEKS OR | SECONDARY |EXPOSURE || | MORE | PHASE +------------++-----------+------------+ |CRITICAL || | | |PERIOD POST || ---- | NONE | |EXPOSURE || | | +------------++-----------+------------+ |ORGAN || | | |SYSTEM || NONE | | |RESPONSIBLE || | | ----------+------------++-----------+------------+ HOSPITAL- |PERCENTAGE || NONE |LESS THAN 5%| IZATION +------------++-----------+------------+ |DURATION || ---- | 45-60 DAYS | ----------+------------++------------------------+ INCIDENCE OF DEATH || NONE | NONE | -----------------------++-----------+------------+ AVERAGE TIME OF DEATH || ---- | ---- | -----------------------++-----------+------------+ || | REASSURANCE| THERAPY || NONE | HEMATOLOGIC| || |SURVEILLANCE| -----------------------++-----------+------------+

[Part 2] -----------------------++--------------------+--------------------------+ || 100-1000 cGy (SUBLETHAL RANGE) | DOSE (RANGE) || | ||--------------------+--------------------------+ || 200-600 cGy | 600-1000 cGy | ----------+------------++--------------------+--------------------------+ |INCIDENCE || | | |OF NAUSEA || 50-100% | 75-100% | |& VOMITING || | | +------------++--------------------+--------------------------+ |TIME OF || APPROX 2-4 HRS | APPROX 1-2 HRS | INITIAL |ONSET || | | PHASE +------------++--------------------+--------------------------+ |DURATION || LESS THAN 24 HRS | LESS THAN 48 HRS | | || | | +------------++--------------------+--------------------------+ | ||CAN PERFORM ROUTINE |CAN PERFORM ONLY SIMPLE | |COMBAT ||TASKS. SUSTAINED |ROUTINE TASKS. SIGNIFICANT| |EFFECT- ||COMBAT OR COMPARABL |INCAPACITATION IN UPPER | | IVENESS ||ACTIVITIES HAMPERED |PART OF RANGE. LASTS MORE | | ||FOR 6-20 HRS. |THAN 24 HRS. | ----------+------------++--------------------+--------------------------+ LATENT |DURATION || APPROX 7-15 DAYS | NONE TO APPROX 7 DAYS | PHASE | || | | ----------+------------++--------------------+--------------------------+ |SIGNS & || SEVERE LEUKOPENIA; PURPURA, HEMORRHAGE; | |SYMPTOMS || INFECTION; EPILATION ABOUT 300 cGy. | +------------++--------------------+--------------------------+ |TIME OF || | |ONSET POST || SEVERAL DAYS TO 2 WEEKS | SECONDARY |EXPOSURE || | PHASE +------------++-----------------------------------------------+ |CRITICAL || | |PERIOD POST || 4-6 WEEKS | |EXPOSURE || | +------------++-----------------------------------------------+ |ORGAN || | |SYSTEM || HEMATOPOIETIC TISSUE | |RESPONSIBLE || | ----------+------------++--------------------+--------------------------+ HOSPITAL- |PERCENTAGE || 90% | 100% | IZATION +------------++--------------------+--------------------------+ |DURATION || 60-90 DAYS | 90-120 DAYS | ----------+------------++--------------------+--------------------------+ INCIDENCE OF DEATH || 0-80% | 90-100% | -----------------------++--------------------+--------------------------+ AVERAGE TIME OF DEATH || 3 WEEKS TO 2 MONTHS | -----------------------++-----------------------------------------------+ || | THERAPY || BLOOD TRANSFUSION, ANTIBIOTICS | || | -----------------------++-----------------------------------------------+

[Part 3] -----------------------++------------------------+----------------------+ || OVER 1000 cGy (LETHAL RANGE) | DOSE (RANGE) || | ||------------------------+----------------------+ || 1000-3000 cGy | OVER 3000 cGy | ----------+------------++------------------------+----------------------+ |INCIDENCE || | |OF NAUSEA || 100% | |& VOMITING || | +------------++-----------------------------------------------+ |TIME OF || LESS THAN 1 HR | INITIAL |ONSET || | PHASE +------------++------------------------+----------------------+ |DURATION || LESS THAN 48 HRS | APPROX 48 HRS | | || | | +------------++-----------------------------------------------+ | ||PROGRESSIVE INCAPACI- |PROGRESSIVE INCAPACI- | |COMBAT ||TATION FOLLOWING AN |TATION FOLLOWING AN | |EFFECT- ||EARLY CAPABILITY FOR |EARLY CAPABILITY FOR | | IVENESS ||INTERMITTENT HEROIC |INTERMITTENT HEROIC | | ||RESPONSE. |RESPONSE. | ----------+------------++------------------------+----------------------+ LATENT |DURATION || NONE TO APPROX 2 DAYS | NONE | PHASE | || | | ----------+------------++------------------------+----------------------+ |SIGNS & ||DIARRHEA; FEVER; DISTUR-|CONVULSIONS; TREMOR | |SYMPTOMS ||BANCE OF ELECTROLYTE |ATAXIA; LETHARGY. | | ||BALANCE. | | +------------++------------------------+----------------------+ |TIME OF || | | |ONSET POST || 2-3 DAYS | | SECONDARY |EXPOSURE || | | PHASE +------------++------------------------+----------------------+ |CRITICAL || | | |PERIOD POST || 5-14 DAYS | 1-48 HR | |EXPOSURE || | | +------------++------------------------+----------------------+ |ORGAN || | | |SYSTEM || GASTROINTESTINAL TRACT |CENTRAL NERVOUS SYSTEM| |RESPONSIBLE || | | ----------+------------++------------------------+----------------------+ HOSPITAL- |PERCENTAGE || 100% | 100% | IZATION +------------++------------------------+----------------------+ |DURATION || 2 WEEKS | 2 DAYS | ----------+------------++------------------------+----------------------+ INCIDENCE OF DEATH || 90-100% | -----------------------++------------------------+----------------------+ AVERAGE TIME OF DEATH || 1-2 WEEKS | 2 DAYS | -----------------------++------------------------+----------------------+ || MAINTENANCE OF | | THERAPY || ELECTROLYTE BALANCE | SEDATIVES | || | | -----------------------++------------------------+----------------------+

A-7. Radiological Patients in Stability Operations and Support Operations

In stability operations and support operations, high levels of environmental contamination and the use of RDD can cause radiological injury to personnel at levels below that necessary to produce performance decrement and traditional casualty status. Treatment and evacuation guidelines will be in accordance with command guidance. Individual physical dosimetry is the most expedient measurement technique for this exposure (see Table A-10). These radiation injuries and effects may also be seen in war; especially, from hostile forces employment of RDDs.

_Table A-10. Stability Operations and Support Operations: Radiation Injuries and Effects of Radiation Exposure of Personnel_

======================================================================== RADIATION TOTAL STOCHASTIC RISK EXPOSURE CUMULATIVE LONG-TERM MEDICAL NOTE MEDICAL ACTIONS STATUS DOSE HEALTH EFFECTS ------------------------------------------------------------------------ 0 <0.05 cGy NORMAL RISK. US BASELINE 20% RECORD IN EXPOSURE LIFETIME RISK OF RECORD IF NORMALLY FATAL CANCER. MONITORED PERSONNEL. ------------------------------------------------------------------------ 1A 0.05 TO UP TO 0.04% NONE (0.001 Sv US RECORD AS HISTORY IN 0.5 cGy INCREASED ANNUAL GEN. POP. MEDICAL RECORD-- RISK LIFETIME EXPOSURE LIMIT.) TACTICAL OPERATION FATAL CANCER. EXPOSURE. ------------------------------------------------------------------------ 1B 0.5 TO 5 cGy US RADIATION REASSURANCE RECORD IN MEDICAL OCCUPATIONAL (0.05 Sv US RECORD-- RISK. ANNUAL TACTICAL OPERATION 0.04%-0.4% OCCUPATIONAL EXPOSURE. INCREASED RISK LIMIT.) LIFETIME CANCER. ------------------------------------------------------------------------ 1C 5 TO 10 cGy 0.4%-0.8% COUNSEL REGARDING RECORD IN MEDICAL INCREASED RISK INCREASED LONG- RECORD-- LIFETIME FATAL TERM RISK. TACTICAL OPERATION CANCER. NO LIVE VIRUS EXPOSURE. VACCINES X 3 MONTHS. ------------------------------------------------------------------------ 1D 10 TO 25 cGy 0.8%-2% POTENTIAL FOR INC- RECORD IN MEDICAL INCREASED RISK REASED MORBIDITY RECORD-- LIFETIME FATAL OF OTHER INJURIES TACTICAL OPERATION CANCER. OR INCIDENTAL EXPOSURE. CONSIDER DISEASE. <2% ROUTINE EVACUATION INCREASED LIFETIME FROM THEATER IAW RISK OF FATAL COMMANDER'S OPER- CANCER. ATIONAL GUIDANCE. ------------------------------------------------------------------------ 1E 25 TO 75 cGy 2%-5.6% INCREASED MORBIDITY RECORD IN MEDICAL INCREASED RISK OF OTHER INJURIES RECORD-- LIFETIME FATAL OR INCIDENTAL TACTICAL OPERATION CANCER. DISEASE. <6% EXPOSURE. CONSIDER INCREASED LIFETIME EXPEDITED EVACU- RISK OF FATAL ATION FROM THEATER CANCER. IAW COMMANDER'S OPERATIONAL GUIDANCE. ========================================================================

A-8. Effects of Biological Weapons

Biological warfare is the intentional use, by an enemy, of live agents or toxins to cause death and disease among personnel, animals, and plants, or to deteriorate materiel.

_a._ _Live Agents._

(1) Live agents are living organisms like viruses, bacteria, and fungi. They can be delivered directly (artillery or aircraft spray), or through a vector such as a flea or tick. Advances in modern weaponizing of biological agents have become easier.

(2) For some agents, only a few organisms are needed to cause infection. Live agents are small and light; they can be spread great distances by the wind and contaminate unfiltered or nonairtight places.

(3) Aerosolized particles of 1 to 5 micron (μ) size carrying live agents are small and light. They require time after they are ingested to multiply enough to overcome the body's defenses. This incubation period may vary from hours to days or weeks depending on the type of organism. Thus, to be effective, a live agent attack would need to be launched well in advance of a tactical assault.

(4) These agents are sensitive to environmental conditions (for example humidity and sunlight). Many bacterial agents will not survive outside the host organism (human and animals).

(5) Live agents are not detectable by any of the five physical senses; usually the first indication of a biological attack is the ill personnel. The diseases caused by live agents may be difficult to control when the aerosol attack is directed against a large population. Some diseases may be transmitted from person-to-person after the initial attack; examples include plague, smallpox, and some viral hemorrhagic fevers.

(6) Because of their incubation period and life cycle, likely areas for live agent use are in the combat service support (CSS) area; but attacks in forward areas cannot be ruled out.

_b._ _Spore Forming Biological Agents._ Spore formers such as anthrax can survive for an extended time, even under very adverse environmental conditions (dry, extremes of temperatures, and flooding). Once inhaled, ingested, or injected into the human body, the spores germinate and produce the illness.

_c._ _Toxins._

(1) Toxins are by-products (poisons) produced by plants, animals, or microorganisms. It is the poisons that harm man, not the organisms that make the toxins. In the past, the only way to deliver toxins on a large scale was by using the organism. With today's technology large quantities of many toxins can be produced; thus, they can be delivered without the accompanying organism.

(2) Toxins have several desirable traits. They are poisonous compounds that do not grow, reproduce, or die after they have been dispersed; they are more easily controlled than live organisms. Field monitors capable of providing prompt warning of a toxin attack are not available; therefore, personnel must learn to quickly recognize signs of attack, such as observing unexplained symptoms of victims. Toxins produce effects similar to those caused by chemical agents; however, the victims will not respond to the first-aid measures that work against chemical agents. Unlike live agents, mycotoxins (T2) can penetrate intact skin; other toxins cannot. Because the effects on the body are direct, the symptoms of an attack may appear very rapidly. The potency of most toxins is such that very small doses will cause injuries and/or death. Thus, their use by an enemy may be an alternative to chemical agents because it allows the use of fewer resources to cover the same or a larger area. Slight exposure at the edges of an attack area may produce severe symptoms or death from exposure to toxins because of their extreme toxicity. Lethal or injury downwind hazard zones for toxins may be far greater than those of CW agents.

