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

VOLUME III

Chapter 829,478 wordsPublic domain

D-19. General

_a._ The primary purpose of Volume III is to assist medical planners, logisticians, and staff officers in predicting CW contingency requirements. Requirements include medical personnel, medical materiel stockpiles, patient transport or evacuation capabilities, and facilities needed for patient decontamination, triage, treatment, and supportive care. An optional purpose is to support medical operational estimates.

_b._ The guide provides medical worst-case estimates of casualties and remaining operational strength after a single CW attack on a tactically deployed, brigade-sized land force units, with protection available and protection unavailable. These worst-case casually estimates are for personnel located within both the targeted and the downwind hazard areas of the brigade. It is assumed that all targeted personnel will be unsheltered and without medical pre-exposure prophylactic treatment. Tables in the guide are designed to show total numbers of--

· Casualties with different types and severities of injury at various times after exposure.

· Personnel at different performance levels and times after exposure.

· Fatalities at specified times after exposure.

_c._ The guide presents estimates of personnel status at specific time points. These range from 1 to 3 hours to 7 to 30 days after an attack, depending on the type of agent considered. Such estimates are projected from all possible combinations of the following conditions:

· Seven operational scenarios involving three types of units: heavy brigade, support brigade, and light infantry brigade.

· Three chemical agents: the nerve agents GB and VX, and the blister agent HD.

· Three types of munitions delivering the agents: aerial bombs, tactical ballistic missiles, and rounds from multiple launch rocket systems/artillery batteries--

· Three attack intensities for each type of munition: light, moderate, and heavy.

· Two postures of individual physical protection against the attacks: unavailable and available.

_d._ An index to essential information and four sample problems to illustrate use of this information are at the end of the guide (see Section 11). Section 11 provides a planning guide overview, describes applications, and presents a brief explanation of modeling methods used to prepare estimates.

_e._ The guide is subject to limitations of extent and content. Since there are many more possible attack variables than those considered, the guide presents a limited number of estimates. These estimates are based upon the best available toxicological values, but such values are qualified estimates. Therefore, medical planners and staff personnel should use FM 8-9, NATO Handbook on the Medical Aspects of NBC Defensive Operations, AMedP-6 (B), Part III--Chemical, for more authoritative medical descriptions and information on effects of longer duration.

_f._ The guide is most value to the user who needs to know what kinds of casualties to expect, relative numbers of each, and the time frames in which they are likely to appear. To assist the user, who lacks experience in actual CW, the guide describes types of injury, relevant factors, general magnitudes of effects, and effects of time courses on chemical casualty numbers. The casualty estimates are appropriate for training exercises. However, this initial attempt to provide complex estimates has limitations for battlefield use. The limitations are described as follows:

· The guide provides estimates for a few of many possible chemical attacks. Each estimate is based upon computer modeling of the consequences of specified conditions. This is like saying that the numbers of men who sneeze, after inhaling an allergic flower pollen, might be predicted if specific information (EXAMPLE: The wind speed and direction, the current weather, altitude, time of day, and sites of concentrated flower growth) is known for the specific geographic location of a particular brigade on a given mountain. If such estimates are made for a few widely different mountains, a user of the estimates may be able to guess the numbers of sneezing men in his own brigade, located on a separate mountain. However, if the conditions on both mountains are not nearly identical, the user will need to estimate a scaling factor and apply it to adjust the number predicted for a different environment.

· It is unlikely that exactly identical conditions will exist for any two mountains or chemical attacks. The user of the guide must decide which scenario best represents his conditions (or interpolate from two scenarios), then use or adjust the estimates. Therefore, each user must recognize any differences from modeled conditions that might require him to increase, or decrease, an estimate. The user may need to apply a commander's guidance on acceptable risk levels, or consider restrictions of available resources, before accepting, interpreting, or modifying the relevant planning guide numbers. The most difficult problem for the user will be to determine how much to increase, or decrease, planning guide numbers to fit the user's situation. This problem is discussed in paragraph 3.4 of the guide.

· The user should be aware that medical worst-case targeting selects for maximal numbers of survivors entering the medical system, not for maximal operational losses. The tabulated estimates are very highly sensitive to the degree of clustering of personnel and their assumed location within a standardized brigade area. Accordingly, use of this targeting method leads to large variations that are based upon the probabilities of hitting clustered personnel, not evenly or widely distributed personnel. Therefore, these estimates do not provide a good basis for estimating the most likely outcomes for a series of "average" attacks, or for comparing a scenario with an actual attack. Although the tabular format of the guide suggests that the listed numbers are exact, the user should understand that different targeting could readily produce other numbers. Selection of a scaling factor Is discussed in paragraph 3.4 of the guide.

D-20. Medical Planning Considerations

_a._ The guide provides medical planners and staff personnel with a systematic means for estimating chemical casualties in various-sized units, without regard to composition. This document provides more accurate and detailed estimates and is based upon detailed operational scenarios for brigade-sized units. Both chemical planning guides support estimates of combat performance from individuals remaining in the unit.

_b._ Effective mass casualty management requires careful planning. The guide is designed to support such planning by providing medical planners and staff personnel with a systematic means for estimating the number, type, and time-related status of chemical casualties.

NOTE

Each user is advised to consult any available national military NBC defense doctrinal publications of similar nature.

_c._ Medical requirements during CW may be substantially different from those for the usual combat situation. There may be no indication of the presence of chemical agents in some tactical situations. Unprotected units downwind from an attack area, or those entering contaminated areas in an unprotected posture, may be unexpectedly exposed to chemical agents. However, casualty management also involves practice of self-aid and buddy aid, on-site medical triage and emergency care, transport to medical facilities, communications, health services, logistics, and evacuation by ground or air transportation.

_d._ The signs and symptoms of chemical agent exposure may be sudden and intense, or delayed and subtle, depending on the agent used and the level of exposure. Individuals may not reach the first level of care for 15 to 60 minutes after the onset of effects. Decontamination may delay medical treatment. Stabilization should occur before casualties leave emergency care areas, but contamination of these areas may delay the stabilization process. However, effects of decontamination or secondary contamination on estimated doses and effects are not considered in the guide. For medical planning, users of the guide need to consider the various qualifications of its casualty estimates, as discussed in paragraphs 3.4 and 3.4.2 of the guide.

_e._ A chemical burn caused by HD can require more care than a same-sized burn induced by conventional munitions. Therefore, the initial prognosis may require revision after treatment is underway, and estimates of percent capable by performance band may require adjustment.

D-21. Triage

Since a chemical attack may produce mass casualties, preparations for a triage system should be in place before the attack. Paragraph 2.5.1 of the guide describes patient categories by injury severity. For a particular described operational scenario, this information may be used to estimate the number of patients with specified levels of injury. The guide does not provide estimates of the number of patients by triage classification or usual medical and toxicological descriptions.

D-22. Evacuation

_a._ An efficient and flexible evacuation plan is essential for adequate casualty treatment and to retain mobility of forward medical resources. For assessment of a potential mass casualty situation, the full range of evacuation assets, limitations, and obstacles should be considered by the medical planner. After an attack, the medical staff may need to estimate the number of casualties that require evacuation resources at given postexposure times.

_b._ Evacuation requirements will vary with the type of chemical agent used. Nerve agent casualties may not be evacuated because the time course of severe effects is relatively short. Depending upon exposure conditions, HD casualties may or may not require evacuation to a facility where they can receive care for several days, or possibly 6 to 9 months. Estimates provided in the guide can be used as a starting point from which to plan for evacuation resources.

D-23. In-Unit Care

The casualty estimates in the guide are presented with no allowance for in-unit care such as self-aid or buddy aid. Soldiers trained in first aid procedures may be the first to see chemical injuries. The guide can provide an estimate of the numbers of injured personnel who will require first aid. However, there may be need for rapid augmentation, support, or other intervention. Delays in obtaining medical care may occur because of physical damage or contamination of the surrounding area. The tables described in paragraphs 3.3.2 and 3.3.3 of the guide give the time courses of effects that may apply to estimation of in-unit and delayed medical requirements.

D-24. Patient Bed Requirements

Requirements for patient beds and hospitalization time may be greater after chemical exposures than after a conventional attack. Such increases are particularly important for agents, such as HD, that produce injuries followed by a long recovery period. Bed requirements can be estimated using the tables described in paragraphs 3.3.2 and 3.3.3 of the guide. Casualties Occurring by Time Period tables (see paragraph 3.3.3) in the guide are useful after an attack since they show gains and losses of casualties over time. Personnel by Injury Category tables (as described in paragraph 3.3.4) in the guide may be more useful in long-range planning. They show maximum numbers of personnel by injury severity category. The tables in the guide only provide estimates for the first 30 days after attack. Depending upon the theater evacuation policy specified for the operation, hospital days may be either in theater or in the national area.

D-25. Medical Logistics

The estimates provided in the guide are intended to support projections of medical materiel and logistical requirements. Increased demands may occur for certain types of medical and general supplies. These may include specific equipment, kits, dressings, antibiotics, and other critical medical materiel. Demands may also increase for items unique to the chemical battlefield (such as nerve agent antidote autoinjectors), as well as items adapted to chemical environments (including IV systems and special self-contained intensive care units). Tables showing maximum numbers of personnel by injury severity category (see paragraph 3.3.4 in the guide) can provide useful input for logistical planning.

D-26. Medical Force Planning

_a._ The assignment of medical support is normally based upon the total military population and the expected conventional casualty rate. The guide may be used to assess requirements for additional medical units. The use of chemical weapons in tactical situations could be one indication of an increased tempo of warfare and need for additional personnel.

_b._ Although a unit may be targeted for chemical attack, that unit might not be located where the highest number of casualties could occur (as in a downwind hazard area). Accordingly, another unit might have priority for support. The tables presented in the guide can be used in planning for either situation. Some tables (see paragraph 3.3.4 in the guide) show estimated maximum numbers of personnel by injury severity category. Such estimates should be combined with a comprehensive array of other available information to increase the effectiveness of medical force planning.

_c._ The guide is organized into 11 sections. Section 1 introduces the guide and presents background and medical planning considerations. Section 2 provides information on the methodology used to develop the estimates of fatalities, casualties, and effectiveness of individuals remaining in the unit. Section 3 explores the use of the casualty prediction tables based on combat effectiveness decrements and estimates of the number of casualties categorized by insult level. Sections 4 through 10 contain tables of casualty estimates. Section 11 is a tutorial on use of the tool.

_d._ These medical worst-case casualty estimates (see paragraph 2.1.2 through 2.1.7 in the guide) are for personnel in the chemical-targeted and downwind hazard areas of the brigade sector. The actual areas presenting chemical agent hazards to personnel are relatively small and localized when compared to the entire brigade sector. These estimates are not valid for acute effects from repeated exposures, possible delayed effects of low dosage exposures, operational worst-case targeting, targets with different numbers or distributions of exposed personnel, or attacks involving different conditions (of meteorology, terrain, protective status, and so forth) than are modeled. Although the guide is primarily designed to support medical force planning for future CW defense, it may be used to anticipate short-term requirements. For example, delayed requirements of HD victims for care or evacuation resources may be predicted from tables that give estimates of casually numbers by injury type at given times after a CW attack (see paragraphs 3.3.2 and 3.3.3 in the guide).

APPENDIX E

Example X-__, ANNEX__, TO HSS PLAN/OPERATION ORDER__, MEDICAL NBC STAFF OFFICER PLANNING FOR HSS IN AN NBC ENVIRONMENT

1. PURPOSE. Establish standardized procedures for medical NBC staff officers planning, preparing for, detecting, reporting, and providing preventive/protective measures for NBC/TIM hazards. Establish planning procedures for conducting HSS in NBC/TIM environments. Also, establish procedures for providing technical guidance/support to leadership before, during, and after an NBC/TIM event.