A-9. Behavior of Biological Weapons

Biological agents can be disseminated in a spectrum of physical states. They may be living microorganisms or spore forms of the organism. See Table A-11 for stability of various biological agents. They may be spread by--

· Arthropods.

· Contact with infected animals.

· Contamination of food and water.

· Aerosol, liquid, or solid dispersion.

The only requirement is that they must be stable enough to survive transport and dissemination. The toxicity of biological agents is not the same for everyone; each individual does not react exactly the same way to the same amount of an agent. Some are more resistive than others because of race, sex, age, or other factors. The dose is the quantity of a biological agent received by the subject. The penetration of agents by various routes need not be accompanied by irritation or damage to the absorbent surface. There are often unique signs and identifying symptoms depending on entry route (inhalation, ingestion, or dermal).

_a._ Biological agents dispersed by spray often enter the body through the respiratory tract (inhalation injury). The agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs.

_b._ Liquid droplets and (less commonly) solids may be absorbed from the surface of the skin, digestive tract, and mucous membranes. Agents penetrating the skin may form temporary reservoirs under the skin.

_c._ Contaminated food and water can produce casualties when ingested.

_Table A-11. Types and Characteristics of Some Biological Agents_

========================================================================= ENTRANCE TYPE OF AGENT STABILITY INCUBATION TIME AEROSOL NONAEROSOL ------------------------------------------------------------------------- ANTHRAX HIGH HOURS TO 7 DAYS INHALATION SKIN, MOUTH ------------------------------------------------------------------------- BOTULINUM TOXIN HIGH 24 TO 36 HOURS INHALATION MOUTH, WOUND ------------------------------------------------------------------------- BRUCELLOSIS HIGH IN 1 TO 4 WEEKS INHALATION MOUTH, SKIN, WET ENV- EYES IRONMENT ------------------------------------------------------------------------- CHOLERA MODERATE HOURS TO 5 DAYS MOUTH ------------------------------------------------------------------------- PLAGUE(PNEUMONIC) LOW 2 TO 4 DAYS INHALATION ------------------------------------------------------------------------- PLAGUE (BUBONIC) MODERATE 2 TO 10 DAYS BITE OF VECTOR ------------------------------------------------------------------------- RICIN HIGH <36 HOURS INHALATION MOUTH ------------------------------------------------------------------------- SMALLPOX HIGH 7 TO 17 DAYS INHALATION LESION CONTACT ------------------------------------------------------------------------- STAPHYLOCOCCAL HIGH 1 TO 6 HOURS INHALATION MOUTH ENTEROTOXIN B ------------------------------------------------------------------------- TRICHOTHECENE HIGH MINUTES TO HOURS INHALATION MOUTH, SKIN MYCOTOXIN ------------------------------------------------------------------------- TULAREMIA LOW 2 TO 10 DAYS INHALATION MOUTH, SKIN, BITE OF VECTOR ------------------------------------------------------------------------- VENEZUELAN EQUINE MODERATE 1 TO 6 DAYS INHALATION BITE OF VECTORS ENCEPHALITIS ------------------------------------------------------------------------- VIRAL HEMORRHAGIC LOW DAYS TO MONTHS INHALATION BITE OF VECTORS FEVERS =========================================================================

A-10. Management of Biological Warfare Patients

_a._ _Management._ Management of patients suffering from the effects of BW agents may include the need for isolation. Barrier nursing for patients suspected of suffering from exposure to BW agents will reduce the possibility of spreading the disease to health care providers and other patients. Specimens must be collected and submitted to the designated supporting laboratory for identification. For details on hospital infection control aspects of managing BW casualties, see FM 8-284.

_b._ _Mass Casualty._ A BW agent attack can produce a mass casualty situation at all levels of HSS. A major problem with a BW mass casualty situation is that HSS personnel are more susceptible to becoming a casualty to BW agents. Also, the ill patient may be the first indicator that a BW agent has been dispersed.

_c._ _Decontamination._ Decontamination is an individual and unit responsibility. However, some individuals may arrive at the MTF that have not been decontaminated or that become contaminated en route to the MTF. These individuals must be decontaminated at the MTF before they are admitted to prevent contamination of the MTF and exposure of medical personnel to the biological agent. See Appendix G for details on patient decontamination.

_d._ _Treatment._ Specific treatment is dependent upon the BW agent used. Patients are treated for symptomatic presentation unless the BW agent identity is known. Field Manuals 8-9 and 8-284 provide detailed information on medical management and treatment.

A-11. Effects of Chemical Weapons

_a._ A chemical agent is a chemical that is used to kill, seriously injure, or incapacitate man because of its physiological effects. They can be disseminated by artillery, aircraft, rocket, or by nonconventional means used by terrorists. When first employed in combat during World War I, the chemical weapon (chlorine) was so effective that the attacking Germans were not prepared to exploit the success.

_b._ Chemical agents are very effective weapons against poorly trained and equipped forces; however, they are less effective against well-trained forces.

A-12. Behavior of Chemical Weapons

Chemical agents can be disseminated as a gas, vapor, or aerosol under ambient conditions. They have a range of odors varying from none to highly pungent characteristics. Their stability is dependent upon the environmental conditions in the area of employment. See Table A-11 for persistency of various chemical agents.

_a._ The toxicity of a chemical agent is not the same for everyone; each individual does not react exactly the same way to the same amount of an agent. Some are more resistant than others because of physiological factors. The dose is the quantity of a chemical received by the individual for percutaneous or oral doses and as a time-weighted concentration, milligrams-minute (m3), for inhalation. It is usually expressed as milligrams of agent per kilogram of subject body weight (mg/kg). The LD50 is the dose that kills 50 percent of the exposed population. The incapacitation dose 50 (ID50) is the incapacitation dose for 50 percent of the exposed subjects. The penetration of agents by various routes need not be accompanied by irritation or delayed superficial damage to the absorbent surface, but there are often unique signs and symptoms identifiable by the route of entry.

(1) Gaseous, vapor, and aerosol chemical agents often enter the body through the respiratory tract (inhalation injury). The agent may be absorbed by any part of the respiratory tract from the mucosa of the nose and mouth to the alveoli of the lungs. Aerosol particles larger than 5 μ tend to be retained in the upper respiratory tract; particles in the 1 to 5 μ range are retained in the deep volume of the lungs; while those below 1 μ tend to be breathed in and out again; although a few are retained in the deep volume of the lungs.

(2) Vapors and droplets of liquids can be absorbed from the surface of the skin and mucous membranes. Toxic compounds that are harmful to the skin can produce their effects in liquid or solid state. Agents penetrating the skin may form temporary reservoirs under the skin; the vapors of some volatile liquids can penetrate the skin and cause intoxication. Additionally, wounds and abrasions may present areas that are more permeable than intact skin.

_b._ Chemical agents may be divided into two main categories (persistent and nonpersistent) that describe how long they are capable of producing casualties. Table A-12 lists the common chemical agents, their effects and time of effectiveness. Table A-13 lists the types and characteristics of common chemical agents.

(1) Persistent agents continue to present a hazard for considerable periods (days) after delivery by remaining as a contact hazard, or by slowly vaporizing to produce a hazard by inhalation.

(2) Nonpersistent agents disperse rapidly after release and present an immediate, short duration (hours) hazard. They are released as airborne particles, aerosols, and gases.

_Table A-12. Common Chemical Warfare Agents_

========================================================================= COMMON NAME EFFECT TIME TO EFFECT ------------------------------------------------------------------------- TABUN (GA) INHALATION: SECONDS TO MINUTES SARIN (GB) LETHAL NERVE AGENTS TOPICAL: MINUTES SOMAN (GD) INGESTION: MINUTES TO HOURS V-AGENTS ------------------------------------------------------------------------- HYDROGEN CYANIDE LETHAL BLOOD AGENT MINUTES ------------------------------------------------------------------------- MUSTARD BLISTER AGENTS 1 TO 12 MINUTES LEWISITE MINUTES ------------------------------------------------------------------------- LSD AND BZ INCAPACITATING AGENTS 15 TO 60 MINUTES ------------------------------------------------------------------------- PHOSGENE LUNG-DAMAGING (CHOKING) MINUTES CHLORINE SECONDS TO MINUTES =========================================================================

_Table A-13. Types and Characteristics of Chemical Agents_

[Part 1] ================================================================ TYPE OF PERSISTENCE RATE OF AGENT SYMBOL SUMMER WINTER ACTION ---------------------------------------------------------------- GA, GB, GD 10 MIN-24 HR 2 HR-3 DAYS VERY QUICK =NERVE= ------------------------------------------------------- VX 2 DAYS-1 WK 2 DAYS-WEEKS QUICK ---------------------------------------------------------------- =CHOKING= CG, DP 1-10 MIN 10 MIN-1 HR IMMEDIATE ---------------------------------------------------------------- HD, HN 3 DAYS-1 WK WEEKS SLOW ------------------------------------------------------ =BLISTER= L, HL 1-3 DAYS WEEKS QUICK ------------------------------------------------------ CX DAYS DAYS VERY QUICK ---------------------------------------------------------------- =BLOOD= AC, CK 1-10 MIN 10 MIN-1 HR VERY QUICK

================================================================

[Part 2] ================================================================ TYPE OF ENTRANCE AGENT SYMBOL VAPOR/AEROSOL LIQUID ---------------------------------------------------------------- GA, GB, GD EYES, LUNGS EYES, SKIN, MOUTH =NERVE= ------------------------------------------------------- VX EYES, LUNGS EYES, SKIN, MOUTH ---------------------------------------------------------------- =CHOKING= CG, DP LUNGS EYES ---------------------------------------------------------------- HD, HN EYES, SKIN, LUNGS EYES, SKIN ------------------------------------------------------ =BLISTER= L, HL EYES, SKIN, LUNGS EYES, SKIN, MOUTH ------------------------------------------------------ CX EYES, LUNGS, SKIN EYES, SKIN, MOUTH ---------------------------------------------------------------- =BLOOD= AC, CK EYES, LUNGS EYES, MOUTH, INJURED SKIN ================================================================

A-13. Characteristics of Chemical Agents

The effectiveness of a chemical agent is a measure of how much agent is required to produce the desired effect. Thus, an agent that is toxic at a lower dose than another similar agent is more effective. Besides dose required for a given effect, persistency may be used to measure effectiveness. Persistency depends on the agent's physical characteristics, the amount of agent delivered, its physical state, weapons system used, the terrain, and weather in the target area. The desired effects will determine the physical, chemical, and toxicological properties of the chemical agent employed.

_a._ Nerve agents are primarily organophosphorus esters similar to insecticides. Those of military importance are combined under this term. Although some have been given names, they are usually known by their code letters: GA; GB; GD; and VX. They are all liquids, varying in volatility that is in a range between gasoline and heavy lubricating oil. Their freezing points are -40 degrees Celsius or lower.

(1) Liquid nerve agents are pale yellow to colorless and are almost odorless. They are moderately soluble in water and highly soluble in lipids (oil). They are rapidly destroyed by strong alkalies and chlorinating compounds. Normal clothing is readily penetrated by liquid or vapor agents. Butyl rubber and synthetic material are more resistant than natural fibers. Agents can penetrate into nonabsorbent material such as web belts and can continue to present a hazard by desorption (off-gassing) of the vapor. Although local sweating and twitching may occur, usually there is no local irritant change after cutaneous exposure. Toxicity depends upon the route of entry and physical characteristics.

(2) Nerve agents strongly inhibit the cholinesterase enzymes. When acetylcholine is released by the nerve junction, it is hydrolyzed by the enzyme. Acetylcholine is the chemical mediator for transmission of the nerve impulses in numerous synapses of the central nervous system (CNS) and the autonomic nervous system and at the endings of the cholinergic nerves (for example: affecting the smooth muscles of the iris, ciliary, bronchial tree, and gastrointestinal tract). The inhibition of cholinesterase by nerve agents is almost irreversible, so the effects are prolonged. Until the cholinesterase level is restored to normal, there is an increased susceptibility to nerve agent exposure. During this time, the effects of repeated exposure are cumulative and the patient may feel "subpar" (for example: tired, fatigue easily, poor appetite, impaired concentration) until recovery is complete.

(3) Nerve agent poisoning is easily identified by the characteristic signs and symptoms as follows:

(_a_) =MILD= symptoms (self-aid). Casualties with MILD symptoms may experience most or all of the following:

· Unexplained runny nose.

· Unexplained sudden headache.

· Sudden drooling.

· Difficulty in seeing (dimness of vision) (miosis).

· Tightness in the chest or difficulty in breathing.

· Localized sweating and muscular twitching in the contaminated area.

· Stomach cramps.

· Nausea.

(_b_) Casualties with =MODERATE= symptoms (buddy aid) will experience an increase in the severity of most or all of the MILD symptoms. Especially prominent will be an increase in fatigue, weakness, and muscle fasciculations. The progress of symptoms from MILD to MODERATE indicates either inadequate atropine treatment or continuing exposure to agent.

(_c_) =SEVERE= symptoms (buddy aid). Casualties with SEVERE symptoms may experience most or all of the MILD symptoms, plus most or all of the following:

· Strange or confused behavior.

· Wheezing, dyspnea (severe difficulty in breathing), and coughing.

· Severely pinpointed pupils.

· Red eyes with tearing.

· Vomiting.

· Severe muscular twitching and general weakness.

· Involuntary urination and defecation.

· Convulsions.

· Unconsciousness.

· Respiratory failure.

_b._ There are three major families of blister agents (vesicants); HD and HN, L, and CX. Most vesicants (except CX) are relatively persistent. Mustards can modify the structure of nucleic acids, cellular membranes, and proteins by combining with certain functional groups (particularly the sulfhydryl-containing enzymes) for which they have an affinity.

(1) The cutaneous syndrome is divided into four phases: latent, erythema, vesication, and necrosis. Vesicants can penetrate the skin by contact with either liquid or vapor. The latent period is characteristic of the agent. For mustards it is usually several hours, for L it is short, and for CX it is negligible. The latent period is also affected by the dose, temperature, and humidity. The symptoms of the erythema phase are red, painful itching followed by painful necrosis that heals slowly.

(2) In the eyes, vesicants produce intense pain and photophobia. Blistering of the eyelids and mucous membranes can result in temporary blindness. Even after recovery, scars on the cornea can reduce visual acuity.

(3) In the respiratory tract, these agents attack the mucous membranes irritating them. They can paralyze vocal chords and can lead to chemical pneumonitis, or possibly death.

(4) Although blister agents can affect other organs and produce deleterious effects, the skin, eyes, and respiratory tract are the principle organs effected.

_c._ Chemical agents that attack lung tissue (choking agents) and cause pulmonary edema are classed as lung damaging agents. Choking agents consist of CG and DP, CL, and PS. Phosgene is typical of the lung-damaging agents; it is used as the example here.

(1) Phosgene is a colorless gas that has an odor resembling new mown hay. Although effects are primarily confined to the lungs, phosgene may also cause mild irritation of the eyes and upper respiratory tract. Phosgene causes a shift in the membrane potential of the alveoli allowing the passage of fluid into the alveoli, resulting in massive pulmonary edema and severely impairing the exchange of oxygen (O_{2}) and carbon dioxide (CO_{2}) between the capillary blood and the alveolar air.

(2) Initially hypoxemia occurs and is followed shortly by hyperventilation when the frothy edema fluid fills the bronchioli and CO_{2} expiration stops.

(3) Signs and symptoms during and immediately following exposure are coughing, tightness of chest, nausea, occasionally vomiting, headache, and lacrimation (tearing).

_d._ Blood agents consist of AC and CK; both are readily absorbed by the mucous membranes and the intact skin. The odor of AC resembles bitter almonds, but many people cannot detect it. Detecting the odor of CK is difficult because of its irritating and lacrimatory effects. It is also poorly absorbed by the metallic salt-impregnated charcoal filters in the protective mask. These agents inhibit certain enzymes (particularly cytochrome oxidase) that are important for oxidation-reduction in the cells; therefore, cell respiration is inhibited and oxygen carried by the hemoglobin is not consumed causing the venous blood to remain bright red. Initial symptoms are characterized by violent convulsions, increased deep respiratory movements, followed by cessation of respiration within one minute, slowing of heart rate to death. High concentrations exert their effects rapidly; however, if the patient is still alive after the cloud has passed, he will probably recover spontaneously.

_e._ Incapacitating agents are chemicals that produce a temporary disabling condition that persists for hours to days after exposure to the agent has ceased (unlike that produced by riot control agents). While not required, medical treatment produces a more rapid recovery. Characteristics of these agents are that they--

· Are highly potent and logistically feasible.

· Produce their effects mainly by altering or disrupting the higher regulatory activity of the CNS.

· Produce effects that last for hours or days rather than momentary or fleeting.

· Do not seriously endanger life, except in exceedingly high doses.

· Produce no permanent injury.

The two types likely to be encountered are CNS depressants and CNS stimulants.

(1) Central nervous system depressants are compounds that have a predominant effect of depressing or blocking the activity of the CNS; often by interfering with the transmission of information across synapses. An example of this type of agent is BZ. The action of acetylcholine, both peripherally and centrally, appears to be blocked by BZ. Low doses disrupt higher integrative functions of memory, problem solving, attention, and comprehension. High doses produce toxic delirium that destroys the ability to perform any military task. Within the CNS, BZ seems to produce its effects in the same way as atropine. Small doses cause sleepiness and decreased alertness with elevated heart rate, dry skin and eyelids, drowsiness, increased pupil size, and elevated skin temperatures. Progressive intoxication is marked by an inability to respond effectively to the environment (4 to 12 hours), followed by increasing activity and random/unpredictable behavior (12 to 96 hours). Because the patient cannot sweat, heat stress becomes a problem.

(2) Central nervous system stimulants are agents that cause excessive nervous activity, often by boosting or facilitating transmission of impulses across synapses. The effect is to "flood" the cortex and other higher regulatory centers with too much information, making concentration difficult and causing indecisiveness and an inability to act. These include LSD, psilocybin, and mescaline. Intoxication shows sympathetic stimulation (rapid heart rate, sweaty palms, pupillar enlargement, and cold extremities) and mental excitation (nervousness, trembling, anxiety, and inability to relax or sleep); feelings of tension, exhilaration, heightened awareness, paranoid ideas, and profound states of terror may also occur.

A-14. Management of Chemical Agent Patients

_a._ _Management._ Movement of chemical agent casualties can spread the contamination to clean areas. All casualties are decontaminated as far forward as the situation permits. All patients must be decontaminated before they are admitted into a clean MTF. The admission of one contaminated patient into an MTF will contaminate the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ A mass casualty situation is presented when chemical agents are employed. Additional HSS personnel and equipment must be provided in a short period of time if the level of care is to be maintained. Treatment at far forward MTFs is limited to life- or limb-saving care. Patients that can survive evacuation to the next level of care are not treated at the forward facility. This provides time for treating those patients that cannot survive the evacuation time.

_c._ _Decontamination._ Decontamination is an individual and unit responsibility. However, some individuals may arrive at the MTF that have not been decontaminated or that become contaminated en route to the MTF. These individuals must be decontaminated at the MTF before they are admitted to prevent contamination of the MTF and exposure of medical personnel to the chemical. See Appendix G for detailed information on patient decontamination procedures.

_d._ _Treatment._ Field Manuals 8-9 and 8-285 provide treatment procedures for chemical agent patients.

A-15. Management of Toxic Industrial Material Patients

_a._ _Management._ Movement of TIM casualties can spread the contamination to clean areas. All casualties are decontaminated as close to the incident site as possible. All patients must be decontaminated before they are admitted into a clean MTF. The admission of one contaminated patient into an MTF may contaminate the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ A mass casualty situation is presented when the number of casualties exceeds the capabilities of medical personnel at the location to provide needed care at the incident site. Treatment at the incident site is limited to life- or limb-saving care. Patients that can survive are evacuated to the nearest MTF with a patient decontamination capability.

_c._ _Decontamination._ Decontamination is an individual and first responder responsibility. However, some individuals that self evacuated or were evacuated due to the mass casualty situation arrive at the MTF that have not been decontaminated. These individuals must be decontaminated at the MTF before they are admitted to prevent contamination of the MTF and exposure of unprotected medical personnel and other patients to the TIM. See FM 8-500 for detailed information on decontamination procedures for TIM contaminated casualties.

_d._ _Treatment._ Field Manual 8-500 provides treatment procedures for some TIM casualties. Treatment for many TIM casualties is agent specific and receiving MTFs must be prepared for these events.

EXAMPLE: Treatment for a casualty exposed to toxic levels of an inorganic phosphate pesticide would be treated in the same manner as a nerve agent casualty except the amount of antidote for the pesticide poisoned casualty will be many times greater than for the nerve agent casualty.

APPENDIX B

SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT

Section I. INTRODUCTION

B-1. General

_a._ Critical elements for accuracy in analysis of NBC samples and physiological specimens are correct collecting, packaging, handling, and transporting techniques. The quality of any analytical evaluation is directly related to the quality of the sample/specimen and the degree of postcollection degradation that occurs prior to testing. Health service support personnel collect and submit specimens for suspect NBC hazards/agents involving humans and animals. Chemical corps and other nonmedical units collect and submit environmental (air, plant, and soil) samples for suspect NBC hazards/agents. Preventive medicine personnel collect and submit water and ice samples for suspect NBC hazards/agents. Veterinary personnel collect and submit food samples, such as fruits and vegetables, and specimens from animals for suspect NBC hazards/agents. Specimens collected from patients that are suspect of being exposed to a biological agent are forwarded to the supporting medical laboratory (such as the TAML, AML or US Navy Forward Deployed PVNTMED Unit) for analysis.

_b._ Essentially all military operations from war to stability operations and support operations may generate medical laboratory testing requirements. Each scenario, geographical region, population base, and suspect agent will impact on the type and amount of samples/specimens required and the collection process. During all operations, express permission is required before collecting specimens from civilians because of religious or sociological beliefs in many cultures. To obtain such specimens without permission could result in unnecessary mission complications.

NOTES

1. The term "sample" refers to nonhuman and nonanimal origin. The term "specimen" refers to human and animal origin.

2. Always consider that chemical agents may have been employed. Check for chemical agents before collecting a biological sample/specimen. Chemical agents can damage or destroy biological agents. Also, chemical agents not identified in the sample/specimen can pose a hazard to receiving laboratory personnel. Mark all samples that are potentially contaminated with chemical agents as such.

3. Precautions should be taken to protect the sample/specimen collector from potential BW agents; at a minimum, respiratory protection and rubber gloves must be worn. Additional care must be taken when collecting samples/specimens to prevent cross-contamination. Gloves must be changed or decontaminated between sample/specimen collections.

4. Samples will not be delivered to the clinical laboratory of an MTF for analysis. They must be delivered to the designated supporting medical laboratory for processing. This will prevent accidentally spreading a biological agent in the MTF.

_c._ Coordination for follow-on testing is absolutely critical to the sample/specimen collection process.

_d._ Coordination with the receiving laboratory should be made to establish sample requirements, preferred collection techniques, methods of preservation, and transportation conditions, when the tactical situation and/or mission permits.

_e._ The number of medical specimens that need to be collected varies with the type of analysis performed and the impact of the values determined. The number and types of "control" samples/specimens required to validate test information is determined by the supporting medical laboratory personnel. Random sampling, matched with control populations, or other techniques will be employed as the requirements are identified.