2. PROCEDURES

_a._ Medical NBC staff officers prepare list of equipment and procedural guidelines for HSS operations under NBC/TIM conditions. (_Provide a list of radiological detection devices, chemical agent detection/identification kits/devices, components of biological sample/specimen collection, and shipping containers. Provide guidelines/references for operating detection/identification devices._)

_b._ Planning actions for use before an NBC/TIM event. (_Provide preventive/protective measures that the leadership can employ to reduce the health effects of a NBC/TIM event. Also, provide preventive/protective measures that leadership can employ to reduce the health effects of existing NBC/TIM hazards/contamination in an AO. Provide HSS leadership with procedures that can be employed to protect their unit and patients._)

_c._ Planning action for use during an NBC/TIM event. (_Provide preventive/protective measures that the leadership can employ to reduce the health effects of a NBC/TIM event. Provide HSS leadership with procedures that can be employed to protect their unit and patients._)

_d._ Planning actions for use after an NBC/TIM event. (_Provide preventive/protective measures that line leadership can employ to reduce/mitigate the health effects of an NBC/TIM event on the force. Provide HSS leadership with procedure that can be employed to mitigate the effects on their unit and patients._)

_e._ Planning actions for preventive medicine support for NBC/TIM events. (_Provide types and numbers of PVNTMED units/personnel required to perform PVNTMED missions during such events. Describe mission requirements for units/personnel preparing for and reacting to the event. Describe types of samples required and how samples must be collected, preserved, packaged, and shipped to supporting medical laboratory for analysis. Describe detection/monitoring equipment required for the event; such as AN/PDR77, AN/VDR2 radiac meter, chemical agent monitor (CAM), and M272 water test kit._)

_f._ Planning actions for veterinary support for NBC/TIM events. (_Provide types and numbers of veterinary units/personnel required to perform the veterinary service missions during such events. Describe mission requirements for units/personnel preparing for and reacting to the event. Describe types of samples/specimens required and how samples/specimens must be collected, preserved, packaged, and shipped to supporting medical laboratory for analysis. Describe food contamination and decontamination procedures. Describe detection/monitoring equipment required for the event; such as AN/PDR77, AN/ VDR2 radiac meter, and CAM._)

_g._ Planning actions for medical laboratory support for NBC/TIM events. (_Provide requirements for medical laboratory support for an NBC/TIM event. Describe types of laboratory test/ procedures required to provide command verification on the use of an NBC device/weapon. Provide medical laboratory reporting requirements; example: provide report to command surgeon; Joint Task Force/theater commander; senior commander in affected operational area._)

_h._ Planning actions for combat health logistics support for NBC/TIM events. (_Provide requirements for combat health logistics support units and personnel. Describe types of Class VIII supplies required to support HSS response to an event. Examples: Numbers of chemical agent patient decontamination MESs, chemical agent patient treatment sets, number of packets of chemical agent pretreatment tablets required, and chemoprophylaxis required for personnel exposed to a biological agent._)

_i._ Planning actions for combat stress control/mental health support for NBC/TIM events. (_Provide requirements for COSC/mental health support units/personnel. Describe where and how COSC/ mental health personnel will provide their support in response to the event._)

_j._ Planning for medical treatment of NBC/TIM event casualties. (_Provide requirements for medical evacuation and treatment (including emergency dental care) support units/personnel. Provide requirements for nonmedical personnel to perform patient decontamination at the MTF. Describe where and how evacuation and treatment personnel will provide their support in response to include supervision of patient decontamination procedures._)

3. COORDINATION REQUIREMENTS. (_Provide requirements for support such as who should transport/escort samples/specimens from unit of origin to support medical laboratory and on to the CONUS gold standard laboratory. Example: The Technical Escort Unit normally provides transportation and escort for suspect NBC samples, in their absence describe who will provide this service. Provide requirements for numbers of personnel required to perform patient decontamination at supporting MTFs. Describe decontamination support requirements for medical units; especially hospitals and major combat health logistics facilities._)

4. REPORTS. (_Describe types of reports required and frequency of reporting on HSS aspects of NBC/TIM events. Reports should provide, at a minimum, aspects of event and recommended preventive/ protective actions needed to prevent or minimize casualties._)

APPENDIX F

EMPLOYMENT OF CHEMICAL AND BIOLOGICAL COLLECTIVE PROTECTION SHELTER SYSTEMS BY MEDICAL UNITS

Section I. INTRODUCTION

F-1. General

To continue the HSS mission under CB conditions, MTFs must search out contamination free areas or employ CPS systems. Levels I and II MTFs may be able to locate contamination free areas; however, due to the mobility limitations of hospitals, they must always be prepared to operate under CB conditions if the area is under attack. Systems that can be employed as an MTF (Levels I, II, III, and IV) are described in this appendix.

F-2. Types of Collective Protection Shelter Systems

_a._ The CBPS system is employed at the BAS, DCS, and FST. The CBPS is attached to the hard-walled box on the rear of a high mobility multi-purpose wheeled vehicle (HMMWV). The BAS will have one CBPS system per treatment team; the DCS will have four CBPS systems; the FST will have three CBPS systems. Also, systems will be issued to other selected medical treatment teams. When employed at the DCS, the patient holding team will also require GP tents to hold their required number of patients (see Chapter 4). Patients held inside the CBPS will be those that have been decontaminated and admitted into the system for treatment and are recovering from the treatment procedures and are awaiting evacuation. Any patients held in the GP tent must remain in MOPP Level 4 (the GP tent will not have collective protection); these patients are those that are expected to RTD within 72 hours.

NOTES

1. Normally, patients will not be held at the DCS under NBC conditions unless evacuation cannot be accomplished. They should be RTD or evacuated to a clean MTF, as soon as the mission permits.

2. The CBPS can also be employed as the DCS in the conventional mode. Employment in either mode still requires GP tentage for patient holding to meet total patient holding requirements.

_b._ The DEPMEDS-equipped patient care areas of the US Army Force XXI hospital and the hospital unit base (HUB) of the Medical Force 2000 (MF2K) will employ the CP DEPMEDS. It will not protect personnel or patients from the thermal, blast, and initial radiation effects of nuclear weapons; however, it will provide some protection against fallout effects. Areas of the hospital that are not included in the chemically protected (CP) DEPMEDS are MF2K general hospital unit medical (HUM), MF2K field hospital unit holding (HUH), MF2K combat support and general hospital unit surgical (HUS), minimum care wards, administrative areas, food service, supply (including Class VIII), and staff quarters. The system includes--

· Chemically/biologically protected liners for tent, expandable, modular, personnel (TEMPER) and passageways.

· CB-filtered and conditioned (heated or cooled) air (field deployable environmental control unit [FDECU] or H80 Army Standard Heater).

· Chemically/biologically protected ambulatory, litter, and supply air locks.

· Chemically/biologically protected latrines.

· Chemically/biologically protected seals for ISO shelters.

· Chemically/biologically protected water supply system.

_c._ The M20 simplified collective protection system is another system that is available. It consists of a chemically protected room liner, a CB filter blower, and an ambulatory air lock. However, it does not have a litter air lock making it unsuitable for litter patient care. The M20 may be used to protect medical staffs at the DCS, FST, and hospitals, patients held in the GP tents at the DCS and in the minimum care wards and staff quarters of the hospitals. Thus providing additional CB protection for staffs and patients.

Section II. EMPLOYMENT OF THE CHEMICALLY BIOLOGICALLY PROTECTED SHELTER SYSTEM

F-3. Establish a Battalion Aid Station in a Chemically Biologically Protected Shelter

To establish a BAS in a CBPS, use one CBPS per treatment team for conventional operations in a split-team mode. When operating in a squad configuration and in the conventional mode, the two CBPS systems may be complexed to provide more workspace. However, keep in mind that the treatment squad is not staffed to operate the two systems in the CB mode. Therefore, when the two systems are complexed and the treatment squad must convert and operate in the CB mode, they may want to close the complexing door and only use one system. When initially setting up the CBPS for operations in the CB mode, only one CBPS is setup; see Note 2 below. Set up the system as described in TM 10-5410-228-10. To be operational as a BAS, set up medical supplies and equipment as required or as designated in the TSOP. A PDS consisting of a contaminated ambulance point, contaminated triage point, a patient decontamination area, and a contaminated treatment area is established on the downwind (prevailing wind) side of the CBPS. An overhead cover of plastic sheeting (approximately 20 feet wide by 50 feet long) is set up over the PDS, the hot line, and the clean treatment/waiting area; the cover overlaps the air locks. The clean treatment/waiting area should have an area at least 20 feet wide by 15 feet long to allow space for placing patients into the litter air lock without crossing the hot line. A second area covered with 20 × 25 feet of plastic sheeting (the evacuation holding area) is set up beside the shelter on the opposite side from the generator. The clean treatment area is separated from the decontamination area by a hot line with a shuffle pit. Only clean (decontaminated) patients or personnel are allowed to cross the hot line into the clean treatment area, or are admitted into the CBPS. Figure F-1 presents one layout of a BAS using the CBPS. See TM 10-5410-228-10 for complete details on setting up, operating, and maintaining the CBPS. Each CBPS provides 300 square feet of work area.

NOTES

1. The overhead cover is not needed when the wind speed exceeds 10 knots per hour. The plastic will not stay in place.

2. Although each treatment team of the BAS has a CBPS; only one system is set up when operating in the CB mode. This is due to the lack of authorized personnel to operate all systems at one time in the CB mode. =Eight medical= personnel are required to operate the BAS (employing one CBPS) in the CB mode. At least eight nonmedical personnel are required to perform patient decontamination =under medical supervision=. Also, only setting up one system in the CB mode provides the BAS the ability to retain its flexibility in order to maintain its support mission of being where it is needed and when it is needed. The CBPS can be used as the treatment shelter in the conventional mode as well. When the treatment squad is operating in the split-team mode, each team will have a CBPS for use as its treatment shelter. When operating one system in the CB mode, the other system provides a replacement in the event the one in use in the CB mode is damaged beyond repair. This ensures continued HSS to the command.

F-4. Division Clearing Station in a Chemically Biologically Protected Shelter

To establish a DCS using the CBPS, set up four shelters as described in the TM. To be operational, medical supplies and equipment are set up as outlined in the unit TSOP. The four shelters are complexed as shown in Figure F-2. With four CBPS systems set up and operational, a total of 1,200 square feet of work area is available. The contaminated triage, decontamination, and contaminated treatment areas are separated from the clean treatment/waiting area by a hot line with a shuffle pit. Overhead covering is provided as described for the BAS. Patients are admitted through the EMT litter or ambulatory air lock. Patients are released through the patient holding air locks. This aids in controlling entry and exits; thus preventing the introduction of contamination into the systems. At least eight nonmedical personnel from supported units are required to perform patient decontamination under medical supervision at the DCS.

NOTE

In the event that the overpressure system fails on a system that is in use with entry/exit air locks, move to the available shelter with an entry/exit air lock in the same direction for use as the entry/exit until the failed system can be restored. Example 1: At the DCS the EMT system fails, move to the ATM shelter to receive patients until the EMT system has been restored. Example 2: At the DCS the patient hold system fails, move exits to the dental/lab/x-ray shelter until the patient hold system can be restored. Example 3: At the FST the postoperative system fails, use the preoperative shelter until the postoperative system can be restored. These options will allow patient care operations to continue until the failed systems can be restored.

F-5. Forward Surgical Team in a Chemically Biologically Protected Shelter

To establish a FST using the CBPSs, follow the procedures for the DCS except set up three CBPSs. All equipment is set up inside the CBPS as required by your unit TSOP. With three CBPSs set up and operational, a total of 900 square feet of work area is available (Figure F-3). When the FST is forward in support of a medical company and operating in the CB mode, the FST systems are connected to the DCS of the supported medical company. Figure F-4 shows the FST and DCS connected. When operating in the CB mode with the medical company, all patients are received through the EMT air lock of the DCS. The patients are triaged in the DCS and, based upon their injuries, they are routed to the DCS treatment area or to the FST for surgical care. Patients released from the FST for evacuation are placed in a PPW and processed through the litter air lock in the FST recovery section. Patient decontamination is performed at the PDS operated by the DCS. The FST cannot operate in a CB environment without being complexed with the DCS. They do not have any patient decontamination capabilities.

Section III. EMPLOYMENT OF THE CHEMICALLY PROTECTED DEPLOYABLE MEDICAL SYSTEMS AND SIMPLIFIED COLLECTIVE PROTECTION SYSTEMS

F-6. Collective Protection in a Deployable Medical System-Equipped Hospital

_a._ When the threat of NBC action is anticipated in the AO, the CP DEPMEDS components must be set up as the hospital is being established. The system cannot be set up in a hospital that has already been established; to do so requires the hospital to be closed, all TEMPERs be struck, and erected with the M28 liners installed during the erection process. To establish CPS in a DEPMEDS-equipped hospital, follow the procedures as described in TM 10-5410-283-14&P. Training Circular 8-13 provides instructions on establishing a US Army DEPMEDS-equipped hospital (without CPS). Figure F-5 presents one layout of the DEPMEDS-equipped patient care area of a MF2K CSH HUB employing the CP DEPMEDS with an internal water supply system. Figure F-6 presents a layout of the patient care area of the DEPMEDS-equipped portion of an 84-bed MRI hospital. Figure F-7 presents a layout of the patient care area of the DEPMEDS-equipped portion of a 164-bed MRI hospital.

_b._ When employing CP DEPMEDS, provisions for waste disposal and protected water and food supplies within the system are established. Additionally, Class VIII supplies must be protected from contamination. Supplies not in use or needed in the protected operational areas are stored in medical chests, shipping containers, or wrapped in layers of plastic that are inside covered areas, such as closed MILVANs or tents. When contamination is present, only open these storage areas for operational area emergency resupply. Use plastic sheeting or other leak-proof material to provide an additional barrier between the supplies and the contamination. Wrap supplies in plastic or other barrier material for movement from the storage area to the resupply air lock of the CP DEPMEDS.

· A water supply system with distribution hoses is established inside the CP DEPMEDS areas (Figure F-5). Pumps continuously circulate the water from the storage tank through the hose system back to the storage tank. The continuous circulation ensures that the chlorine residual is maintained in the water supply. Personnel in areas that are not included in the continuous flow system must draw water from the system and carry it to their work areas in 5-gallon water cans or other containers. Water resupply is accomplished by passing a hose through the utility port at the end of the TEMPER and M28 liner for a connection to the water transport vehicle. The ends of both hoses must be decontaminated with a 5 percent chlorine solution before connecting them together. The vehicle must have a tank or water supply container that is NBC protected to ensure that the water supplied is free of NBC contamination.