B-2. Sample/Specimen Background Information

_a._ A complete history of the circumstances about each sample's/specimen's acquisition must be provided to the agency conducting the analysis.

_b._ Critical information includes, but is not limited to--

· Meteorological conditions. Describe what the meteorological conditions were at the time of the alleged attack and at the time of the sampling.

· Attack to collection time. State the length of time after alleged attack when sample/specimen was taken.

· Circumstances of acquisition. Describe how the sample/specimen was obtained and the source of the sample/specimen.

· Physical description. Describe the physical state of the sample/specimen (solid, liquid, powder, apparent viscosity), color, approximate size, identity of the sample/specimen (that is, dirt, leaves, blood, tissue), and dose rate (if radiologically contaminated).

· Circumstances of the agent deposition. Describe 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 the burst, and colors of smoke, flames, or mists that may be associated with the attack.

· Agent effects on vegetation. Describe the general area (jungle, mountain, grassland) and changes in the vegetation after the agent deposition (that is, color change, wilting, drying, dead) in the main attack and fringe areas.

· Agent effects on humans. 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 before, during, or after an attack; measures taken that alleviated or worsened the effects; and the approximate number of victims and survivors (include age and gender).

· Agent effects on animals. Describe how they are affected.

· Grid coordinates or other descriptive information on sample collection location.

B-3. Sample/Specimen Collection and Preservation

_a._ _Ante mortem Specimens._ Physiological specimens from living human or animal patients can include just about any conceivable body source or excreted by-product. It must be noted that specimen types are seldom interchangeable; the exact type and amount of specimen required for a specific assay must be known before a collection procedure is initiated (see Table B-1).

· Patients seen in an MTF may be the first and in some cases the only source for sampling for suspect biological agent release. The primary medical care provider will determine the level of treatment for these patients and the specimens required for laboratory diagnosis. The MTF laboratory is not equipped to handle biological agents and, therefore, specimens generated will be forwarded to the supporting medical laboratory for analysis. Patient disposition will be based on evacuation policies, exposure, suspect agent, clinical symptoms, and required treatment/isolation.

· Blood specimens represent the most common analytical sample. Certain techniques and special care must be exercised to ensure an acceptable specimen is collected and to minimize an adverse affect to the patient or specimen collector. In general, phlebotomy requires the use of a 20 to 22-gauge needle to minimize mechanical hemolysis during aspiration using a syringe or Vacutainer^{TM} tube collection system. Blood collected with a syringe and needle should be transferred to an appropriate Vacutainer^{TM} tube immediately after collection. The type of tube, type of anticoagulant or preservative, and amount of blood collected will vary with the specific assay requested. Unless some special sample preparation step is required, the blood is best left in the original rubber-stopper tube for transport.

· Urine specimens are best collected using a clean-catch (midstream, if possible) technique in a sterile urine cup. The volume of sample required will vary depending on the specific assay requested; however, 25 to 50 ml is sufficient for most tests.

· Tissue specimens can originate from any body source accessible by scraping, swabbing, or minor excision. Tissue specimens are collected only by medical trained personnel. Specific techniques for collecting these specimens are not provided in this appendix.

· Sputum specimens are best collected using a sterile cup. The volume of specimen will normally be very small. However, a sufficient quantity must be collected to provide for in-theater testing and to provide for CONUS laboratory testing.

· Nasal swabs should be collected using sterile cotton-tipped swabs. The swabs with specimen from each person should be placed in a separate sterile container to prevent cross-contamination.

NOTE

In cases where the supporting laboratory cannot be contacted, as a minimum the following specimens should be collected: Urine--25 to 50 ml in a sterile container. Blood--two 7 to 10 ml tubes without anticoagulant (red-stopper Vacutainer^{TM}); two 7 to 10 ml tubes with potassium or sodium ethylenediaminetetraacetate (EDTA) (lavender-stopper Vacutainer^{TM}).

· All specimens (regardless of physiological source) must be labeled to positively identify the individual or animal from whom it was collected; at a minimum, the individual's full name, unique personal identification number (social security number, when possible), military unit and location, and date and time of collection should be written on the label of the specimen container.

· All specimens are collected using aseptic techniques. All specimens are packaged, handled, and transported in a manner that ensures they arrive at the final destination laboratory in a testable condition. Personal protection guidelines must be adhered to when collecting or processing specimens; at a minimum, this includes gloves and a mask. In the laboratory, a gown or other protective items may also need to be used. In the field, under suspect NBC conditions, collectors should be in MOPP Level 4 or inside NBC-protected vehicles. Common sense and the clinical and/or tactical situation will determine the extent of personal protection necessary.

· Preservation of specimens, either chemically or mechanically (cooling), will be necessary to minimize the amount of analyte degradation that occurs after removing the specimen from its physiological microenvironment. The optimal preservation technique will vary with different laboratory tests and must be confirmed for each requested assay. While freezing may preserve some serum constituents, freeze-thawing cycles may denature others. Freezing may also completely destroy certain microorganisms. This caution also applies to tissue specimens since "fixing" tissue with a standard 10 percent formalin solution will preserve tissue for special staining techniques; however, it renders the specimens completely useless for microbiological culture. Always verify specimen preservation requirements for storage and transport with the supporting medical laboratory before processing the specimen. Ideally, confirmation of the correct handling conditions should be coordinated before collection.

· The importance of coordinating sample/specimen collection with the supporting laboratory facility cannot be overstated. Contact the receiving laboratory for instructions when doubt exists about the appropriate source, collection technique, storage and preservation conditions (such as, aerobic or anaerobic environment), and transportation requirements for samples/specimens. Extremely small volumes of samples/specimens, properly collected and handled, can yield a tremendous amount of information to assist in making medical, tactical, and strategic decisions. Conversely, very large quantities of poorly collected and insufficiently preserved samples/specimens are essentially worthless for most analytical techniques.

· Analysis beyond intratheater capabilities will be coordinated by the supporting laboratory, when deployed, or through medical channels in the absence of an in-theater supporting laboratory.

_b._ _Post mortem and Forensic Specimens._ The analysis of specimens from deceased humans and animals can provide valuable information about the disease, organisms, injuries, or environmental conditions at the time of death. This information can greatly enhance the treatment of others affected by the same, or physiologically similar, process. Specimen collection for post mortem or forensic examination is very important; the techniques involved reflect a significant degree of training, experience, and skill. Most specimens will be of the same type and size as for ante mortem specimens, but types and amounts of specimens will be determined by the collector.

(1) The collection of specimens from remains should be conducted exclusively by a pathologist, or other personnel specifically trained in forensic collection techniques. An exception is when Special Operations Forces (SOF) personnel are operating under radio silence conditions; the most qualified medical person with the operation collects, preserves, and transports or coordinates transport of specimens for evaluation. The same chain of custody requirements applies to specimens collected by SOF personnel, as with all other specimens.

(2) A large amount of support information can be gained by analyzing the site of injury and subsequent death. This "site scene" investigation requires a tremendous attention to detail and a trained observer. If forensic personnel cannot be contacted, or will be unduly delayed in arriving at the scene, then photographs of the victim and the immediate surroundings should be made. The scope and extent of the photographs should be composed to reflect as much detail as possible to assist forensic personnel in reviewing the scene retrospectively. In the event that photography is not feasible, detailed sketches of the scene should be made to assist the forensic investigation.

(3) Techniques such as cardiac or bladder puncture, needle biopsy of organs, spinal tap, or exploratory laparotomy will not be performed by untrained personnel unless specifically requested and directed by forensic investigators.

_Table B-1. Specimen Collection for Suspect Biological Warfare Agents_

======================================================================== EARLY POSTEXPOSURE CLINICAL CONVALESCENT/TERMINAL/POSTMORTEM ------------------------------------------------------------------------ =ANTHRAX= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL AND THROAT SWABS, AND SERUM (TT OR RT) FOR TOXIN ASSAYS. INDUCED RESPIRATORY SECRETIONS BLOOD (E, C, H) FOR PCR. FOR CULTURE, FA, AND PCR. BLOOD (BC OR C) FOR CULTURES. _3 TO 10 DAYS._ SERUM (TT OR RT) FOR TOXIN ASSAYS. BLOOD (BC OR C) FOR CULTURE. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =PLAGUE= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL SWABS, SPUTUM, AND BLOOD (BC AND C) FOR CULTURE AND INDUCED RESPIRATORY SECRETIONS BLOODY SPUTUM (C) FOR FA. SERUM FOR CULTURE, FA, (TT OR RT) FOR F-1 ANTIGEN ASSAYS. AND PCR. BLOOD (E, C, OR H) FOR PCR. _>6 DAYS._ SERUM (TT OR RT) FOR IgM, LATER FOR IgG. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =TULAREMIA= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE. INDUCED RESPIRATORY BLOOD (E, C, OR H) FOR PCR. SECRETIONS FOR CULTURE, FA, SPUTUM FOR FA AND PCR. AND PCR. _>6 DAYS._ SERUM (TT OR RT) FOR IgM AND LATER IgG, AGGLUTINATION TITERS. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =MELIOIDOSIS/GLANDERS= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE. INDUCED RESPIRATORY BLOOD (E, C, OR H) FOR PCR. SECRETIONS FOR CULTURE AND SPUTUM AND DRAINAGE FROM SKIN PCR. LESIONS FOR PCR AND CULTURE. _>6 DAYS._ BLOOD (BC OR C) AND TISSUE FOR CULTURE. SERUM (TT OR RT) FOR IMMUNOASSAYS. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =BRUCELLOSIS= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE. INDUCED RESPIRATORY BLOOD (E, C, AND H) FOR PCR. SECRETIONS FOR CULTURE AND _>6 DAYS._ PCR. BLOOD (BC OR C) AND TISSUE FOR CULTURE. SERUM (TT OR RT) FOR IMMUNOASSAYS. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =Q FEVER= _0 TO 24 HOURS._ _2 TO 5 DAYS._ NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE IN EGGS INDUCED RESPIRATORY OR MOUSE INOCULATION. SECRETIONS FOR CULTURE AND BLOOD (E, C, AND H) FOR PCR. PCR. _>6 DAYS._ BLOOD (BC OR C) FOR CULTURE IN EGGS OR MOUSE INOCULATION. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =BOTULISM= _0 TO 24 HOURS._ _24 TO 72 HOURS._ NASAL SWABS AND INDUCED NASAL SWABS AND RESPIRATORY RESPIRATORY SECRETIONS FOR SECRETIONS FOR PCR (CONTAMINATING PCR (CONTAMINATING BACTERIAL DNA) AND TOXIN ASSAYS. BACTERIAL DNA) AND TOXIN _>6 DAYS._ ASSAYS. USUALLY NO IgM OR IgG. SERUM (TT OR RT) FOR TOXIN PATHOLOGY SPECIMENS (LIVER AND ASSAYS. SPLEEN FOR TOXIN DETECTION). ------------------------------------------------------------------------ =RICIN INTOXICATION= _0 TO 24 HOURS._ _36 TO 48 HOURS._ NASAL SWABS AND INDUCED SERUM (TT OR RT) FOR TOXIN RESPIRATORY SECRETIONS FOR ASSAY. PCR (CONTAMINATING CASTOR TISSUE FOR IMMUNOHISTOLOGICAL BEAN DNA) AND TOXIN ASSAYS. STAINING. SERUM (TT OR RT) FOR TOXIN PATHOLOGY SPECIMENS. ASSAYS. _>6 DAYS._ SERUM (TT OR RT) FOR IgM AND IgG IN SURVIVORS. ------------------------------------------------------------------------ =STAPH ENTEROTOXICOSIS= _0 TO 3 HOURS._ _2 TO 6 HOURS._ NASAL SWABS AND INDUCED URINE FOR IMMUNOASSAYS. RESPIRATORY SECRETIONS FOR NASAL SWABS AND INDUCED PCR (CONTAMINATING BACTERIAL RESPIRATORY SECRETIONS FOR DNA) AND TOXIN ASSAYS. PCR (CONTAMINATING BACTERIAL SERUM (TT OR RT) FOR TOXIN DNA) AND TOXIN ASSAYS. ASSAYS. SERUM (TT OR RT) FOR TOXIN ASSAYS. _>6 DAYS._ SERUM FOR IgM AND IgG. ------------------------------------------------------------------------ =T-2 TOXICOSIS= _0 TO 24 HOURS POSTEXPOSURE_ _1 TO 5 DAYS._ NASAL AND THROAT SWABS AND SERUM (TT OR RT) AND TISSUE FOR INDUCED RESPIRATORY TOXIN DETECTION. SECRETIONS FOR IMMUNOASSAYS, _>6 DAYS POSTEXPOSURE._ HPLC/MASS SPECTROMETRY. URINE FOR DETECTION OF TOXIN METABOLITES. ------------------------------------------------------------------------ =EQUINE ENCEPHALOMYELITIS= (VEE, EEE, AND WEE VIRUSES) _24 TO 72 HOURS._ _0 TO 24 HOURS._ SERUM (TT OR RT) AND THROAT FOR NASAL SWABS AND INDUCED CULTURE. RESPIRATORY SECRETIONS FOR SERUM (E, C, H, TT, OR RT) FOR RT-PCR AND VIRAL CULTURE. RT-PCR. THROAT SWABS UP TO 5 DAYS FOR CULTURE THEN CSF. SERUM (TT OR RT) FOR ANTIGEN ELISA. _>6 DAYS._ SERUM (TT OR RT) FOR IgM. PATHOLOGY SPECIMENS PLUS BRAIN. ------------------------------------------------------------------------ =POX= (SMALLPOX AND MONKEYPOX) _2 TO 5 DAYS._ _0 TO 24 HOURS._ SERUM (TT OR RT) FOR VIRAL NASAL SWABS AND INDUCED CULTURE RESPIRATORY SECRETIONS FOR _>6 DAYS._ PCR AND VIRAL CULTURE. SERUM (TT OR RT) FOR VIRAL CULTURE DRAINAGE FROM SKIN LESIONS/ SCRAPINGS FOR MICROSCOPY, EM, VIRAL CULTURE, AND PCR. PATHOLOGY SPECIMENS. ------------------------------------------------------------------------ =EBOLA= _0 TO 24 HOURS._ _2 TO 5 DAYS._ NASAL SWABS AND INDUCED SERUM (TT OR RT) FOR VIRAL RESPIRATORY SECRETIONS FOR CULTURE. RT-PCR AND VIRAL CULTURE. _>6 DAYS._ SERUM (TT OR RT) FOR VIRAL CULTURE PATHOLOGY SPECIMENS PLUS ADRENAL GLAND. ------------------------------------------------------------------------ =LEGEND:=