· Rations, as determined by the hospital commander, should be available within the protected area for personnel and patients. Under emergency conditions the commander can authorize feeding patients MRE rations for limited periods of time (up to 72 hours), if they are able to chew and swallow. However, attempts must be made to ensure the required types of rations for patient feeding are available in the CPS. The rations can be stored in any available space; however, the rations must be protected from exposure to possible contaminants, especially liquids. Ration control measures are established to ensure that the rations are only consumed as provided for in the hospital TSOP.

· Two CB protected latrine systems are included in the CP DEPMEDS. The latrines contain bedpan wash areas. The waste from the latrines is collected in an outside receiving container. The waste is removed from the container and disposed of as outlined in the unit TSOP.

· Solid waste (including medical) must be placed in plastic bags. Seal the top of the bags to prevent spillage, odors, or spread of infections/disease. NEVER overfill the bags; always leave enough room in the bag to make a good seal. Place the sealed bags in the supply air lock. Inside personnel close the inner door to the air lock. Outside personnel check to ensure that the inner air lock door is closed before opening the outside door. Remove the bags and take them to the designated waste collection/disposal site. Disposal may be by burial on site or by transport to a designated disposal facility. Transport may be by organic vehicles or contractor support vehicles. The specific technique for disposal will be outlined in the unit TSOP.

· All liquid waste produced within the CP DEPMEDS is collected through a piped liquid waste system to a central collection container. The waste container for the latrines may be used to collect the liquid waste from the operational areas of the CP DEPMEDS. The container is emptied and the waste disposed of as outlined in the unit TSOP.

F-7. Chemically/Biologically Protecting the International Organization for Standardization Shelter

To chemically/biologically protect the ISO shelters, seal all seams and openings of the ISO to prevent the entry of CB agents. The seals connecting the various sides and floor of the shelter may be a CB protected material; thus providing a seal to the shelter. When the seals are not of a CB protected material, the seams must be taped to provide a CB protected barrier over the soft seals. Any openings not being used for introduction of support power lines, water lines or waste water lines must be sealed to prevent entry of CB agents. All access panels must be securely closed to prevent entry of vapors.

F-8. Chemically/Biologically Protecting the Vestibules

The vestibules connect TEMPERs to TEMPERs, ISOs to ISOs, and ISOs and TEMPERs. To harden the vestibules, install the CB liners inside and fasten the ends to the liners of the TEMPER or to the doors of the ISOs. Vestibule liner connectors are provided for use at the entry of each ISO.

F-9. Chemically/Biologically Protecting Air Handler Equipment

_a._ The FDECU is chemically/biologically protected. The system can be operated without the CB filters. When required to operate in the CB mode, the fresh air intake on the FDECU is closed and the CB filter blower is turned on drawing fresh air through the filters to support the FDECU and to provide clean air for the CPS. Additionally, recirculation filters are placed within the shelter system to remove any agent that may have entered through any of the entry/exit areas or through breaches in the shelter system.

_b._ When heaters are required, they must be chemically/biologically protected to prevent entry of contamination. The CB filter units are connected to the fresh air intake side of the heater and the heated air discharge side of the heater is connected to the air supply of the TEMPER/ISO.

F-10. Establish Collective Protection Shelter Using the M20 Simplified Collective Protection System

The M20 is used to establish a CPS within a room of opportunity, or inside a tent; however, the available space will be limited by tent poles and other components of the tent. Currently this system only provides ambient temperature air. See the TM and manufacturer's publication provided with the system and system components for details.

NOTE

The M20 does not have a litter air lock. Only staff or ambulatory patients can enter. See the TM provided with the system for setup procedures.

F-11. Casualty Decontamination

Patients admitted into the MTF must be contamination free. Therefore, a casualty decontamination area must be established near the MTF. The casualty decontamination area should be provided with an overhead cover as described for the CBPS system, except that it does not overlap the entry to the hospital. Also, consideration must be given to the location of other operations at the hospital site when establishing the casualty decontamination area. However, the area must be close enough to the entry/exit of the CPS to protect the patients from the environment and reduce their exposure to recontamination. Keep in mind that under NBC conditions personnel outside of the CPS are at MOPP Level 4 (except decontaminated patients; they have their mask on), thus increasing the stress load and reducing their overall performance capabilities. The entry/exit area must have overhead cover to protect patients awaiting access to the CPS. See Appendix I for setting up a casualty decontamination area and for decontamination procedures.

Section IV. OPERATIONS, ENTRY, AND EXIT GUIDELINES

F-12. Operations

These operations, entry, and exit guidelines may be used to prepare a unit SOP for the operation of CPS systems in your unit.

_a._ When using these guidelines, the following should be considered:

· Location of the shelter (flat, hilly, rocky ground).

· General climate of the AO (high and low temperature variations during operation).

_b._ Information on setting up, striking, and operating the CPS is contained in the equipment publications. Where applicable, special procedures are provided in these publications for setting up in both clean and CB vapor hazard areas. However, the CP DEPMEDS is NOT set up in a CB vapor hazard area. The commander will determine which procedures to use.

_c._ During operations, periodic checks are made of the atmosphere within the shelter. These checks are made by using available chemical agent detection equipment and material to determine if chemical agent penetration has occurred. Should chemical agent penetration occur, all personnel must mask; then ensure that patients are protected until the agent has been purged from the shelter.

F-13. Decontamination of Entrance Area

_a._ Normally, the MTF will not operate in a CB vapor hazard environment. However, if the MTF must remain in an area on a temporary basis and liquid agent contamination is present, the immediate area around the entrance must be decontaminated.

_b._ To decontaminate the area around the entrance, use one or more of the following methods:

· Turn over about 2 inches of soil.

· Remove the top 1-inch layer of soil containing the liquid agent. Use the CAM or M8 detector paper to check the area after the topsoil is removed to ensure complete agent removal.

· Add several inches of clean soil or sand.

· Mix STB into the top 1/2 to 1 inch of soil.

· Use DS2 on contaminated hard-surfaced areas or frozen ground.

F-14. Procedures Prior to Entry

All personnel (staff and patients) must be decontaminated before they are permitted entry into the CPS.

· Use chemical detection equipment to check for the presence of contamination on individuals and their equipment; also check for presence of contamination on individual weapons if they are allowed in the CPS. Normally, weapons will not be allowed in the patient care areas, but will be stored outside near the entry/exit. Thorough decontamination is critical in preventing contamination transfer into the CPS.

· When a chemical agent is detected, follow the procedures in Appendix C for patient decontamination and FM 3-5 for other personnel decontamination before entering the CPS. All contaminated clothing and equipment are placed in the contaminated dump. Weapons should not have been evacuated with patients. However, if weapons are evacuated with the patient, they are decontaminated and held by the MTF (administrative personnel or hospital supply) for disposition instructions.

· Decontamination must be thorough; procedures must be strictly followed. Failure to do so can contaminate the interior of the MTF and injure medical treatment personnel; thus reducing their mission support capabilities.

F-15. Entry/Exit for the Collective Protection Shelter System

_a. Ambulatory Personnel._

(1) _Entry procedures._

(_a_) Ambulatory patients and others remove their MOPP (except their mask), BDUs, and boots outside the air lock. This procedure reduces the amount of possible contamination entering the air lock.

(_b_) A check is made to ensure that the ambulatory air lock is empty and the inner door is closed.

(_c_) The individual enters the air lock and closes the outer door.

(_d_) The air lock is purged for 3 minutes. At the end of the purge cycle, the individual checks for contamination. If contaminated, the individual must return to the outside and decontaminate his skin; then return to the air lock and repeat the purge cycle and contamination check. If no contamination is detected, the protective mask is removed and placed in a plastic bag. The plastic bag is sealed and labeled. The individual opens the inner air lock door and enters the CPS; the plastic bag is carried into the shelter with the individual.

(2) _Exit procedures._

(_a_) A check is made to ensure that the ambulatory air lock is empty and the outer door is closed.

(_b_) The individual enters the air lock and closes the inner door.

(_c_) The individual puts on his protective mask; then exits through the outer door.

(_d_) The individual puts on his BDU and boots then assumes the established MOPP level before departing the immediate area of the exit door.

NOTES

1. Ambulatory patients that enter the CBPS become litter patients and are placed in PPW when released because the MTF does not have replacement MOPP ensembles for patient issue.

2. Exits must be spaced so that at least a 3 minute purge of the air lock is accomplished before the inside door is opened. Only open the doors long enough to permit passage.

_b._ _Litter Patients._

(1) _Entry procedures._

(_a_) An outside aidman notifies an inside aidman that a litter patient is ready for admission.

(_b_) The inside aidman ensures that the inner litter air lock door is closed. The outside aidmen open the outer air lock door and place the litter on the litter rails; they push the patient into the air lock headfirst; then they close the outer door. After a purge time of 3 minutes, an aidman inside the CPS opens the inner door and checks the patient to ensure that he is contamination free. The patient is checked by placing the CAM nozzle near absorptive surfaces, such as the patient's hair. If no contamination is found, the aidman removes the patient's mask and places it in a plastic bag. The inside aidmen remove the patient from the air lock and position him on treatment litter stands, or move him to the treatment area as directed by supervisory personnel.

(_c_) Patients received at the treatment facility in the PPW are checked for contamination; if they are contamination free, they may be processed through the litter air lock in the PPW. The inside aidmen ensure that the inner litter air lock door is closed. The outside aidmen open the outer air lock door and place the litter on the litter rails and push the patient into the litter air lock headfirst, then close the outer door. Purge the air lock for 3 minutes. After the purge time, an aidman inside of the CPS opens the inner air lock door and uses the CAM to check the patient to ensure that he is free of contamination. If no contamination is found, the inside aidmen remove the patient from the air lock. (If the patient is wearing a protective mask, the mask is removed and placed in a plastic bag before the patient is moved from the air lock.) As the patient is removed from the air lock, the PPW is opened and rolled inside out so that any desorbing vapors are adsorbed by the charcoal layer. The inside aidmen remove the patient from the air lock and position him on litter stands. The patient is transferred to a clean litter; then moved to the treatment area as directed by supervisory personnel. The receiving litter and PPW is returned to the outside; dispose of the PPW in the contaminated waste dump. Decontaminate the litter and return it to the litter pool.

NOTE

Should contamination be found when monitoring the air lock in (_b_) or (_c_) above, repeat the purge cycle, then retest for contamination. All vapor hazards must be eliminated before the patient is moved into the CPS. Repeating the purge cycle may NOT be possible if the patient is in need of immediate lifesaving care. The patient may have to be returned to the outside treatment area for immediate care.

(2) _Exit procedures._

(_a_) The litter patient is placed in a PPW. A battery operated blower unit with a CB filter may be attached to the PPW to provide fresh air to the patient; thus reducing the heat load on the patient and the carbon dioxide buildup inside the PPW.

(_b_) An inside aidman notifies an outside aidman that the patient is ready to exit the shelter. An outside aidman ensures that the outer air lock door is closed. The patient is placed in the litter air lock feet first. The inner air lock door is closed. The outside aidmen open the outer door and remove the patient.

(_c_) Hospital staff, visitors, or ambulatory patients exit through the ambulatory air lock. Before entering the air lock, each individual must ensure that the outer air lock door is closed. The individual enters the air lock and closes the inner door; puts on his protective mask and exits through the outer door. The individual puts on his BDU and boots, and then assumes the established MOPP level before departing the immediate area of the exit door.

NOTE

Exits must be spaced at least 3 minutes apart to allow for a complete purge cycle of the air lock.

F-16. Resupply of Protected Areas

Resupply of protected areas is accomplished by placing contamination-free supplies or equipment on a litter and passing it through the litter air lock, or processing it through the supply air lock. The litter air lock must be purged for 3 minutes. The supplies must be checked for contamination before they are removed and placed within the CPS. The supply air lock must be purged for the stated time as outlined in the supporting technical manual; usually 45 minutes. Again the supplies must be checked for contamination before they are removed and placed within the CPS.

APPENDIX G

PATIENT DECONTAMINATION

Section I. INTRODUCTION

G-1. General

_a._ Patient decontamination presents special problems for units and HSS personnel. Nuclear, biological, and chemical contaminated patients create increased hazards to rescuers and HSS personnel; thus, causing delays in providing essential first aid and medical treatment for injuries from sources other than the exposure to NBC weapons/agents. Casualty decontamination procedures are performed by each individual, as buddy aid, or at a unit decontamination station prior to the arrival of medical personnel. See FM 3-5 for procedures on individual, buddy aid, and unit decontamination. Patient decontamination procedures are normally performed at an MTF under medical supervision. Patient decontamination stations may be established (collocated) at central unit decontamination faculties, if medical support is available. However, augmentation medical support must be requested to provide patient care and supervise the patient decontamination process. Because, when the unit is undergoing decontamination operations, organic medical personnel must also decontaminate their equipment and personnel. Therefore, they are not available to provide medical support for operating the patient decontamination station that is collocated with the central unit decontamination facility.

_b._ The term "decontamination" as used herein means the removal or neutralization of radioactive particles, BW agents, and CW agents to levels low enough that patients may be treated without contaminating the MTF and without posing health risks to unprotected medical providers. "Decontamination" does not imply absolute removal of contaminants.

NOTE

The decontamination procedures described below are for NBC contaminated patients. These procedures may also be used for most TIM contaminated patients. However, soap and water will suffice for most TIMs; but some TIMs react with water. For those TIMs another material must be used to decontaminate patients. For detailed information on decontamination of TIM contaminated patients, see FM 8-500.

_c._ Physical removal of contaminants is the primary method of decontamination. Physical removal does not require vigorous scrubbing; in fact, vigorous scrubbing can force some agents deeper into the skin; thus, increasing the agent effect rather than reducing its effects. The use of a M291 skin decontaminating kit (SDK) neutralizes/reduces the effects of an agent, but physical removal is of utmost importance. When a SDK is not available, the use of soap and water should be considered as the next best method. However, the use of soap and water requires large amounts of water that may not be available because the soap must be rinsed from the skin to reduce skin irritation from the soap. An alternate skin decontaminant is a hypochlorite solution; but it should only be used when SDKs and/or sufficient quantities of water are not available. Use a 0.5 percent hypochlorite solution on the protective mask and skin. A 5 percent hypochlorite solution can be used on the mask hood, gloves, and other outer garments.

G-2. Immediate Decontamination

Decontamination must begin at the platoon and company level with the individual soldier, prior to the arrival of medical personnel. The soldier himself or members of his team must perform immediate decontamination. When the casualty's condition and the mission permits, they may go through a MOPP gear exchange at their unit before evacuation (see FM 3-5). Performing a MOPP gear exchange at the unit before evacuation will reduce the amount of contamination that can be transferred to the MEDEVAC vehicle. However, the MOPP gear exchange must not cause further injury to the casualty. First aid for CW agent must be administered; such as administering nerve agent antidotes (such as nerve agent antidotes and convulsant antidote for nerve agent [CANA]), as required. Enter the time and type of contamination on a field expedient NBC casualty card (Figure G-1). Use the CAM, M8 chemical agent detector paper, or M9 tape to determine the type of chemical contamination. Use a radiation detection meter/device to determine the level of radioactive contamination, if required. Currently, there are no BW agent detectors that can be used to check patients for BW agent contamination. Therefore, all patients suspected of being contaminated with a BW agent must be decontaminated. When medical personnel arrive, they should enter the time and type of contamination and number of antidote injections that were administered as first aid on the Department of Defense (DD) Form 1380 (Field Medical Card [FMC]).

G-3. Patient Decontamination and Thorough Decontamination Collocation

_a._ Collocating patient and thorough decontamination operations in the BSA may provide several advantages (Figure G-2). It--

· Preserves the principle of limiting the spread of contamination.

· Reduces confusion on the battlefield.

· Reduces demand on logistics support elements.

· Improves contamination control and reporting: One location and one person in charge.

· Reduces overall security requirements.

· Speeds PDS closure by using the thorough decontamination site.

_b._ An identified disadvantage is the increased size of the site and the requirement for medical support augmentation (a treatment squad from another organization with required patient decontamination and treatment MESs) to operate the PDS.

NOTE

Organic medical personnel must not be used to perform the HSS mission at the collocated site. They must go through the decontamination process with their unit.

_c._ These operations do not require that both patient decontamination and unit thorough decontamination be executed simultaneously. The PDS can be running while the thorough decontamination site is being prepared. Patient decontamination cannot be delayed since patients may be suffering life-threatening injuries as well as exposure to NBC agents. Therefore, the PDS must be established and operational before the first patients arrive. The wind direction must be common to both sites.

_d._ The decontamination platoon leader is responsible for establishing the combined decontamination site. The medical unit commander/surgeon coordinates with the decontamination platoon leader for the location of the patient receiving, PDS, and MTF. The lowest level at which this operation will usually be planned is brigade. This operation requires extensive planning and must involve the brigade chemical officer, brigade S4, and the medical company commander/brigade surgeon. Decontamination support for special operation forces, other unique operational organizations, or for nonlinear operations may require execution at a lower level. The supporting medical personnel operate the PDS. Nonmedical personnel perform patient decontamination procedures under medical supervision. Patient decontamination procedures are described below.

NOTE

Patient decontamination differs from thorough decontamination in that the patients' medical status must be monitored and medical treatment must be provided during the decontamination process.

_e._ Although a PDS may be collocated with thorough decontamination, a PDS must be operational at Levels I, II, III, and IV MTFs. Contaminated patients may present directly to the MTF for care, or patients previously decontaminated may become contaminated en route. Therefore, all patients arriving at an MTF must be checked for contamination. If contaminated, they must be decontaminated before they are admitted to the MTF.

G-4. Patient Decontamination at the Battalion Aid Station (Level I)

_a._ When battle conditions prevent patient decontamination procedures forward or the patient is contaminated en route, the patient may have to be decontaminated at the BAS. Contaminated patients arriving at the BAS must be decontaminated before admission into the clean treatment area.

_b._ Patient decontamination is performed by eight nonmedical personnel from the supported unit at the BAS. The patient decontamination personnel operate as two-man teams to perform the patient decontamination procedures. The patient decontamination teams operate under the supervision of medical personnel to ensure that no further injury is caused to the patient by the decontamination process. Each team receives a patient from the triage point and performs both clothing removal and skin decontamination procedures. The team requires assistance from another team to perform litter changes; see details below.

G-5. Patient Decontamination at the Medical Company Clearing Station (Level II)

The medical company clearing station may receive patients from the BAS or directly from other areas who have not been decontaminated. The clearing station must also have a patient decontamination area. As with the BAS, the clearing station must have a minimum of eight nonmedical personnel from the supported units to perform patient decontamination. Procedures for patient decontamination at the clearing station are the same as for the BAS.

G-6. Patient Decontamination at a Hospital (Level III or IV)

To the maximum extent possible, hospitals are located away from tactical or logistical targets. Contaminated patients will arrive from forward MTFs and units located within the geographical area of the hospital. Patient decontamination is done by at least 20 nonmedical personnel from units located in the geographical area/base cluster of the hospital. Procedures for patient decontamination at the hospital are the same as for the BAS. However, several patient decontamination stations can be operated simultaneously at the hospital patient decontamination site. Further, all patients arriving at the hospital will be decontaminated and receive full treatment within the capabilities of the hospital.

G-7. Prepare Hypochlorite Solutions for Patient Decontamination

An alternative patient decontamination agent is a hypochlorite solution; however, the hypochlorite solution must be prepared. Two concentrations of the hypochlorite solution are required. A 5 percent hypochlorite solution to decontaminate gloves, aprons, litters, cutting devices, the patient's mask hood, and other nonskin contact areas. The patient's mask, skin, splints, and tourniquets and their wounds are irrigated using a 0.5 (½) percent hypochlorite solution. To prepare the solutions, use calcium hypochlorite (HTH) granules (supplied in 6-ounce jars in the chemical agent patient treatment and chemical agent patient decontamination MES), bulk HTH, or sodium hypochlorite (household bleach). Prepare the required solutions as shown in Table G-1 below.

_Table G-1. Preparation of Hypochlorite Solutions for Patient Decontamination_

================================================================== HTH HTH MRE HOUSEHOLD PERCENT IN 5 OUNCES SPOONFULS BLEACH GALLONS OF WATER ------------------------------------------------------------------ 6 [*]5 2 QUARTS 0.5 48 40 [**] 5.0 ------------------------------------------------------------------

[*] THESE MEASUREMENTS ARE USED WHEN BULK HTH IS USED. TO MEASURE THIS PREPARATION, USE THE PLASTIC SPOON SUPPLIED WITH YOUR MEAL, READY-TO-EAT (MRE). THE AMOUNT OF HYPOCHLORITE TO BE USED IS A HEAPING SPOONFUL (THAT IS, ALL THAT THE SPOON WILL HOLD). DO NOT SHAKE ANY GRANULES OFF OF THE SPOON BEFORE ADDING TO THE WATER.

[**] DO NOT DILUTE IN WATER; HOUSEHOLD BLEACH IS 5 TO 6.25 PERCENT SOLUTION; IT IS USED FULL STRENGTH FOR 5 PERCENT APPLICATIONS. ==================================================================

G-8. Classification of Patients

On the NBC battlefield, two classifications of patients will be encountered--contaminated and uncontaminated. Those contaminated may suffer from the effects of an NBC agent, of a conventional wound, or both. Some may suffer combat stress or heat injuries induced by the stress of NBC conditions and extended time spent in MOPP Level 4. It is important to follow proper decontamination procedures to limit the spread of contamination to others and equipment. The most important decontamination is performed at the site of contamination. Decontamination at a later time may be too late to prevent injury to the individual, especially when exposed to vesicants. All agents should be promptly removed from the skin.

G-9. Patient Treatment

_This appendix only describes patient decontamination procedures._ For NBC treatment procedures, refer to FM 4-02.283, FM 8-284, and FM 8-285.

Section II. PATIENT DECONTAMINATION PROCEDURES

G-10. Decontaminate a Litter Chemical Agent Patient

Before contaminated patients receive medical treatment in the clean treatment area, they must be decontaminated. Place the cutting device in a container of 5 percent hypochlorite solution between each use. Each decontamination team member decontaminates his gloves and apron with the 5 percent hypochlorite solution frequently to prevent spreading any contamination to patient's skin. Decontaminate the patient's skin, bandages, wounds, mask, identification tags with chain, and splints with a 0.5 percent hypochlorite solution. The litter patient is decontaminated and undressed as follows:

NOTE

Litter patients requiring EMT or ATM in the clean area of the MTF will be completely decontaminated. A patient not requiring clean EMT or ATM at the MTF, but requiring further evacuation (for example: a stable patient with a partial amputation of a lower extremity) should only have his wound area and MOPP spot decontaminated to remove any gross contamination. The patient should be evacuated in his MOPP.

_a._ =Step 1. Physically remove gross contamination.= Use any stiff material (stick, cardboard, plastic strip, metal banding strap) to physically remove gross contamination from the patient's MOPP ensemble. Much of the CW agent contamination can be removed through physical means.

_b._ =Step 2. Decontaminate the patient's mask and hood.= The patient has been triaged and stabilized (if necessary) by the senior trauma specialist in the patient decontamination area. A two-man decontamination team moves him to the litter stands at the clothing removal station.

(1) =Decontaminate the mask and hood.= Use the SDK, or use a 5 percent hypochlorite solution or household bleach to sponge down the front, sides, and top of the mask hood. Decontaminate spots with the SDK or the 5 percent hypochlorite solution.

(2) =Remove hood.= Remove the hood by cutting the hood. Before cutting the hood, dip the cutting device in a 5 percent hypochlorite solution. For the M17-series mask, cut the neck cord and the small string under the voicemitter. Release or cut the hood shoulder straps and unzip the hood zipper. Cut the hood, close to the filter inlet cover and eye-lens outsert, upward to the top of the eye-lens outsert, and across the forehead to the outer edge of the other eye-lens outsert. Proceed downward toward the patient's shoulder, staying close to the eye-lens, then across the lower part of the voicemitter to the zipper. After dipping the cutting device in the 5 percent hypochlorite solution, cut the hood from the center of the forehead over the top of the head (see Figure G-3). Fold the left and right sides of the hood to the side of the patient's head, laying the sides of the hood on the litter. For the M40-series protective mask cut the hood shoulder straps, then cut the quick-doff hood from the front bottom center to the chin through the elastic band under the chin. Fold the left and right sides of the hood over the shoulders away from the head.

(3) =Decontaminate the protective mask and exposed skin.= Using the SDK, soap and water, or a 0.5 percent hypochlorite solution, wipe the external parts of the mask. Cover the mask air inlet(s) with gauze or your hand to keep the mask filter dry. Continue by wiping the exposed areas of the patient's face, including the neck and behind the ears.

(4) =Remove the Field Medical Card.= Cut the patient's FMC tie wire, allowing the FMC to fall into a plastic bag. Seal the plastic bag and rinse the outside of the bag with a 5 percent hypochlorite solution. Place the plastic bag with the FMC under the back of the protective mask head straps. The FMC will remain with the patient.

_c._ =Step 3. Remove gross contamination from the patient's overgarment.= Remove all visible gross contamination by scraping with a stick or other device.

_d._ =Step 4. Remove the patient's personal effects and protective overgarment.=

(1) =Remove patient's personal effects.= Remove the patient's personal effects from his protective overgarment and BDU pockets. Place the articles in a plastic bag, label with the patient's identification, and seal the bag. If the articles are not contaminated, return them to the patient. If the articles are contaminated, place them in the contaminated holding area until they can be decontaminated, and then return them to the patient.

(2) =Cut the patient's overgarment.= The overgarment jacket and trousers may be cut simultaneously. Two persons may be cutting clothing at the same time. =Cut around bandages, tourniquets, and splints, leaving them in place.=

NOTE

A cut is a separation of material by use of a cutting device that cuts material into two pieces. EXAMPLE: Cutting the sleeve from the cuff to the jacket collar is one cut.

+-----------------------------------------------------------+ | CAUTION | | | | Bandages may have been applied to control severe bleeding | | and are treated like tourniquets. Only medical personnel | | remove bandages, tourniquets, and splints. | +-----------------------------------------------------------+

(3) =Remove overgarment jacket.= Make two cuts, one up each sleeve from the wrist up to the shoulder, and then through the collar (Figure G-4). Do not allow the gloves to touch the patient along the cut line. Dip the cutting device in the 5 percent hypochlorite solution before making each cut to prevent contamination of the patient's uniform or underclothing. Keep the cuts close to the inside of the arms so that most of the sleeve material can be folded outward. Unzip the jacket; roll the chest sections to the respective sides, with the inner surface outward. Continue by tucking the clothing between the arm and chest. Roll the cut sleeves away from the arms, exposing the black liner.