BC Blood culture C Citrated blood CSF cerebrospinal fluid DNA deoxyribonucleic acid E EDTA EEE eastern equine encephalitis ELISA enzyme-linked immunosorbent assay EM electron microscopy F-1 fraction-1 FA fluorescent antibody H Heparin HPLC high-pressure liquid chromatography IgG immunoglobulin class G IgM immunoglobulin class M PCR polymerase chain reaction RT Red Top, if TT is not available RT-PCR reverse transcriptase/polymerase chain reaction TT Tiger top VEE Venezuelan equine encephalitis WEE western equine encephalitis =========================================================================

_c._ _Water Sample Collection._

(1) Water samples for identification or verification of biological agent contamination are collected by PVNTMED personnel. The supporting laboratory should provide guidance on sampling procedures and collecting kits for use in collecting the samples. In the absence of guidance, a technique for use of the Sep-Pak^{TM} is described in FM 3-19.

(2) When sampling kits are not available, samples may be collected in other available sterile containers. The best containers for use are the 100-ml glass bottles used for collecting routine water samples. All water samples must be collected and placed in a cooler or refrigerator until the sample is transported to its destination. During transportation the samples must be maintained at a temperature between 1°C and 4°C.

_d._ _Food Samples._ Veterinary personnel must collect suspect biologically contaminated food samples for submission to the supporting laboratory for in-theater verification of contamination. All food samples must be collected and placed in sterile containers. Place the samples in a cooler or refrigerator until the sample is transported to its destination. During transportation the samples must be maintained at a temperature between 1°C and 4°C.

_e._ _Animal Specimens._ Veterinary personnel collect specimens from suspect biologically contaminated/diseased animals. The same types and amounts of specimens are prepared and shipped in the same manner as are human specimens.

_f._ _Environmental Samples._ Environmental samples are collected as directed in the operators' manual or other publications for operating collection systems. Example: The Biological Integrated Detection System (BIDS) collects an environmental sample using a single liquid sample collector. The collector is a high-volume aerosol sampling and collection device. On demand it samples ambient air through a two-stage virtual impactor that concentrates aerosol particles in the 2 to 10 micrometer diameter-size range. The concentrate particle stream is directed through a wet collector containing a buffer solution and, over a 45-minute period, a 40 to 50 ml sample is collected. On order or when test results indicate a suspected agent, the sample and associated documentation are packaged and transported IAW FM 3-101-4.

B-4. Chain of Custody

_a._ A strict chain of custody must be maintained for every sample/specimen collected. Use DD Form 1911 (Material Courier Receipt), or other document (such as DA Form 4137 [Evidence/Property Custody Document]) as directed for each sample/specimen collected. The chain of custody document must accompany the sample/specimen during transport from the point of collection to the final receiving laboratory. Each time the sample/specimen is transferred to another individual, the receiving person must sign the document to show that they received the sample/specimen and state what happened to the sample/specimen while in their custody. The document will provide the answer to the following questions:

· When was the sample/specimen collected?

· Who has maintained custody of the sample/specimen?

· What has been done with the sample/specimen at each change of custody?

_b._ The samples/specimens must be appropriately packaged, labeled, and evacuated to the designated medical laboratory for confirmation of a biological attack. The standard chain of custody for the evacuation would be as follows:

· Sampling unit.

· Unit S2/security office or medical operations officer.

· Technical escort unit or other command-designated escort personnel.

· In-theater supporting medical laboratory.

· Designated CONUS laboratory.

Section II. SAMPLING TECHNIQUES AND PROCEDURES

B-5. General

The collection of environmental, and background (control) samples/medical specimens is an integral part of investigating allegations pertaining to the first use of chemical or biological agents. The types of samples/specimens taken and the collection methods primarily depend upon the circumstances encountered by the collector. During all chemical and biological sampling operations, the commander establishes the required protective equipment to fit the situation. This appendix includes a recommended list of equipment for use during chemical and biological sampling operations (Table B-2).

_Table B-2. Example NBC Collection and Shipping Equipment List_

====================================================================== AMOUNT DESCRIPTION STOCK NUMBER ---------------------------------------------------------------------- 20 LABELS, PAPER, PRESSURE SENSITIVE 7530-00-577-4376 2 GLOVES, 8-8½, EDMONT WILSON^{TM} 8415-00-JO2-2902 2 GLOVES, 9-9½, EDMONT WILSON^{TM} 8415-00-634-4639 1 TAPE, ADHESIVE, PRESSURE SENSITIVE, 2 INCH 7510-00-159-4450 1 PLIERS, #47, 5 INCHES 6520-00-543-5330 1 SCREWDRIVER, FLAT TIP, ¼ INCH 5120-00-596-865 1 TONGS, TEFLON^{TM} TIPS AF 15-202-5 2 MICROSPATULA, WITH TEFLON^{TM} ENDS AF 21-401-50A 1 SCISSORS, UNIVERSAL TYPE AF 08-951-30 1 SCOOP, POLYPROPYLENE, 5X2X2 ASP S1021-5 2 SPOON/SPATULA WITH TEFLON^{TM} AF 14-356-10 1 KNIFE, POCKET 5110-00-526-8740 5 BOTTLES, SAMPLE, POLYETHYLENE, 6 OUNCE CP J-6103-50 1 PIPET, JUMBO, TRANSFER TYPE (500/PKG) AF 13-711-7 10 PIPET, GRADUAL, TRANSFER TYPE (500/PKG) AF 13-711-9A 10 BAG, INSULATED, TYPE I AF 01-814-8 10 BAG, INSULATED, TYPE 2[*] AF 01-814-10 1 BAG, WHIRL/PAK, 6 OUNCE (500/PKG) AF 01-812-6B 1 STRIP, pH TESTING, NONBLEEDING, PLASTIC SW S-65271 1 SEP-PAK^{TM} C18 W51910 (50/BOX) 2 SYRINGE, HYPODERMIC, 50 OR 60 ml 6515-00-168-6913 2 STOPCOCK, THREE-WAY ASP S8965-2 1 TUBING, LABORATORY, R3602 CLEAR AF 14-169-3B 1 PEN, MARKING, WATERPROOF AF13-381 (12/PKG) 2 TUBES, TENAX^{TM} EC ST-023 1 BLADE, SURGICAL, CS2L 150S 6515-01-009-5297 2 PACK, ICE CP TR-6345-20 6 PAD, NONADHESIVE, 3X4, 100s 6510-00-111-0708 4 PAD, COOLING, CHEMICAL, 4S 6530-00-133-4299 2 PIGLETTES SPECIAL ORDER 1 TAPE, ANTISEIZE 8030-00-889-3535 1 AIR SAMPLER, PERSONAL LSS G4980 1 KIT, METRIC, POCKET BUBBLE GL4981 2 METHANOL 1 WATER, DISTILLED (5 BOTTLE/PKG) 1 MATCHES, WATERPROOF 20 RAZOR, SURGICAL PREP 6515-00-926-2089 10 WATCH, WRIST 6645-00-066-4279 2 PARAFILM WITH DISPENSER 6640-01-185-3289 2 FLOOR SWEEP (VERMICULITE) 8720-01-026-9419 100 SEALS, TAMPER-RESISTANT 1 A GAS METER CAPABLE OF PROVIDING ON-STATION ANALYSIS/DETECTION CAPABILITY FOR MULTIPLE GASES TO INCLUDE INDUSTRIAL GASES. 1 A COMBUSTIBLE GAS INDICATOR THAT INDICATES PERCENTAGE OF OXYGEN AND EXPLOSIVITY. 1 A GAS METER THAT DETECTS VAPOR IN PARTS PER MILLION (PPM) AND INDICATES PRESENCE OF VAPOR AND ITS STRENGTH. 1 SWABS, THROAT 2 CAN, 6 POUND, METAL 10 BAG, MYLAR 1 CONTAINER, LEAD SHIELDING (FOR RADIATION SAMPLES) 1 CONTAINER, SHIPPING, IATA 1 CHEST, ICE 10 BAG, PLASTIC, RECLOSABLE

[*] WILL BE REPLACED BY MYLAR BAGS ======================================================================

B-6. Expended Material

The NBC recon units collect samples under various circumstances. For example, a recon unit may collect samples in an area free of hostile forces. The Special Forces NBC Reconnaissance team may collect samples within the enemy area of operations or deep into the enemy's rear area. Samples include toxic agent munitions, chemical products, air, water, soil, and vegetation. In addition, all expended material used to collect the samples should be turned in to the laboratory with the samples. This material includes items such as expended M256A1 kits, M8 and M9 paper. These items should be recovered, packaged, and shipped with the suspected samples for analysis. Different information may be derived from each type of sample; Table B-3 compares different types of samples.

B-7. Environmental Samples

Control or background samples that are collected from clean samples must be identical to the samples collected from the areas near the attack areas as baseline data. The contaminated samples must be compared to the baseline data (control samples). This is especially true if unknown or nonstandard chemical and/or suspected biological agents were employed. The analysis center uses the control samples to compare with a contaminated one. The recon unit collects control samples of soil, water, and vegetation from areas about 500 meters upwind of an alleged attack area. Control samples generically are the same as those collected in an alleged attack area. For example, if leaves from an apple tree in an attack area were collected as a suspected contaminated sample, the recon team should collect leaves (as a control sample) from an apple tree outside of the contaminated area. If water from a pond in the attack area is collected, the recon unit should collect control samples of water from a pond (not a moving stream) in a nearby clean area. The size of an environmental control sample should be about the same as the suspected contaminated sample collected from the attack area (see Table B-4, page B-20).