(4) =Remove overgarment trousers.= Cut both trouser legs starting at the ankle as shown in Figure G-5. Keep the cuts near the inseams to the crotch. With the left leg, continue cutting to the waist, avoiding the pockets. With the right leg, cut across at the crotch to the left leg cut. Place the cutting device in the 5 percent hypochlorite solution. Fold the cut trouser halves away from the patient and allow the halves to drop to the litter with contaminated (green) side down. Roll the inner leg portion under and between the legs.

(5) =Remove outer gloves.= This procedure can be done with one person on each side of the patient working simultaneously. The decontamination team will decontaminate their gloves in 5 percent hypochlorite solution. Next, lift the patient's arms up and out of the cutaway sleeves unless detrimental to the patient's condition. Grasp the fingers of the glove, roll the cuff over the fingers, turning the glove inside out. Do not remove the inner cotton glove liners at this time. Carefully lower the arms across the chest after the outer gloves have been removed (Figure G-6). Do not allow the patient's arms to come into contact with the exterior of his overgarment. Drop his gloves into the contaminated waste bag. Dip your gloves in the 5 percent hypochlorite solution.

(6) =Remove overboots.= Cut the overboot laces and fold the lacing eyelets flat outwards. If the green vinyl overboot (GVO) is worn, first try to remove the overboot without cutting; if necessary, cut the boot along the front. While standing at the foot of the litter, hold the heel with one hand, pull overboot downwards, and then pull towards you to remove the overboot over the combat boot heel. Remove the two overboots simultaneously. This reduces the likelihood of contaminating one of the combat boots. While holding the heels off the litter, have a decontamination team member wipe the end of the litter with the 5 percent hypochlorite solution to neutralize any liquid contamination that was transferred to the litter from the overboots. Lower the patient's heels onto the decontaminated litter. Place the overboots in the contaminated waste bag. Decontamination personnel dip their gloves in the 5 percent hypochlorite solution.

_e._ =Step 5. Remove patient's battle dress uniform.=

(1) =Remove battle dress uniform.= Cut the BDU jacket and trousers as described above for the protective overgarment. Roll the jacket and trousers as described for the protective overgarment.

(2) =Remove combat boots.= Cut the bootlaces along the tongue. Remove the boots by pulling them towards you. Place the boots in the contaminated waste bag. Do not touch the patient's skin with contaminated gloves when removing his boots.

(3) =Remove undergarments.= Remove the patient's tee shirt. Dip the cutting device in the 5 percent hypochlorite solution between each cut. Cut both sleeves from the inside, starting at the elbow, up to the armpit. Continue cutting across the shoulder to the collar. Cut around bandages or splints, leaving them in place. Next, peel the tee shirt away from the body to avoid spreading contamination. If the patient is wearing a brassiere, cut it between the cups. Cut both shoulder straps where they attach to the cups and lay them back off of the shoulders. Remove the patient's under shorts/panties by cutting from the lower side of the hip to the waist on both sides. Fold the front flap of the shorts/panties down between the patient's legs onto the litter. Do not allow the outside of the garment to touch the patient's skin. Remove the socks and cotton glove liners. Do not remove the patient's identification tags.

_f._ =Step 6. Transfer the patient to a decontamination litter.= After the patient's clothing has been cut away, he is transferred to a decontamination litter or a canvas litter with a plastic sheeting cover. Three decontamination team members decontaminate their gloves and aprons with the 5 percent hypochlorite solution. One member places his hands under the patient's legs at the thighs and Achilles tendons, a second member places his arms under the patient's back and buttocks, and a third member places his arms under the patient's shoulders and supports the head and neck. They carefully lift the patient using their knees (not their backs) to minimize back strain. While the patient is elevated, another decontamination team member removes the litter from the litter stands and replaces it with a decontaminated (clean) litter. The patient is carefully lowered onto the clean litter. The contaminated clothing and overgarments are placed in bags and moved to the contaminated waste dump. The dirty litter is rinsed with the 5 percent hypochlorite solution and placed in the litter storage area.

_g._ =Step 7. Decontaminate skin.=

(1) =Spot decontamination.= With the patient in a supine position, spot decontaminate the skin using the SDK or a 0.5 percent hypochlorite solution. Decontaminate areas of potential contamination. Include areas around the neck, wrists, and lower parts of the face. Decontaminate the patient's identification tags and chain, if necessary.

NOTE

Complete body wash is not appropriate and may be injurious to the patient. During complete body wash, the patient would have to be rolled over to reach all areas of the skin. This is not necessary for adequate decontamination.

(2) =Trauma specialist care.= During decontamination, the clothing around bandages, tourniquets, and splints was cut and left in place.

· The trauma specialist replaces the old tourniquet by placing a new tourniquet ½ to 1 inch above the old one. He then removes the old tourniquet and decontaminates the patient's skin using the M291 pads or a 0.5 percent hypochlorite solution.

· The trauma specialist gently cuts away bandages and decontaminates the area around the wound; dusts the wound with the SDK, or irrigates soft tissue wounds with the 0.5 percent hypochlorite solution. If bleeding begins, the trauma specialist replaces the bandage with a clean one. The trauma specialist ensures splints are not removed, but are decontaminated in place by applying the 0.5 percent hypochlorite solution to them, to include the padding and cravats. Splints will only be removed by a physician or under the supervision of a physician.

(3) =Check patient for completeness of decontamination.= The patient is checked with the CAM or with M8 detector paper for completeness of decontamination.

NOTE

Other monitoring devices may be used when available.

(4) =Dispose of contaminated waste.= Dispose of contaminated bandages and coverings by placing them in a contaminated waste bag. Seal the bag and place it in the contaminated waste dump.

_h._ =Step 8. Transfer the patient across the shuffle pit.=

(1) The patient's clothing has been cut away; his skin, bandages, and splints have been decontaminated. Now the litter is transferred to the shuffle pit and placed upon the litter stands. The shuffle pit is wide enough to prevent the patient decontamination team members from straddling it while carrying the litter. Four decontamination team members transfer the patient to a clean treatment litter in the shuffle pit. A member of the patient decontamination team removes the bagged FMC and holds it so that a trauma specialist on the clean side of the hot line can read it. A trauma specialist on the clean side of the hot line prepares a new FMC before the patient is moved to the clean area. The old FMC is disposed of with other contaminated waste.

(2) Decontamination team members rinse or wipe down their aprons and gloves with the 5 percent hypochlorite solution.

(3) Three decontamination team members lift the patient off the decontamination litter (see Step 6 for lifting procedures).

(4) While the patient is elevated, another decontamination team member removes the litter from the stands and returns it to the decontamination area. A trauma specialist from the clean side of the shuffle pit replaces the litter with a clean one. The patient is lowered onto the clean litter. Two trauma specialists from the clean side of the shuffle pit move the patient to the clean treatment area. The patient is treated in this area or waits for processing into the CPS. The litter removed by the decontamination team member is wiped down with the 5 percent hypochlorite solution in preparation for reuse.

NOTE

Before decontaminating another patient, each decontamination team member drinks approximately one-half quart of water. The exact amount of water consumed is increased or decreased according to the temperature (see Table G-2 below).

_Table G-2. Heat Injury Prevention and Water Consumption._

===========+=========+===============+================+=============== | | EASY WORK | MODERATE WORK | HARD WORK | +-------+-------+-------+--------+-------+------- HEAT | WBGT | WORK/ | WATER | WORK/ | WATER | WORK/ | WATER CATEGORY | INDEX | REST | INTAKE| REST | INTAKE | REST | INTAKE |DEGREES F| MIN | QT/HR | MIN | QT/HR | MIN | QT/HR -----------+---------+-------+-------+-------+--------+-------+------- 1 (WHITE) | 78-81.9 | NL | ½ | NL | ¾ | 40/20 | ¾ 2 (GREEN) | 82-84.9 | NL | ½ | 50/10 | ¾ | 30/30 | 1 3 (YELLOW)| 85-87.9 | NL | ¾ | 40/20 | ¾ | 30/30 | 1 4 (RED) | 88-89.9 | NL | ¾ | 30/30 | ¾ | 20/40 | 1 5 (BLACK) | >90 | 50/10 | 1 | 20/40 | 1 | 10/50 | 1 -----------+---------+-------+-------+-------+--------+-------+-------

THE WORK/REST TIMES AND FLUID REPLACEMENT VOLUMES WILL SUSTAIN PERFORMANCE AND HYDRATION FOR AT LEAST 4 HOURS OF WORK IN THE SPECIFIED HEAT CATEGORY.

NL=NO LIMIT TO WORK TIME PER HOUR.

REST MEANS MINIMAL PHYSICAL ACTIVITY (SITTING OR STANDING) ACCOMPLISHED IN SHADE, IF POSSIBLE.

CAUTION: HOURLY FLUID INTAKE SHOULD NOT EXCEED 1 QUART.

DAILY FLUID INTAKE SHOULD NOT EXCEED 12 QUARTS.

WEARING BODY ARMOR ADDS 5° F TO WBGT INDEX.

WEARING ALL MOPP OVERGARMENTS ADDS 10° F TO WBGT INDEX.

+----------------------------------------------------------+ | =WARNING= | | | | Do not exceed a fluid intake of 1 quart per hour. Do not | | exceed a fluid intake of 12 quarts per day. | | | +----------------------------------------------------------+

G-11. Decontaminate an Ambulatory Chemical Agent Patient

_a._ All ambulatory patients requiring EMT or ATM in the clean area of the BAS will be decontaminated. A member of the decontamination team or other ambulatory patients will assist the patient in removing his clothing and decontaminating his skin.

_b._ Patients requiring only minimal care will undergo spot decontamination of their MOPP gear as required for their medical treatment. They will be treated in the contaminated EMT area and returned to duty. They will undergo decontamination and a MOPP gear exchange with their unit.

_c._ Stable patients not requiring treatment at the BAS, but requiring evacuation to a higher level of care for treatment (example: A patient with a broken arm) should be evacuated in MOPP Level 4 by any available transportation. However, before evacuation, spot remove all thickened/persistent agents from protective clothing.

NOTES

1. Remember, do not remove clothing from an ambulatory patient unless he requires treatment in the clean treatment area of the BAS or clearing station. Only spot decontaminate the patient's clothing and evacuate him to the next level of care.

2. Place cutting device used in this procedure in a container of 5 percent hypochlorite solution when not in use. Most ambulatory patients will be treated in the contaminated treatment area and returned to duty. Upon removal of an ambulatory patient's clothing, he becomes a litter patient. The BAS and clearing station do not have clothing to replace those cut off during the decontamination process. The patient must be placed in a PPW for protection during evacuation. A battery operated blower unit with a CB filter may be attached to the PPW to provide fresh air to the patient; thus reducing the carbon dioxide buildup inside the PPW (Figure G-7).

_d._ =Step 1. Remove load-carrying equipment.= Remove load-carrying equipment (LCE) by unfastening/unbuttoning all connectors or tie straps; then place the equipment in a plastic bag. Place the plastic bag in the designated storage area for later decontamination.

_e._ =Step 2. Decontaminate the patient's mask and hood.= After the patient has been triaged and treated (if necessary) by the senior trauma specialist in the PDS, the patient (assisted by another ambulatory patient or a member of the patient decontamination team, if necessary) begins the clothing removal process.

(1) =Decontaminate and remove mask hood.= Sponge down the front, sides, and top of the hood with a 5 percent hypochlorite solution. Remove the hood by cutting (Figure G-3) or, with the quick-doff hood or other hoods, by loosening the hood from the mask attachment points. Before cutting the hood, dip the cutting device in the 5 percent hypochlorite solution. Begin by cutting the neck cord and the small string under the voicemitter. Next, release or cut the hood shoulder straps and unzip the hood zipper. Proceed by cutting the hood upward, close to the filter inlet cover and eye-lens outserts, to the top of the eye-lens outsert, across the forehead to the outer edge of the other eye-lens outsert. Proceed downward toward the patient's shoulder, staying close to the eye-lens and filter inlet. Cut across the lower part of the voicemitter to the zipper. After dipping the cutting device in the 5 percent hypochlorite solution again, cut the hood from the center of the forehead over the top of the head and fold the right and left sides of the hood away from the patient's head, removing the hood.

(2) =Decontaminate the mask and patient's face.= Decontaminate the mask and the patient's face by using the SDK or a 0.5 percent hypochlorite solution. Wipe the external parts of the mask; cover both mask air inlets with gauze or your hands to keep the mask filters dry. Continue by wiping the exposed areas of the patient's face, to include the neck and behind the ears.

_f._ =Step 3. Remove Field Medical Card.= Cut the FMC tie wire, allowing the card to fall into a plastic bag. Seal the plastic bag and rinse it with the 5 percent hypochlorite solution. Place the plastic bag under the back of the protective mask head straps.

_g._ =Step 4. Remove all gross contamination from the patient's overgarment.= Remove all visible contamination spots by using the SDK (preferred method) or a sponge dipped in a 5 percent hypochlorite solution.

_h._ =Step 5. Remove overgarments.=

(1) =Remove the patient's personal effects.= Place the patient's personal effects in a clean bag and label with the patient's identification. If they are not contaminated, give them to him. If his personal effects are contaminated, place the bagged items in the contaminated storage area until they can be decontaminated, then return them to the patient.

(2) =Remove overgarment jacket.= Have the patient stand with his feet spread apart at shoulder width. Unsnap the jacket front flap and unzip the jacket. If the patient can extend his arms, have him clinch his fists and extend his arms backward at about a 30° angle. Move behind the patient, grasping his jacket collar at the sides of the neck, peel the jacket off the shoulders at a 30° angle down and away from the patient. Avoid any rapid or sharp jerks that can spread contamination. Gently pull the inside sleeves over the patient's wrists and hands. If the patient cannot extend his arms, you must cut the jacket to aid in its removal. Dip the cutting device in the 5 percent hypochlorite solution between each cut. As with the litter patient, cut both sleeves from the inside, starting at the wrist, up to the armpit. Continue cutting across the shoulder to the collar. Cut around bandages or splints, leaving them in place. Next, peel the jacket back and downward to avoid spreading contamination. Ensure that the outside of the jacket does not touch the patient or his inner clothing.

(3) =Remove overgarment trousers.= Unfasten or cut all ties, buttons, or zippers before grasping the trousers at the waist and peeling them down over the patient's combat boots. Again, the trousers are cut to aid in removal. If necessary, cut both trouser legs starting at the ankle, keeping the cuts near the inside of the legs, along the inseam, to the crotch. Cut around all bandages, tourniquets, or splints. Continue to cut up both sides of the zipper to the waist and allow the narrow strip with the zipper to drop between the legs. Place the cutting device in the 5 percent hypochlorite solution. Peel or allow the trouser halves to drop to the ground. Have the patient step out of the trouser legs, one at a time. Place the trousers in the contaminated disposal bag.

(4) =Remove overboots.= Remove the patient's overboots by cutting the laces with cutting device dipped in the 5 percent hypochlorite solution. Fold the lacing eyelets flat on the ground. Step on the toe and heel eyelets to hold the overboot on the ground and have the patient step out of it. Repeat this procedure for the other overboot. If the GVO are worn, first try to remove the overboots without cutting; if necessary, cut the overboots along the front. If the overboots are in good condition, they can be decontaminated and reissued.

(5) =Remove the patient's outer gloves.= Grasp the heel of the glove, peel the glove off with a smooth downward motion. Place the contaminated gloves in a plastic bag with the overgarment jacket. Do not allow the patient to touch his clothing or other contaminated objects with his exposed hands.

(6) =Remove the patient's cotton glove liners.= Have the patient remove his cotton glove liners to reduce the possibility of spreading contamination. Have the patient grasp the heel of one glove liner with the other gloved hand, peeling it off of his hand. Hold the removed glove by the inside and grasp the heel of the other glove, peeling it off of his hand. Place both glove inserts in the contaminated waste bag.

_i._ =Step 6. Remove patients BDU.=

(2) =Remove BDU jacket.= Have the patient stand with his feet spread apart at shoulder width. Unbutton the front flap of the jacket. If the patient can extend his arms, have him clinch his fists and extend his arms backward at about a 30° angle. Move behind the patient, grasping his jacket collar at the sides of the neck, peel the jacket off the shoulders at a 30° angle down and away from the patient. Avoid any rapid or sharp jerks that can spread contamination. Gently pull the inside sleeves over the patient's wrists and hands. If the patient cannot extend his arms, you must cut the jacket to aid in its removal. Dip the cutting device in the 5 percent hypochlorite solution between each cut. As with the litter patient, cut both sleeves from the inside, starting at the wrist, up to the armpit. Continue cutting across the shoulder to the collar. Cut around bandages or splints, leaving them in place. Next, peel the jacket back and downward to avoid spreading contamination. Ensure that the outside of the jacket does not touch the patient or his inner clothing.

(3) =Remove BDU trousers.= Unfasten or cut all ties, buttons, or zippers before grasping the trousers at the waist and peeling them down over the patient's combat boots. Again, the trousers are cut to aid in removal. If necessary, cut both trouser legs starting at the ankle, keeping the cuts near the inside of the legs, along the inseam, to the crotch. Cut around all bandages, tourniquets, or splints. Continue to cut up both sides of the zipper to the waist and allow the narrow strip with the zipper to drop between the legs. Place the cutting device in the 5 percent hypochlorite solution. Peel or allow the trouser halves to drop to the ground. Have the patient step out of the trouser legs, one at a time. Place the trousers in the contaminated disposal bag.

(4) =Remove undergarments.= Remove the patient's tee shirt. Dip the cutting device in the 5 percent hypochlorite solution between each cut. Cut both sleeves from the inside, starting at the elbow, up to the armpit. Continue cutting across the shoulder to the collar. Cut around bandages or splints, leaving them in place. Next, peel the tee shirt away from the body to avoid spreading contamination. If the patient is wearing a brassiere, cut it between the cups. Cut both shoulder straps where they attach to the cups and lay them back off of the shoulders. Remove the patient's under shorts/panties by cutting from the lower side of the hip to the waist on both sides. Allow the shorts/panties to fall to the ground. Do not remove the patient's identification tags.

_j._ =Step 7. Check patient for contamination.= After the patient's BDU and underwear has been removed check the skin for contamination by using M8 detector paper or the CAM. Carefully survey all areas of the patient's skin, paying particular attention to areas around the neck, wrist, ears, and dressings, splints, or tourniquets.

_k._ =Step 8. Decontaminate skin.=

(1) =Spot decontamination.= Use the SDK or the 0.5 percent hypochlorite solution to spot decontaminate exposed neck and wrist areas, splints, other areas where the protective overgarment was damaged, and where dressings or bandages were removed. Decontaminate the patient's identification tags, if necessary. Have the patient hold his breath and close his eyes. Have him, or assist him, lift his mask at the chin. Wipe his face with the M291 pad or the 0.5 percent hypochlorite solution. Wipe quickly from below the top of one ear, being careful to wipe all folds of the skin, top of the upper lip, chin, dimples, earlobes, and nose. Continue up the other side of the face to the top of the other ear. Wipe the inside of the mask where it touches the face. Have the patient reseal and check his mask.

(2) =Trauma specialist care.= During clothing removal, the clothing around bandages, tourniquets, and splints was cut and left in place.

· The trauma specialist replaces the old tourniquet by placing a new one ½ to 1 inch above the old tourniquet. When the old tourniquet is removed, the skin is decontaminated with the SDK or the 0.5 percent hypochlorite solution.

· _Do not remove splints._ Decontaminate them by thoroughly rinsing the splint, padding, and cravats with the 0.5 percent hypochlorite solution.

· Usually, the trauma specialist will gently cut away bandages. The area around the wound is dusted with the M291 pad or rinsed with the 0.5 percent hypochlorite solution, and the trauma specialist applies the M291 pad or irrigates the soft tissue wound with the 0.5 percent hypochlorite solution. If bleeding begins, the trauma specialist replaces the bandage with a clean one.

_l._ =Step 9. Dispose of contaminated waste.= Dispose of contaminated bandages and coverings by placing them in a plastic bag and sealing the bag with tape. Place the plastic bags in the contaminated waste dump.

_m._ =Step 10. Proceed through the shuffle pit to the clean treatment area.= Have the decontaminated patient proceed through the shuffle pit to the clean treatment area. Make sure that the patient's boots are thoroughly decontaminated by stirring the contents of the shuffle pit with his boots as he crosses it. The patient will remove his combat boots and socks at the entrance of the clean treatment area or CPS; remove the protective mask at the entrance to the clean treatment area or inside the ambulatory air lock of the CPS.

G-12. Biological Patient Decontamination Procedures

The decontamination station as established for chemical agent patients is also used for biologically contaminated patients. The eight-man patient decontamination team is required for biologically contaminated patient decontamination procedures.

G-13. Decontaminate a Litter Biological Agent Patient

_a._ =Remove the patient's personal effects.= Place the patient's personal effects in a clean bag and label with the patient's identification. If they are not contaminated, give them to him. If his personal effects are contaminated, place the bagged items in the contaminated storage area until they can be decontaminated, and then return them to the patient.

_b._ =Remove the Field Medical Card.= Remove the FMC by cutting the tie wire and allowing the FMC to drop into a plastic bag. Keep the FMC with the patient.

_c._ =Remove the patient's clothing.= Patient decontamination team members first apply the 5 percent hypochlorite solution to the patient's clothing and the litter. Then, remove the patient's clothing as in decontamination of chemical agent patients. Bandages, tourniquets, and splints are not removed. Move patient to a clean litter as described for a chemical agent patient. Place patient's clothing in a plastic bag and dispose in the contaminated waste dump.

_d._ =Decontaminate the patient's skin.= Bathe the patient with soap and warm water or apply the 0.5 percent hypochlorite solution. The trauma specialist places a new tourniquet ½ to 1 inch above the old tourniquet, and then he removes the old one. The trauma specialist removes bandages and decontaminates the skin and wound with the 0.5 percent hypochlorite solution; he replaces the bandage, if needed, to control hemorrhage. Splints are disinfected by soaking the splint, cravats, and straps with the 0.5 percent hypochlorite solution.

NOTE

Use a 0.5 percent hypochlorite solution to decontaminate patients suspected of being contaminated with mycotoxins.

_e._ =Transfer patient to hot line.= Two decontamination team members move patient to the hot line. Request assistance from two other decontamination team members to transfer him to a clean litter as described for chemical agent patients. Place the patient's FMC in the plastic bag on the clean litter with him. Two trauma specialists from the clean side of the hot line move the patient from the hot line to the clean treatment/holding area.

G-14. Decontaminate an Ambulatory Biological Agent Patient

_b._ =Remove the Field Medical Card.= Remove the FMC by cutting the tie wire and allowing the FMC to drop into a plastic bag. Keep the FMC with the patient.

_c._ =Remove the patient's clothing.= Patient decontamination team members first apply the 5 percent hypochlorite solution to the patient's clothing. Then remove the patient's clothing as in decontamination of chemical agent patients. Bandages, tourniquets, and splints are not removed. Place patient's clothing in a plastic bag and dispose in the contaminated waste dump.

_d._ =Decontaminate the patient's skin.= Have the patient bathe with soap and warm water or apply the 0.5 percent hypochlorite solution. If the patient is unable to bathe himself, a member of the decontamination team must bathe him. The trauma specialist places a new tourniquet ½ to 1 inch above the old tourniquet, and then he removes the old one. The trauma specialist removes bandages and decontaminates the skin and wound with the 0.5 percent hypochlorite solution; he replaces the bandage, if needed, to control hemorrhage. Splints are disinfected by soaking the splint, cravats, and straps with the 0.5 percent hypochlorite solution.

NOTE

Use a 0.5 percent hypochlorite solution to decontaminate ambulatory patients suspected of being contaminated with mycotoxins.

_e._ =Direct patient across hot line.= Direct the patient to cross the hot line to the clean treatment area. His boots must be decontaminated at the hot line before he enters the clean treatment area.

NOTES

G-15. Decontaminate Nuclear-Contaminated Patients

The practical decontamination of nuclear-contaminated patients is easily accomplished without interfering with the required medical care.

NOTE

Patients must be monitored by using a radiac meter (AN/VDR2, AN/PDR27, or AN/PDR77) before, during, and after each step of the decontamination procedure.

G-16. Decontaminate a Litter Nuclear-Contaminated Patient

_a._ =Remove patient's personal effects.= Patient decontamination team members remove the patient's personal effects and place them in a plastic bag. Place plastic bag in a clean holding area.

_b._ =Remove patient's clothing.= Patient decontamination team members remove the patient's outer clothing as described for chemical agent patients. Do not remove bandages, tourniquets, or splints. Move the patient to a clean litter. Place the patient's contaminated clothing in a plastic bag and move the bagged clothing to the contaminated waste dump.

NOTE

Patients arriving at the MTF in MOPP will only have their MOPP removed. They can remain in their BDU unless contamination is found on it.

_c._ =Spot decontaminate patient's skin.= Wash exposed skin surfaces with soap and warm water. Wash the hair with soap and warm water, or clip the hair and wash the scalp with soap and warm water.

_d._ =Transfer patient to hot line.= Move the patient to the hot line. Two trauma specialists from the clean side of the hot line move the patient into the clean treatment area.

G-17. Decontaminate an Ambulatory Nuclear-Contaminated Patient

_a._ =Remove patient's personal effects.= Have the patient remove his personal effects and place them in a plastic bag.

_b._ =Remove patient's outer clothing.= Have the patient remove his outer clothing (or have a decontamination team member assist him). Place his contaminated clothing in a plastic bag and move the bagged clothing to the contaminated waste dump.

NOTE

Patients arriving at the MTF in MOPP will only have their MOPP removed. They can remain ambulatory in their BDU unless contamination is found on it.

_c._ =Spot decontaminate patient's skin.= Have the patient wash his exposed skin surfaces with soap and warm water. Wash his hair with soap and water, or clip the hair and wash the scalp with soap and water.

_d._ =Transfer patient to hot line.= Direct the patient to move to the hot line. Decontaminate his boots by stirring the shuffle pit contents with his feet before he crosses into the clean treatment area.

NOTE

If a new protective overgarment is not available, after treatment, the ambulatory patient must be placed in a PPW for protection during MEDEVAC to the next level of care MTF. Thus, he becomes a litter patient for evacuation.