_Table B-3. Comparison of Sample Types_

====================================================================== SAMPLE STABILITY ANALYSIS SAMPLE TYPE INFO VALUE TO COLLECT TIME REQUIRED RELIABILITY ---------------------------------------------------------------------- AIR GOOD GOOD 20 MIN HIGH WATER GOOD GOOD 5 MIN HIGH SOIL FAIR FAIR 5 MIN MODERATE VEGETATION FAIR POOR 10 MIN LOW TISSUE EXCELLENT FAIR 30 MIN HIGH BLOOD GOOD FAIR 10 MIN HIGH URINE GOOD FAIR 10 MIN HIGH MUNITION FRAGMENTS FAIR FAIR 10 MIN FAIR PACKING MATERIALS FAIR FAIR 10 MIN FAIR ======================================================================

B-8. Collection of Air and Vapor Samples

_a._ Air is a good sample matrix since it is a well-mixed medium. Air from a sample site contains a static concentration of contaminants. The concentration of contaminants depends upon the flow rate of the contaminant into the environment, the wind speed, and the physical state of the contaminant, the terrain contours, and temperature as a variable. The sample should be taken within 102 meters of a contaminated surface and at the downwind edge of a contaminated area. The method should consist of pumping a given volume of air, by hand or electric pump, through sample tubes.

_b._ To avoid contamination, persons conducting air sampling should not use cologne, perfume, insect repellent, medical creams, or strong soaps before taking a sample. The fragrances from these products are volatile organic compounds that may be absorbed on the filter and skew analytical results. Smoke also severely interferes with air sampling, therefore, avoid tobacco and vehicle exhaust smoke.

_c._ The primary method for collecting air samples is with the PAS 1000 automatic air sampler in conjunction with a Tenax^{TM} tube for a total of three to four minutes when possible. Upon completion of sampling, place the Tenax^{TM} tube in a 2¼-inch piglette. Seal the piglette around the cap with either pressure-sensitive or Teflon^{TM} tape. Once sealed, place the piglette into a Mylar or reclosable bag. Fold the bag around the piglette in a circular motion, then apply another bag and fold again. Once the bag is folded around the piglette, use any type tape to secure the bag around the piglette. Place the piglette into a refrigerator or cooler until the sample is transported to its destination.

_d._ When chemicals are permitted into the atmosphere from a facility, the best places to obtain samples are close to the emission source where the concentration of the chemical is not diluted. The further from the original point of release, the more diluted the sample becomes from mixing with air, water, or environmental pollutants.

_e._ Natural and man-made terrain features such as hills, valleys, and rows of buildings, sometimes aid the collector by channeling emissions. When these features are associated with a particular facility, their downwind side is a suitable place to collect a sample because the emission remains more concentrated further from the release point.

_f._ For collection in a possibly contaminated location, and if the situation permits, initially use a detection kit such as the M18A2/M256AI to determine if a possible vapor hazard exists from known chemical agents. Also, use the kit when personnel are required to examine possible toxic agent munitions. In any case, collect air samples with the white-band tubes and save for identification and analysis.

_g._ Small air samplers also enable the collector to obtain vapor samples from alleged toxic agent munitions at a safe distance while explosive ordnance disposal (EOD) operations are performed. If EOD personnel are not on the scene, the air sampler can be activated, and the collector can stand at a safe distance while the sampler is operating.

_h._ Perform sampling operations as soon as possible when directed by a higher headquarters or after suspected chemical or biological contamination is encountered.

B-9. Collection of Water Samples

_a._ Water sampling is a matter of collecting enough water to get acceptable information about the contaminants. The collector should provide the analysis center with one C18 and one silica cartridge when using the Sep-Pak^{TM} technique or 100 ml in a sterile bottle when Sep-Pak^{TM} is not available.

_b._ General guidelines: If it is believed that the threat has used standard chemical agents during an attack, use the M272 chemical agent water test kit for initial screening and sampling.

_c._ When collecting water samples using the Sep-Pak^{TM} C18 cartridge, the following items are required:

· One 60 cc syringe without needle.

· One 3-way sterile, plastic, stopcock with protective covers.

· One piece of plastic tubing (3/16" inner diameter × 6" long minimum).

· Sterile water or methanol.

· One clean container, such as a Teflon^{TM} cup or glass jar.

_d._ Prior to collecting each sample, prime the Sep-Pak^{TM} system in the following manner:

· =Step 1.= Attach Sep-Pak^{TM} directly to 60 cc syringe.

· =Step 2.= Pour small amount of sterile water or methanol into container.

· =Step 3.= Insert tip of Sep-Pak^{TM} into container.

· =Step 4.= Withdraw at least 40 cc of solution.

· =Step 5.= Detach Sep-Pak^{TM} from syringe and discard solution from syringe.

· =Step 6.= Repeat steps 3 through 5 using the same syringe.

_e._ After priming the Sep-Pak^{TM}, assemble the components in the following configuration:

· Attach the 3-way stopcock to a 60 cc syringe.

· Attach the Sep-Pak^{TM} to the opposite end of stopcock.

· Attach the plastic tubing to the open end of the Sep-Pak^{TM}.

_f._ Use the following procedures to collect samples with Sep-Pak^{TM}:

· =Step 1.= Ensure that the lever on the stopcock is turned sideways with the off arrow pointed toward the large outlet port.

· =Step 2.= Place the open end of the plastic tubing into the water near the bottom, without touching the bottom or sides of the body of water.

· =Step 3.= Draw 60 cc of water into the syringe.

· =Step 4.= Turn the stopcock lever to the off position by positioning the lever to point toward the stopcock.

· =Step 5.= Push the plunger all the way in, discharging the water from the syringe through the outlet port.

· =Step 6.= Repeat steps 1 through 5.

· =Step 7.= Detach a plastic tubing from the Sep-Pak^{TM}, and discard it as contaminated waste.

· =Step 8.= Detach Sep-Pak^{TM} from 3-way stopcock; place into sample container; seal with pressure-sensitive tape; and mark for Identification.

NOTE

You should take a minimum of four samples: three samples of the suspected contamination and one control sample from a nearby unaffected (none contaminated) area for reference.

· =Step 9.= Dispose of the syringe and stopcock as contaminated waste.

· =Step 10.= Insert the sample container in a cooler or refrigerator until the sample is transported to its destination.

_g._ For samples to be representative of the overall contaminated area, the collection point should be carefully selected. Collect samples from--

· Drains and slow-moving streams, since contamination and dilution from other sources are minimized.

· Stagnant pools of water if the pools of water are part of chemical waste areas, such as a landfill or chemical disposal area. Chemicals may percolate into stagnant pools or sumps close to the site.

NOTE

If an oil film, globules of organic materials, or an unnatural appearing powder-like material is visible on the water's surface, collect a surface sample of the material. If not, collect the sample from near the bottom of the water source (stream, lake, pond, water container). The upper layers of water may have lesser amounts of contaminants, due to higher temperatures that promote decomposition. Since most chemicals of interest are more dense than water, contaminants usually sink to the bottom of the water source.

_h._ Collect the sample without the Sep-Pak^{TM} by immersing a capped or stoppered container to the desired depth, removing the cap or stopper, letting the container fill, and then capping the container. An alternate method for deeper water is to use a plastic, pump-operated siphon to pump water from a specific depth.

_i._ The best time to collect a sample of water from a location is when intelligence or local reports indicate that a process of possible interest is ongoing. In the absence of reliable reporting, this may be indicated by increased activity, higher than normal amounts of security, or increased flow from facility chimneys or water discharge pipes. In field areas where a toxic agent has been sprayed or disseminated over a land area, the best time to collect water samples is just after the start of a rainstorm when runoff is beginning. Natural surface drainage will concentrate any remnants of toxic compounds in depressions, streams, or ditches.

B-10. Collection of Soil Samples

Soil is a suitable medium to collect as samples for toxic organic compounds. A critical point, however, is that the precise site of the agent deposition must be sampled for best results. Contamination may be recognized by discoloration or apparent deposition of material on the soil's surface. If discoloration or deposits of material are evident, only collect the discolored soil or deposited materials, if possible. Dead, malformed, and wilted foliage is an indicator of contamination. Soil samples should be collected from open areas, along the drip line tents, stationary equipment, bottom of ditches and terrain depressions.

_a._ Collect the soil samples by using a knife, spoon, spatula, or similar item to scrape a square of topsoil (2×5×1 centimeters) from areas that appear to have been contaminated in to a collection container. If chunks or clods of earth are collected, select those that are no larger than 10×5×1 centimeters (see Table B-4). Also, collect a control sample of soil of the same type and texture from a nearby uncontaminated area.

_b._ Use a glass bottle, jar, or Teflon^{TM} jar as the container when available. When these containers are not available, Mylar bags may be used. When using a glass bottle, jar, or Teflon^{TM} jar, seal the cap with either pressure-sensitive or Teflon^{TM} tape, and mark for identification. When using Mylar bags, place each sample in a separate bag, push excess air out, and seal by folding the open end over two to three times and wrapping the bag with tape. Insert the first bag into a second bag, seal, tape, and mark for identification. If possible, place the samples in a piglette.

+-----------------------------------------------------------+ | CAUTION | | | | Avoid direct contact with the sample to prevent exposing | | yourself to the suspect agent (MOPP 4 is required). | +-----------------------------------------------------------+

_c._ Collect samples as soon as possible when directed, upon detection of a suspect substance, or after the alleged incident.

B-11. Collection of Contaminated Vegetation

As with soil samples, vegetation is also a suitable medium to collect as samples for toxic organic compounds.

_a._ Collect samples of vegetation that appear to be different from normal. Select leaves that have wilted or appear to have been chemically burned. Collect samples of vegetation that appear to have liquid or solid substances deposited on their surfaces (this may be noticed as a shiny or moist area).

_b._ Collect samples of vegetation at several locations within the suspected contaminated area. Using a cutting tool or any sharp object, cut several affected leaves and/or a handful of grass whenever possible. Do not crush the sample. Place the sample into a Mylar or reclosable bag. Squeeze excess air out of the bag and seal it. Fold the open end of the Mylar bag over two to three times, and wrap it with tape. The minimum size for a sample is three leaves or three handsful of grass. One leaf is of little value, but is better than nothing. Bark is acceptable but not preferred. Mark the bag for identification. Take a control sample of similar material from an unaffected (uncontaminated) area. Fold, seal, tape, and mark the control sample in the same manner as the actual sample.

_c._ When it is possible to determine a probable center of attack in an area, collect vegetation samples near the center of the area, about 100 meters upwind of the area, and in several 100-meter increments downwind of the area. If the collector can discern a contamination pattern in the area, this should be reported.

B-12. Medical Specimens

_a._ Just as blood and urine specimens are taken from humans who were allegedly exposed in an attack, also collect specimens from individuals who claim not to be affected by a toxic agent and are from the same group as exposed personnel. The purpose is the same as collecting environmental control specimens; that is, to determine if a toxic substance is present in the individuals' natural environment or if it has been artificially introduced.

_b._ Selection of humans for control sampling is somewhat more complicated than selection of environmental control samples. This is because ethnic diets, racial differences, physiological makeup, and actual living conditions of persons who are outwardly similar may introduce potentially large deviations. Each of these factors must be accurately considered before selecting subjects as controls.

_c._ Consideration of ethnic diets is important because of unique foods or methods of food preparation that may exist. As an example, individuals in settled areas may purchase beer that has been carefully filtered and sterilized, while individuals in a nearby unsettled area may ferment their own beer by burying home crafted jugs in the ground and extracting the product little by little over several months.

_d._ Racial differences can account for differences in mortality and morbidity rates in specific populations. One example of this could be the high rate of hemophilia in a population versus the rarity of the disease in another.