APPENDIX H

FIELD EXPEDIENT PROTECTIVE SYSTEMS AGAINST NUCLEAR, BIOLOGICAL, AND CHEMICAL ATTACK

H-1. General

Medical units must have protection from NBC attack and contamination to survive and function effectively. The extent of protection provided is only limited by the resources available and efforts of unit personnel. Protection as simple as an individually dug foxhole or as elaborate as the subbasement of a concrete building may be used. Expedient protection from the effects of biological and chemical agents are usually much less labor intensive.

H-2. Protection Against Radiation

The level of protection from radiation is expressed in terms of shielding. Material is available on the battlefield to construct/prepare expedient fallout shelters that offer substantial shielding against gamma radiation (see Table H-1). Generally, the denser or heavier the material, the better shielding it offers. The degree of protection afforded by a fallout shelter is expressed as a "protection factor," or a "transmission factor." The protection factor is simply the fraction of the available radiation dose that penetrates the shelter and reaches those inside compared to the radiation received by an unprotected person. Thus, a protection factor of 2 indicates that an individual in the shelter receives one-half of the radiation dose he would receive if unprotected. A protection factor of 100 (associated with about six half-value thicknesses) indicates that only 1/100 or 1 percent of the radiation dose reaches the inside. Transmission factors are expressed in percentages, or in decimals. Either refers to that fraction of the ambient unshielded dose that is received by personnel within the shelter. Fallout gamma transmission factors for some common shelters are shown in Table H-2.

_Table H-1. Shielding Potential of Common Materials--Fallout Gamma Protection_

============================================================= MATERIAL 1/2 VALUE LAYER THICKNESS[*] ------------------------------------------------------------- STEEL 1.8 CM (.7") CONCRETE 5.6 CM (2.2") EARTH 8.4 CM (3.3") WATER 12.2 CM (4.8") WOOD 22.4 CM (8.8") -------------------------------------------------------------

[*] 1/2 VALUE LAYER THICKNESS--THICKNESS OF A GIVEN MATERIAL WHICH REDUCES THE DOSE OR DOSE RATE TO APPROXIMATELY ONE-HALF OF THAT FALLING UPON IT. =============================================================

_Table H-2. Transmission factors for Nuclear Radiation[*]_

================================================================== INITIAL ENVIRONMENTAL SHIELDING NEUTRONS GAMMA RESIDUAL ------------------------------------------------------------------

BUILT-UP CITY AREA (IN OPEN) 1.0 0.5 0.7 FOXHOLES 0.3 0.2 0.1 FRAME HOUSE: FIRST FLOOR 1.0 0.9 0.5 BASEMENT 0.5 0.3 0.1 MULTISTORY BUILDINGS: TOP FLOOR 1.0 0.9 0.1 INTERMEDIATE FLOORS 0.9 0.9 0.02 LOWER FLOOR 0.9 0.5 0.1 BASEMENT 0.5 0.3 0.01 SHELTER, CLOSED 91 CM (3 FT) (EARTH COVER) 0.05 0.02 0.005 ARMORED VEHICLES: ARMORED PERSONNEL CARRIER 0.3 0.2 0.1 TANKS 0.3 0.2 0.1 WOODED FOREST 1.0 1.0 0.8 ------------------------------------------------------------------

[*] INSIDE DOSE = TRANSMISSION FACTOR TIMES OUTSIDE DOSE. ==================================================================

H-3. Expedient Shelters for Protection Against Radiation

_a._ In many cases it will be unnecessary to construct field expedient or other types of fallout shelters. There are many structures and terrain features available that afford a degree of fallout protection. Existing fallout shelters are tunnels, caves, culverts, overpasses, ditches, ravines, and man-made structures. The best existing shelters are basements. Figure H-1 shows typical protection provided in buildings. Windows can be sandbagged or covered with dirt from the outside to provide additional protection.

_b._ Planners should attempt to locate HSS units near existing shelters, whenever possible. However, if an HSS unit is already established, or must be established where fallout shelters are not available, then a shelter must be constructed. Elaborate shelters are not required, since they usually only need to be occupied for a few days. There are a number of field expedients that will serve to save personnel and patients even though they may not be comfortable for those few days.

_c._ When engineer support is available, a bulldozer trench about 2.7 meters (9 feet) wide and 1.2 meters (4 feet) deep can be dug (Figure H-2). The length of the trench will be determined by the number of patients/personnel to be sheltered. About 0.6 meter (2 feet) length of trench is required for each person to be sheltered. These trenches reduce exposure of personnel lying on the floor to about 20 to 30 percent of the radiation that they would receive in the open. Protection and comfort can be improved, as time permits, by digging the trenches deeper; undercutting the walls (care must be taken in this option; the earth may cave in); erecting tents over the trenches; and providing improved flooring. When used with other individual and collective protection measures, bulldozer trenches provide adequate fallout shelters for most situations; they can be provided in a minimum of time and effort. Trenches should not be dug in areas subject to flooding during rainstorms; a berm should be formed on the uphill side of the trench to direct water around the trench in the event rainfall occurs in the area. Undercutting will not be possible in sandy soil; also some form of support to keep the walls from caving in is required.

_d._ Dug-in tents (Figure H-3) for hospitals provide more comfort and require less movement than the bulldozer trench; however, they have two drawbacks. First, they offer far less radiation protection than the bulldozer trench, and second, they require considerably more engineer effort. This option should work well with GP tents, but will probably be hard to accomplish with the TEMPER.

_e._ Sandbagged walls around the hospital tents, as shown in Figure H-4, or lightly constructed buildings provide protection from fallout. Sandbagged walls 1.2 meters high give significant protection (20 to 40 percent transmission factor); however, the effort required to achieve the protection is such that it is marginally feasible. Sandbagging is an effective means for supplementing other shelters by--

· Bolstering the shielding at weak points.

· Forming baffles at entryways.

· Blocking open ends of trenches.

· Covering windows and gaps.

_f._ When other shelters are not available, HSS units must prepare foxholes and trenches for patients and unit personnel. As time permits, improve these shelters by deepening, covering, undercutting, and sandbagging.

H-4. Expedient Shelters Against Biological and Chemical Agents

_a._ When CPS systems are not available, well-sealed shelters (TEMPER, ISO, and GP) can significantly minimize or prevent the entry of CB agents. The ventilation system must be turned off, and kept off, before, during, and after the attack. The shelter must be totally sealed during this time to maximize protection. Table H-3 provides examples of protection values for well-sealed shelters. For example, a well-sealed TEMPER will only permit 1/60 of the CB agent outside to enter the shelter. If a persistent agent is used, be aware of agent off-gassing hazards. Persistent agents can penetrate TEMPER fabric and create a vapor hazard inside. In a CB agent attack, ensure that all staff and patients are protected by wearing their MOPP or are in PPWs.

_Table H-3. Ratio at Nonpersistent Agent Concentrations (Inside/Outside) for Different Shelters_

================================================================= SHELTER RATIO INSIDE/OUTSIDE ----------------------------------------------------------------- TEMPER TENT 1:60[*] GENERAL PURPOSE TENT, MEDIUM, WITH COTTON LINER 1:50 GENERAL PURPOSE TENT, LARGE, WITH COTTON LINER 1:30 ISO SHELTER 1:60 -----------------------------------------------------------------

[*] THE VENTILATION SYSTEM MUST BE TURNED OFF ON ALL SHELTERS TO PROVIDE THIS LEVEL OF PROTECTION. =================================================================

_b._ Sealing shelters to prevent entry of CB agents does not require elaborate materials or procedures.

(1) Materials needed for sealing shelters include, but are not limited to the following:

· Duct tape (or similar tape) for sealing.

· Velcro kits for TEMPER.

· Sand/dirt to seal base of GP tents.

· Plastic sheeting and tape to seal large openings, such as doors and windows of GP tents.

(2) All vulnerable areas must be sealed. Seal--

· Joints in ISO shelters and GP tents with tape. Tape does not work very well on TEMPER fabrics; use Velcro kits.

· Base of GP tents with sand/dirt.

· Stove pipe openings with tape and plastic.

· Windows of GP tents with tape and plastic. Seal TEMPER tent windows by aligning and securing the Velcro border tightly; tape may be applied to the seams to provide some additional barrier.

· All ISO shelter doors that do not have CB protective seals, with tape. Seal GP tent doors with plastic sheeting and tape.

· All windows, doors, and other openings of fixed sites with plastic and tape.

· All air ventilation system vents.

NOTES

1. Do not allow any entries/exits to shelters during a CB attack.

2. In hot climates the heat load will rise in sealed shelters with the ventilation system turned off. Personnel must carefully monitor each other and the patients. All personnel must drink plenty of water to prevent heat injuries; see FM 21-10.

APPENDIX I

DETECTION AND TREATMENT OF NUCLEAR, BIOLOGICAL, AND CHEMICAL CONTAMINATION IN WATER

I-1. General

Water supplies in areas with NBC contamination and in surface water supplied by runoff from such areas will most likely be contaminated. The contamination of water, whether intentional or inadvertent, may reach concentrations that will produce casualties. By special methods of analysis, the presence of contamination can be determined. Treatment of contaminated water requires chemicals and equipment that are only available to quartermaster water purification units; individuals or units should not attempt to treat their water. Decontamination of water is only undertaken when uncontaminated sources are not available; then ONLY with the approval of the medical authority (PVNTMED or surgeon).

I-2. Detection of Contamination in Water

_a._ Detection of nuclear contamination in water is accomplished by using the AN/PDR77, AN PDR/27 or AN VDR/2 radiac meters.

+------------------------------------------------------+ | CAUTION | | | | DO NOT allow the probe to come into contact with the | | water source; allow at least one inch of air space | | between the probe and water surface. | +------------------------------------------------------+

_b._ Detection of BW agents in water is accomplished by the use of field biological water test kits and specially designed collection and detection kits. The specialty kits will be provided as needed, and will be available to PVNTMED and supporting medical laboratory personnel. When required for the President and Secretary of Defense purpose, samples must be collected and prepared for shipment to the supporting medical laboratory. A chain of custody document must be prepared by the collector and maintained as the sample(s) is being transported to the supporting medical laboratory and throughout its transit to the CONUS laboratory. See Appendix F for details on suspect BW sample collection, packaging, chain of custody, and handling.

_c._ The Chemical Agent Water Testing Kit, M272, provides a rapid field test to detect chemical agent contamination in water. The test must be conducted before the water is treated with chlorine; the chlorine will affect the accuracy of the test for chemical agents.

I-3. Procedures on Discovery of Contamination in Water

When contamination is discovered the following actions are taken:

_a._ Mark the water source, using the standard NBC contamination markers, and ensure that personnel do not consume the water until approved.

_b._ Notify the commander that the water source is contaminated and unfit for drinking, food preparation, and personal hygiene.

_c._ Notify the supporting water production unit, such as the quartermaster water production and distribution unit of the contaminated water source.

_d._ The commander establishes safeguards to prevent personnel from using the contaminated water supply.

_e._ An alternative source of uncontaminated water is sought and used. The primary source for obtaining water is from quartermaster-operated water production and distribution points. Other sources are considered only when quartermaster-operated faculties are not available. Alternative sources that may be considered include--

· Ground water sources that are least likely to be contaminated.

· Local fixed facility water supplies. However, these supplies must be tested before use. If NBC contamination is found do not use.

· Using another location to obtain an uncontaminated water source, when the tactical situation permits.

_f._ Contaminated water must not be used until it has been treated by quartermaster water production and distribution units or other equally capable water purification units and approved for use by the medical authority.

I-4. Treatment of Contaminated Water

Contaminated water requires additional equipment and supplies to remove the contamination. Quartermaster water purification and distribution units are equipped to perform these duties. See FM 10-52 for details.

APPENDIX J

FOOD CONTAMINATION AND DECONTAMINATION

J-1. General

_a. Food Susceptibility._ Stored, transported, and prepared food is susceptible to NBC contamination throughout the TO. Planning for any battle or operation must include food protection from contamination; food contamination detection; and contaminated food disposition (decontaminate or destroy).

_b. Countermeasures._ There are three primary countermeasures to overcome or reduce the NBC hazard to food:

(1) Contamination avoidance.

(2) Nuclear, biological, and chemical agent detection.

(3) Nuclear, biological, and chemical agent decontamination.

_c. Priorities._ The priorities for conducting NBC countermeasures are--

(1) _Contamination avoidance._ Contamination avoidance includes using natural and fabricated barriers to prevent, or significantly reduce the spread of contamination. Also, using specific procedures for entry and exit between contaminated and uncontaminated areas reduce the potential for spreading contamination. Use of these barriers and procedures may reduce the subsequent need for detection and decontamination.

(2) _Detection, measurement, and identification._ These activities are essential for determining the presence, extent, and nature of NBC contamination. This information is essential in identifying the existence of uncontaminated supplies, or decontamination requirements.

(3) _Decontamination._ Decontamination removes the contaminant and provides food that is safe for consumption.

_d. Decontamination._ Decontamination efforts require an extensive amount of labor, time, and supplies. The use of hasty decontamination is emphasized. That is, decontaminate just enough to sustain operations and keep fighting, rather than to make a contamination-free environment. Normally, decontamination efforts will be limited to the packaging and packing materials. Food decontamination will only occur in critical situations where other food supplies are not available. Most decontamination is performed in or very near the AO. Before beginning decontamination procedures, divide exposed food items into groups based on protection of item at time of exposure. These groups establish priorities based on ease of decontamination and the ability to monitor the food.