_e._ Physiological makeup is critical because of the differences in hormone balance and tissue composition in males, females, adults, and juveniles. For this reason, medical control specimens should be drawn from individuals of the same gender and approximate age as specimens from exposed personnel, if possible.

_f._ Differences in the actual living conditions of people also require a close look. The point here is that conditions in remote, semicivilized camps are seldom the same as those in a well-established camp that has access to modern amenities.

_g._ The bottom line in selecting subjects for medical control sampling is that they be as similar in all aspects as possible.

B-13. Collection of Medical Specimens

_a._ Trained medical technicians or physicians should collect medical specimens (human or animal); however, Special Forces NBC Reconnaissance team personnel are trained to do this procedure. Remember, the collector must have express permission (authority) to collect medical specimens from the dead, because of religious beliefs in many cultures. To obtain such specimens without permission may result in unnecessary mission complications. Ensure all personnel handling or collecting medical specimens have received proper immunizations for their own protection. They must be inoculated IAW The Surgeon General's guidance.

_b._ Medical specimens collected during an investigation include blood, urine, sputum, nasal swabs, and tissue specimens from living victims and blood and urine specimens from unexposed persons (background control specimens).

_c._ Collect blood specimens using either a standard 10 cc disposable syringe with a 1- to 1½-inch needle (20 to 22 gauge), or by using a Vacutainer^{TM} system. When using a Vacutainer^{TM} system, ensure that multiple specimen needles and "red top" vacuum tubes are used. Ten cc of blood is sufficient for analytical testing. Do not take more than 5 cc from small, malnourished children. After blood is collected, it should be transferred to a polypropylene-type container and sealed with parafilm before transporting.

All body fluids should be collected without violating antiseptic techniques. Also, prior to transporting specimens, collectors need to check specimen containers for paper labels IAW guidelines for labeling medical specimens. Collect blood specimens using the following materials equipment:

· Gloves.

· 10 cc sterile, disposable syringe.

· 1- to 1.5-inch sterile needle (20 to 22 gauge).

· Vacutainer^{TM} device (adapter with needle).

· Constricting band.

· Disinfectant pads, Betadine, or alcohol.

· Sterile 2×2-inch gauze pads.

· Labels.

NOTE

Gloves should be worn whenever handling medical specimens. Do not freeze liquid blood and urine specimens (ideal cooling temperature is between 35° and 40°F [2° to 4°C].)

_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.

NOTE

For correct procedures on catheterization refer to STP 8-91W15-SM-TG.

_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

Post mortem specimens should be collected by individuals trained in forensics. When forensics-trained individuals are not available, the most qualified medical person should collect human specimens. Specimens from animals should be collected by veterinary personnel. In either case, the following specimens are collected:

· =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.

NOTE

Before attempting any of the above procedures, collector must be certified by a qualified person (medical doctor) on the correct procedures to collect specimens from cadavers.

_Table B-4. Standard Sizes of CB Samples/Specimens to be Collected_

======================================================================== TYPE SIZE NOTES ------------------------------------------------------------------------ =CHEMICAL WARFARE SAMPLES= SOIL (10 CM X 5 CM X 1 CM) CIGARETTE-PACK SIZE OR LARGER AREA IS MORE USEFUL THAN GREATER DEPTH DILUTE AGENT 10 ML WATER 500 ML (MAXIMUM) C18 SEP-PAK^{TM} 200 ML VEGETATION (EQUIVALENT TO 3 LEAVES DEPENDS ON AMOUNT OF CONTAMIN- OR 3 HANDSFUL OF GRASS) ATION. BEST SAMPLES WILL BE FOUND NEAR THE RELEASE POINT ------------------------------------------------------------------------ =BIOLOGICAL WARFARE SAMPLES= SOIL (10 CM X 5 CM X 1 CM) CIGARETTE-PACK SIZE OR LARGER AREA IS MORE USEFUL THAN GREATER DEPTH LIQUID 25 TO 50 ML DO NOT USE C18 SEP-PAK^{TM} WITH MEDICAL SPECIMENS VEGETATION SIZE OF SOFT DRINK CAN BEST SAMPLES DEPEND ON THE AMOUNT OF CONTAMINATION FOUND NEAR THE RELEASE POINT ------------------------------------------------------------------------ =MEDICAL SPECIMENS= URINE 20 TO 50 ML MUST OBTAIN CONSENT TO COLLECT SPECIMENS FROM OTHER THAN US CASUALTIES WHOLE BLOOD OR 5 ML MUST OBTAIN CONSENT TO COLLECT SERUM SPECIMENS FROM OTHER THAN US CASUALTIES CEREBRAL SPINAL 2 ML MUST OBTAIN CONSENT TO COLLECT FLUID SPECIMENS FROM OTHER THAN US CASUALTIES ORGAN TISSUE 30 G (MINIMUM) MEDIASTINAL 2 SHOULD BE REMOVED BY A SURGEON LYMPH NODES DURING AN AUTOPSY ========================================================================

B-15. Reporting, Packaging, and Shipment

Although a sample/specimen collected from an alleged attack area can be significant, it can become useless if proper steps are not taken to record critical information about its collection or if it is improperly packed and breaks during shipment to an analysis center. This section discusses the information needed when acquiring samples/specimens and the preferred methods for handling and packing samples/specimens for 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

Materials used for packaging samples/specimens primarily consist of Mylar collection bags, Teflon^{TM} specimen jars and tubes, pigs and piglettes, ice chests, sealing materials, and wrapping and cushioning supplies.

_a._ _Collection Bag._ Use the Mylar bag as the initial container for such samples as protective masks and filter canisters, individual antidote and decon kits, munition fragments, and other items too large to place in a specimen jar. Use it also to package sample/specimen containers to ensure a vapor barrier in case the container is broken in transit. The bag acts as an initial or secondary vapor barrier to prevent air from leaking inward and toxic material outward. Follow the procedures below when using the bag.

· 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.

NOTE

Suspect CB samples/specimens are first delivered to the supporting medical laboratory in the AO for in-theater analysis before they are transported out of the AO. The supporting laboratory will withdraw an aliquot of selected samples/specimens for analysis. The supporting medical laboratory is responsible for providing the AO commander confirmatory identification within the AO. The CONUS-based reference laboratory is responsible for providing confirmatory identification for President and Secretary of Defense purposes.

FM AMEMBASSY DDTTTTZ JAN 02 TO CDR TEU APG MD//SMCTE-OPE// SECSTATE WASHDC SECDEF WASHDC//OSD-ISA/OUS-DRE// INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)// JCS WASHDC//J-3/J-5// DIA WASHDC//DT-3B/DT-5A// DIR NSA FT MEADE MD DIR AFMIC FT DETRICK MD//AFMIC-CR/AFMIC-SA// DA WASHDC/DAMI-FIT/DAMO-SWC// CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2// CDR CBDA APG MD//SMCCR-OPF// CDR USACMLS FT MCCLELLAN//ATZN-CM-CU//

CLASSIFICATION

SECSTATE FOR... SECDEF FOR... CIA FOR... JCS FOR J-3/J-5 FOR... DA FOR DAMO-SWC FOR... AFMIC FOR... CBDA FOR FIO... FSTC FOR AMXST-FW... USACMLS FOR THREAT MGR...

E.0.12356: DECL: OADR (Note: This is included if the message is classified.) TAGS: ...

Subject: Shipment of CB Samples/Specimens REF(S): TEU MSG #, (DTG DDTTTT [time zone] JAN 02)

1. (W) SHIPPING INFORMATION:

A. DATE SHIPPED: JANUARY 11, 2002. B. MODE OF TRANSPORTATION: AIR EXPRESS, AIR BILL NUMBER RPT C. FLIGHT SCHEDULE: TO TYO BY JAL XXX, JANUARY 11, 2002. TO JFK BY JAL YYY, JANUARY 12, 2002. TO IAD BY DEC ZZZ, JANUARY 12, 2002. D. DESTINATION: DULLES INTERNATIONAL AIRPORT. E. ESTIMATED TIME OF ARRIVAL: 2010 HOURS, JANUARY 12, 2002.

2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.

3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMIC) CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID BREAKAGE. THE FOLLOWING SAMPLES ARE INCLUDED IN THE SHIPMENT:

SAMPLE/SPECIMEN NUMBER MESSAGE REFERENCE TH-850102-001AG THRU TH-850102-005AG BANGKOK DDTTTTZ JAN 02

4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.

_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).

1. ID NUMBER___________

2. COLLECTION (DATE/TIME):______________________

3. COLLECTOR/UNIT:_______________________________

4. TYPE: ENVIRONMENTAL___ BIOMEDICAL___ SINGLE___ MULTIPLE___

5. PURPOSE: ATTACK___ CHEM/BIO ALARM___ CHEM DETECT___ RECON ILLNESS/DEATH___ OTHER___

6. POSTEXPOSURE: HOURS___ DAYS___ WEEKS___ UNKNOWN___

7. LOCATION: TOWN_______________ COORDINATES__________________________

A. TERRAIN: FLAT___ HILLS___ MOUNTAIN___ DESERT___ JUNGLE___ SPARSE TREES___ GRASS___ BODY OF WATER/TYPE___

B. WEATHER: CLEAR___ CLOUDY___ RAIN___ FOG___ SNOW___ DUST___

C. WIND: LIGHT___ HEAVY___ GUSTY___ NONE___

D. ODOR: SWEET___ FRUITY___ PEPPER___ FLOWER___ IRRITATING___ CHANGING___ NONE___ OTHER_____

E. TEMPERATURE AT TIME OF ATTACK:_____ TEMPERATURE AT TIME OF SAMPLE COLLECTION:_____

8. COMMENTS: ______________________________________________________________________ ______________________________________________________________________

9. ATTACK: DATE/TIME_______ METHOD: ARTILLERY___ ROCKET___ AIRCRAFT___ MORTAR___ RPG/GRENADE___ OTHER, DESCRIBE:__________________________

A. EXPLOSION: AIR_______ (HEIGHT)_______ GROUND_________ SIZE_______ DISTANCE_________ DESCRIBE:____________________

B. CONSISTENCY: SMOKE___ MIST___ DUST___ RAIN___ GEL___ INVISIBLE, DESCRIBE:_______

10. ENVIRONMENTAL SAMPLE: SOIL__ WATER__ VEGETATION__ AIR__ OTHER___

11. BIOMED SPECIMEN: ACUTE___ CONVALESCENT___ EXPOSED___ NOT ILL___ POSTMORTEM___ CONTROL, EXPLAIN:_________________ BLOOD___ LIVER___ LUNG___ SPLEEN___ BRAIN___ SKIN___ KIDNEY___ URINE___ OTHER, DESCRIBE:_________________________

12. COMMENTS: __________________________________________________________________

13. CASUALTY: SSN_______________ UNIT_______________________ SEX______

14. SIGNS/SYMPTOMS: ONSET__ DURATION__

A. HEAD: FEVER___ CHILLS___ HEADACHE___ FLUSHED___ DIZZINESS___ UNCONSCIOUSNESS___ COMA___ HALLUCINATIONS___

B. EYES: SUNLIGHT SENSITIVE___ PAINFUL___ BURNING___ DROOPY EYELIDS___ DOUBLE VISION___ BLURRED VISION___ LARGE PUPILS___ PINPOINT PUPILS___

C. NOSE: RUNNY___ BLEEDING___

D. THROAT: SORE___ DRY___ SALIVATING___ BLOODY SPUTUM___ HOARSENESS___ DIFFICULTY SPEAKING___

E. RESPIRATION: DIFFICULTY BREATHING___ CHEST/PAIN DISCOMFORT___ WHEEZING (IN/OUT)___ COUGHING___ LABORED BREATHING___

F. HEART POUNDING OR RUNNING___ IRREGULAR HEARTBEAT___

G. GI: LOSS OF APPETITE___ NAUSEA___ FREQUENT VOMITING___ FREQUENT DIARRHEA___ VOMITING BLOOD___ DIARRHEA WITH BLOOD___

H. URINARY: BLOODY URINE___ UNABLE TO URINATE___

I. MUSCULOSKELETAL: NECK PAIN____ MUSCLE TENDERNESS___ MUSCLE TREMBLING/TWITCHING___ WEAKNESS___ PARALYSIS, DESCRIBE:_____________________ CONVULSIONS___ TREMORS___ MUSCLE ACHES___ BACK PAIN___ JOINT PAIN___

J. SKIN: RASH___ REDDENING___ ITCHING___ BLISTERS___ PAIN___ NUMBNESS___ PROFUSE PERSPIRATION___

15. COMMENTS: ______________________________________________________________________

16. ANIMALS AFFECTED: YES___ NO___ DESCRIBE:__________________________

17. RELATED SPECIMENS_________________________________________ ID NUMBER_____________________________________ DESCRIPTION__________________________________

18. COLLECTOR SIGNATURE____________________________ NAME___________________________ PHONE NUMBER______________________ E-MAIL________________________

19. REVIEWER SIGNATURE NAME PHONE NUMBER_________________ E-MAIL_________________

_Figure B-2. Sample/specimen background document._

CB INCIDENT INTERVIEW

DATE:_____________________ INTERVIEWER: ______________________________ SUBJECT'S NAME: ______________________________________________________ ALIAS #1_____________________________ #2______________________________ AGE:____________ SEX: ____ M ____F YEAR OF BIRTH:__________ NATIONALITY:__________________________________________________________ SUBJECT'S ADDRESS:____________________________________________________ IDENTITY CARD #:______________________________________________________ DELIVERY METHODS: TYPE: ____UNKNOWN _____GROUND ____AIR _____ARTILLERY/ROCKET ____MINE OTHER, DESCRIBE:______________________________________________________ HEIGHT: ______(M) SIZE: _____________ (AFFECTED AREA IN METERS) DISTANCE: __________(M) AGENT CHARACTERISTICS ODOR: _____NONE _____SWEET _____FRUITY _____IRRITATING _____PEPPER _____FLOWER _____CHANGING _____OTHER, DESCRIBE:_______________________ COMMENTS:_____________________________________________________________ ______________________________________________________________________ CONSISTENCY: ______SMOKE ______MIST _____DUST _____RAIN ______GEL ______DRY ____VISIBLE ____INVISIBLE ____OTHER, DESCRIBE:________________________ COLOR:_____________ DESCRIBE DEVELOPMENT OF COLOR:____________________ AREA COVERAGE:________________________________________________________ PHYSICAL DISSEMINATION/COVERAGE (i.e., DROPLET SIZE AND DISTRIBUTION): WRITE OR DRAW_________________________________________________________ SYMPTOMS:_____________________________________________________________ ______________________________________________________________________ INDIVIDUAL'S ACTIONS: DURING ATTACK:________________________________________________________ ______________________________________________________________________ AFTER ATTACK:_________________________________________________________ ______________________________________________________________________ PROTECTIVE MEASURES:__________________________________________________ TREATMENT RECEIVED:___________________________________________________ ______________________________________________________________________ ENVIRONMENTAL EFFECTS: VEGETATION CHANGE? ___YES ___NO DESCRIBE:_____________________________________________________________ ______________________________________________________________________ ANIMALS AFFECTED? ___YES ___NO DESCRIBE:_____________________________________________________________

OTHERS AFFECTED:

NAME AGE SYMPTOMS RESOLUTION ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

_Figure B-3. Chemical/biological incident interview._

FM AMEMBASSY DDTTTTZ JAN 02

1.00 SHIPPING

TO CDR TEU APG MD/SMCTE-OPEI/ SECSTATE WASHDC SECDEF WASHDC//OSD-ISA/OUS-DRE// INFO CIA WASHDC//OSWR-STD-LSB/NIC-NIO(STP)// JCS WASHDC//J-3/J-5// DIA WASHDC//DT-3B/DT-5A// DIR NSA FT MEADE MD DIR AFMIC FT DETRICK MD//AFMIC- CR/AFMIC-SA//DA WASHDC// DAMI-FIT/DAMO-SWC// CDR FSTC CHARLOTTESVILLE VA//AIAST-RA-ID2// CDR CRDEC APG MD//SMCCR-OPE// CDR USACMLS FT LEONARD WOOD MO//ATSN-CM-CO// CDR USAMRIID FT DETRICK MD// (FOR SUSPECT BIOLOGICAL SAMPLES/SPECIMENS ONLY)

CLASSIFICATION

SECSTATE FOR... SECDEF FOR CIA FOR JCS FOR J-3/J-5 FOR DA FOR DAMO-SWC FOR AFMIC FOR CRDEC FOR FIO FSTC FOR AMXST-FM USACMLS FOR THREAT MGR E.O. 12356: DECL: OADR (NOTE: This is included if the message is classified.) TAGS:

=SUBJECT: SHIPMENT OF CB SAMPLES= REF(S): TEU MSG, #______. (DTG DDTTTT [time zone] Jan 02)

1. INFORMATION: A. DATE SHIPPED: JANUARY 11.2002. B. MODE OF TRANSPORTATION: AIR EXPRESS. AIR BILL NUMBER RPT C. FLIGHT SCHEDULE: TO TYO BY JAL XXX JANUARY 11, 2002. TO JFK BY JAL YYY, JANUARY 13, 2002. TO IAD BY DEC ZZZ, JANUARY 12, 2002. D. DESTINATION: DULLES INTERNATIONAL AIRPORT E. ESTIMATED TIME OF ARRIVAL; 2010 HOURS. JANUARY 12, 2002.

2. SPECIAL HANDLING REQUIREMENTS: DRY ICE ENCLOSED AS COOLANT.

3. SHIPMENT CONSISTS OF TWO ICE CHESTS (1 FOR CRDEC AND 1 FOR AFMICO) CONTAINING SIX SAMPLES/SPECIMENS. ALL LIQUID SAMPLES/SPECIMENS ARE IN POLYPROPYLENE TUBES AND HAVE BEEN CAREFULLY PACKED TO AVOID BREAKAGE. THE FOLLOWING SAMPLES/SPECIMENS ARE INCLUDED IN THE SHIPMENT:

SAMPLE/SPECIMEN NUMBER MESSAGE REFERENCE TH-8501 1AG THRU TH-850102-005AG BANGKOK DDTTTTZ JAN 0202-00

4. USDAO HAS STATED THAT THIS SHIPMENT IS PARTIAL FULFILLMENT OF CIR.

_Figure B-4. Sample/specimen shipping report._

APPENDIX C

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

C-1. General

As the HSS unit prepares for its support role, NBC, TIM, and CBRNE considerations must be included. This appendix provides guidelines for HSS planning, preparing for, and conducting operations in an NBC environment and responding to a homeland defense CBRNE event.

C-2. Predeployment

When preparing the unit's mobilization plan and TSOP, include the supplies and equipment that will be required for the unit to operate in an NBC environment. DO NOT wait until ordered to mobilize to begin preparation for the mission. A well-prepared and trained unit stands a much better chance of surviving and accomplishing their assigned mission. At a minimum include the following:

· 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

During mobilization the unit must ensure that all supplies and equipment are on hand and are serviceable. Commanders and leaders must also ensure that--

· Movement plans are prepared.

· Transportation support requirements are identified and requested.

· Load plans include provisions for the transportation of NBC supplies and equipment (medical and nonmedical).

· A MOPP level has been established for the movement, if applicable.

· A checklist of training shortfalls is prepared and a training plan is in place.

C-4. Establish a Medical Treatment Facility

Plans for establishing a BAS, DCS, or FST for operating in a NBC environment must include employment of CBPS systems. When establishing a hospital using Deployable Medical Systems (DEPMEDS), the chemically protected (CP) DEPMEDS must be set up as the conventional shelters are being set up. Once the conventional shelter has been set up and is operational, CP DEPMEDS cannot be established without first taking down the existing shelter. Follow the technical manual provided with the CP DEPMEDS system issued to your unit. Plans for operating a DEPMEDS equipped hospital in the NBC environment should include, but not be limited to--

· 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

Individuals should have decontaminated themselves or have been decontaminated by unit personnel; however, an MTF must plan for and be prepared to receive contaminated patients. The patients may not have been decontaminated at the unit, or they may have become contaminated en route to the MTF. Selected CSHs may be designated as the primary NBC MTF and be augmented with additional supplies and medical staff. When designated as such, plans must be prepared designating the location of the CSH that can best support the forward deployed MTFs. All actions listed in paragraph C-4 must be taken. During operations, actions that must be taken are--

· 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

Plans for providing preventive medicine services must include monitoring water supplies for contamination. To perform this mission, equipment and supplies must be available and operational. Essential equipment and supplies include--

· Radiation detection equipment such as AN/PDR77, AN/PDR27, AN/VDR2.

· Preventive Medicine Water Quality Control Set.

· M272 Chemical Agent Detection Set.

· Biological sample collection kit, shipping containers, refrigerant, and chain of custody forms.

C-7. Veterinary Services

Plans for veterinary services must include provisioning for treatment to government-owned animals and quality control of food supplies. To perform their mission, essential supplies and equipment include--

· Treatment for NBC injured animals. Especially, antidotes and treatment for CB agents.

· Radiation detection equipment.

· M272 Chemical Agent Detection Set.

· Biological sample/specimen collection kit, shipping containers, refrigerant, and chain of custody forms.

C-8. Dental Services

Most dental services at the dental treatment facilities will have to be suspended in NBC contaminated areas due to a lack of CPS. Plans must include for emergency dental services to be provided in a clean area or in an MTF with a CPS. Essential supplies and equipment include--

· Dental treatment set for maxillofacial injuries.

· Material for covering and protecting supplies and equipment.

C-9. Combat Operational Stress Control

Although specific supplies and equipment are not required for COSC, plans must be prepared to provide these services under NBC conditions. The COSC staff must locate clean areas to conduct COSC activities or manage the COSC patients in a MOPP level commensurate with the command MOPP guidance.

C-10. Medical Laboratory Services

Planning for medical laboratory support must include plans for conducting analysis on suspect NBC samples/specimens. Designated supporting medical laboratories must be prepared to analyze and provide confirmation/identification on specimens/samples of suspect NBC agents from humans, water sources, food supplies, and the environment (air and soil). The samples/specimens may be collected by MTF personnel, chemical corps personnel, PVNTMED personnel, veterinary personnel, or other services personnel. To perform this mission, supplies and equipment should include--

· General supplies and equipment.

· 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

Plans must include health service logistics support to continue under NBC conditions. To continue this role, all supplies must be protected from contamination. Materials required include--

· 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.

NOTE

This guideline contains items that are required specifically for HSS operations in an NBC environment. The items are in addition to supplies and equipment required for conventional operations. This guideline is not all inclusive, but is a starting point for HSS units to develop their specific guidelines.

C-12. Homeland Security

Health service support units and installation medical activities/centers must be prepared to provide support in the event that CBRNE are used on the United States. Medical commanders and leaders should develop plans on how the provision of medical support will be provided to a CBRNE event. The plan should include, but not be limited to--

· Number and type of units required to respond.

· Medical equipment and supplies required.

· Personal protective equipment required for medical response personnel.

· Time required to prepare unit/personnel to respond.

· Length of time response support is required.

· Sources for food, shelter, local transportation, and resupply of expended or lost equipment and supplies.

APPENDIX D

MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES

Section I. INTRODUCTION

D-1. General

The primary purpose of the Medical Planning Guide for the Estimation of Nuclear, Biological, and Chemical Battle Casualties--AMedP-8(A), a three-volume publication for NBC, is to assist medical planners, medical logisticians, and medical staff officers in predicting NBC warfare contingency requirements for HSS personnel, medical materiel stockpiles, patient transport or evacuation capabilities, and facilities needed for patient decontamination, triage, treatment, and supportive care. The optional use of these guides is for projecting medical NBC operational estimates at brigade, division, corps, and EAC.

NOTE

The use of "the guide" in this appendix refers to AMedP-8(A),