(1) Group I--Canned or packaged items exposed only to a chemical agent vapor.

(2) Group II--Canned or packaged items that are contaminated on the outside with a liquid chemical agent, a biological agent, or radioactive fallout.

(3) Group III--Unpacked or poorly packaged items that have been exposed to any NBC agent.

(4) Group IV--Food contaminated through the food chain.

J-2. Protection of Food from Contamination

An adequate defensive posture for a chemical attack will also protect food against biological contamination and radiation fallout.

_a. Operational Rations._ Operational rations include, but are not limited to, MREs; unit group ration (UGR), A; unit group ration, heat and serve; and medical diet supplement.

(1) Packaging materials and storage methods normally protect these rations. The packaging and packing of operational rations protect the contents from deterioration. As a result, the contents are protected from moisture, to include chemical liquids, chemical vapors, and biological agents. Operational rations delivered to an AO will usually have increased levels of packaging and/or packing protection. Operational rations are substantially protected while contained in the shipping cases, especially if protected with an overlay of fiberboard, shrink wrap, or film wrap.

(2) Enclosed storage is used whenever possible. Refrigerated warehouses, cold storage rooms, and even prefabricated refrigerators and trailers provide excellent protection. Underground shelters, caves, and tunnels that can be made airtight provide maximum NBC protection. Buildings provide protection depending on how well they can be closed and sealed. The basement of a building is a good storage place. However, keep in mind that chemical vapors tend to seek out low-lying areas. Storing rations indoors will protect them from liquid droplet and fallout contamination unless the building is damaged by an attack. Complete protection against chemical vapors is only offered by airtight closed spaces like cold storage facilities.

(3) Chemical protective measures are to be integrated into daily logistical operation to avoid the contamination of operational rations. Maximum use is made of alarm and detection equipment, overhead shelter, shielding materials, and protective covers. Back up stocks of operational rations should be dispersed to minimize the risk of destruction or contamination.

(4) An NBC Protective Cover or similar equipment will help greatly. The NBC Protective Cover is discarded and replaced upon becoming contaminated; it reduces overall decontamination requirements; and it improves the survivability of supplies and equipment. The NBC Protective Cover provides 24-hour protection against liquid chemical contamination. Detection paper used on the NBC Protective Cover will rapidly identify a contaminated cover.

_b. Bulk and Fresh Foods._

(1) Field expedient or improvised storage may be the only choice available under high-risk conditions. Expedient storage for food supplies may be a natural or man-made depression lined to protect contents against moisture, and then covered with earth and sod. The earth gives good protection against all forms of chemical or biological contamination and nuclear fallout.

(2) Foods are only stored outdoors or in partially protected areas when absolutely necessary. Only cases of foods packed in cans, bottles, or airtight foil or film wraps, and foods packed in sealed boxes or multilayered wrappings can be subjected to exposed storage. Partial protection is provided by open sheds, temporary roofing, or tents. When subsistence must be stored in the open, give as much protection as possible. Protection material may include NBC Protective Covers, tarpaulins, tarpaulin sheds, or any other available covering such as plastic sheeting. Tarpaulins and other treated or waterproof coverings do not prevent contamination by chemical vapors, but they do reduce contamination from liquid agents. Canvas will keep out more than 95 percent of liquid contamination for a short period of time after the attack. The canvas must be removed soon after the attack to prevent the agent from seeping through onto the subsistence; placement of spacers between the covering and the food will greatly reduce this problem. Even the thinnest material will offer some protection and is better than nothing at all. Therefore, food supplies must be covered by whatever material is available.

J-3. Nuclear

_a. Contamination._

(1) Following a nuclear detonation, food can become contaminated in three ways:

· _Direct contamination._ Direct contamination results by fallout collecting on plants, animals, and stored food (surface contamination). Fallout has two effects. First, it produces a gamma radiation field over the fallout area. Second, it contaminates the surface of anything on which it is deposited. The whole-body gamma irradiation hazard to an individual far outweighs any potential hazard from food contamination. The basic rule is: If you can safely be in the area to salvage the food, then the food salvaged is safe to use (although slightly contaminated).

· _Indirect contamination._ This form of contamination can be spread throughout the food chain. Humans can ingest contamination by eating plants that have absorbed radioactive isotopes; products (milk or meat) from animals allowed to graze on contaminated pastures; or fish from contaminated water.

· _Induced radiation._ It is possible that food will be exposed to sufficient neutron flux (an increase in the number of free neutrons) as the result of a nuclear explosion to produce considerable induced radioactivity in food without it being destroyed by blast and heat. This is possible with enhanced radiation weapons in the energy range of 1 KT where the radiation kill radius exceeds the blast destruction zone. The elements that are most prominently involved are sodium, potassium, sulfur, copper, bromine, zinc, and especially phosphorous. Thus, in an area of induced radiation, foods requiring the most caution are dairy products, high salt content foods, dry beans, raisins, and ready-mixed cake and biscuit flours. The radioactivity has a short half-life; therefore, the radiation will decay very rapidly. It should be possible to consume foods containing induced radiation within a week or two. Cans, particularly those with "C" enamel, may incur a high level of induced radiation (from zinc in the enamel, not from iron in the can). Glass, because of its high salt content, will show very high levels of activity; clear glass will turn brown. Container radioactivity has no bearing on the food, it is safe to use. The radioactivity is not transferred to the contents. No significant toxic by-products are formed in the exposed canned food.

(2) Consumption of food contaminated with radioactive fallout may cause a risk of radiation injuries from internal radiation; that is, radiation from radioactive sources within the body. Most isotopes will pass through the digestive tract or be excreted very quickly. However, the intestinal tract may receive a considerable dose. Some isotopes are more hazardous because they are absorbed from the digestive tract and enter the metabolism of man and animals.

· Strontium-89 (Sr-89) and Strontium-90 (Sr-90) are beta emitters and have half-lives of 51 days and 28 years, respectively. Therefore, Sr-90 is the greatest radiation hazard in the long term. These two isotopes are absorbed in the body and used in the same way as calcium. They accumulate in bone, where bone marrow with its blood forming cells is vulnerable. Milk and other dairy products are the primary sources of Sr-89 and Sr-90 in the human diet.

· Iodine-131 (I-131) is a beta and gamma emitter and has a short physical half-life of approximately 8 days. It is efficiently absorbed and used by the body. Iodine-131 will contaminate plants that will be eaten by grazing animals. Smaller amounts can also be absorbed by breathing contaminated air. Cattle will excrete a large amount of I-131 in milk. Milk and other dairy products are the primary sources of I-131 intake. One can also get smaller amounts by eating contaminated fruits and vegetables. Iodine-131 will be concentrated in the thyroid gland. The intake of I-131 will have its greatest impact the first few days to weeks following a nuclear explosion.

· Cesium-137 (Cs-137) is a beta emitter and has a half-live of 30 years, but is eliminated relatively quickly from the body. The biological half-live is 70 to 140 days. Cesium-137 is found in most tissues of the body, but it will concentrate in muscle tissue. Cesium-137 is absorbed and used the same way as potassium. Meat and milk are the primary sources of Cs-137. Much precipitation, lack of minerals in the soil, and extensive cultivation increase the plants' absorption of Cs-137; thus, the contamination of plant products.

(3) Operational rations are safe when surface decontamination is performed before breaking the package. Operational rations stored close to ground zero may become radioactive from induced radiation. It is more likely, however, that the food will be damaged or destroyed by the blast and thermal effects of the nuclear explosion.

(4) Bulk and fresh food stored in the open without protection will be contaminated. Decontamination is very difficult and time-consuming. Efforts should be made to ensure proper packing to prevent food contamination from radioactive fallout. Packing made from hard and nonporous materials, such as plastic or multilayer cardboard with a smooth surface, should be used. In addition, storage facilities should be enclosed to avoid the entry of fallout. Any material used as a protective cover will give some protection against nuclear fallout. Protection against induced radiation, blast, and thermal effects requires a hardened shelter or underground storage.

(5) Food supplies require protection throughout the chain of production or procurement. Protection of the civilian-based food supply includes countermeasures along the production chain. Meats and milk are the most vulnerable products because of the possibility for concentration of radioactive isotopes (Strontium, Cesium, and Iodine). The primary, and possibly the only, protection of animal products is to keep the animals indoors and to avoid contaminated fodder. Immediate slaughter of food animals is recommended if there is a shortage of uncontaminated fodder. Also, food animals exposed to fallout should be considered fit for consumption and slaughtered using routine procedures. Unharvested crops cannot be protected.

_b. Inspection and Monitoring._

(1) Fallout close to ground zero, especially after a surface burst, may be visible as dust. The presence of dust is an immediate indicator of contamination. Fallout on unprotected food produces a grittiness that is unpleasant and warns against eating the food. The degree and means of food protection (packaging and storage faculties) must be considered. Food in a building that remains intact should not receive enough contamination to be dangerous when eaten.

(2) Veterinary units have the AN/VDR2 Radiac Set and UDR13 dosimeter to conduct ground or aerial surveys for gamma radioactive contamination levels in an area. The measurement of the external gamma radiation in the fallout area is an indication, but not a quantitative measure, for the degree of hazard from food contamination. These units also use the AN/VDR2 Radiac Set for point detection of gamma and beta radiation sources. Food monitoring is conducted in an area with low background radiation. If the storage area is contaminated, the food must be moved to a cleaner area for monitoring. With the AN/VDR2, the initial food monitoring is performed with the probe cover in place and the probe passed approximately 6 inches from the surface. If the reading is twice the background dose rate, the food is considered contaminated. If the reading is not above the background level but contamination is still suspected, place the probe closer to the food with the beta probe cover off. Monitor meat and fish with the probe cover off; pass the probe approximately one-half inch from the surface of the food.

(3) Monitoring food contaminated through the food chain is more complicated; depending on the detection instrument used, special procedures must be followed. Gamma and beta emitting radionuclides in small volumes may be detected using radiac sets such as the AN/VDR2; however, alpha emitting ones cannot. They are rough instruments and may be used only for screening surface contaminated food. To evaluate the hazards; the isotopes contributing to the radioactivity must be identified. Surface contaminated food will contain a mixture of isotopes with some more hazardous than others, depending upon whether they are used by the body. Milk will contain mostly I-131, Cs-137, Sr-89, and Sr-90. Meat and fish will contain mostly Cs-137. To verify I-131, Cs-137, Sr-89, and Sr-90 contamination, samples must be sent to laboratories equipped to analyze the samples.

(4) All newly selected food supplies must be surveyed. Begin continuous monitoring immediately following receipt of a fallout warning, or when increased levels of radiation are detected by periodic monitoring.

(5) Periodic monitoring is needed to establish baseline levels of background radiation in the environment and various food products. This monitoring is performed during peacetime, when possible, and throughout the time US forces are deployed in a TO.

NOTE

The AN/VDR2 is being replaced by the AN/PDR77 Radiac Set.

_c. Decontamination._ There are two methods for nuclear decontamination: aging and removing. Aging is the process of allowing natural radiation decay to occur. The time necessary for this decay to take place depends upon the isotopes present; each has a different decay rate (half-life). Aging may not be possible when there is a short food supply. In some instances, such as with induced radioactivity, it may be the only way to decontaminate. Removing nuclear contamination from areas, personnel, food, or moving equipment to another location eliminates the immediate hazard. To determine which decontamination method is required, food supplies are divided into groups. See Table J-1 for additional information on food items and decontamination.

(1) Group II--Food in sealed and dust-proof packing such as cans, jars, fiberboard, and cellophane. These products are easily decontaminated by removing the radioactive dust covering the packing; brush, wash with soap and water, or remove the packing (depending on the type of packing material). If radiation is still detected after removing the dust, repeat the brush/wash procedure and remonitor. If radiation is still present, the food itself is then considered radioactive (induced radiation) and is unfit for consumption. Decontamination of induced radiation is possible only through aging. After aging one to two weeks, the food should be safe for consumption. After surface decontamination, the contents are safe to eat unless the food has induced radiation.

(2) Group III--Unprotected food. The method chosen to decontaminate unprotected food items will depend upon whether or not the food supply is critical. If the food supply is not critical, the contaminated items are isolated and allowed to decontaminate by aging. If the food supply is critical, food with surface contamination can, in principle, be decontaminated by removing the contaminated surface, or by washing.

(3) Some products can be decontaminated by washing, peeling, or trimming the outer skin or leaves. Decontaminate potatoes and hard-skinned fruits and vegetables by washing or scrubbing under running water, followed by peeling or scraping, then washing again. Potatoes, carrots, beets, and turnips can be washed at the supply depot. However, do not wash beans, rice, and onions until they are delivered to the field kitchen; washing reduces their storage quality and shelf life. Citrus fruits, pineapples, corn, peas, beans, melons, pumpkins, cabbage, and nuts can be peeled. Decontaminate cucumbers, tomatoes, cherries, cranberries, grapes, pears, plums, and thin-skinned squash by soaking in a water or detergent solution and rinsing with vigorous agitation or brushing. Apricots, peaches, most berries, asparagus, broccoli, and leafy vegetables cannot be satisfactorily decontaminated because of fuzzy surfaces, irregular shapes, or small size, which makes washing difficult.

· Fresh carcass meat, sausages, and fish can be decontaminated by several washings with cold water. The exterior layer of the food item is removed if radioactivity is still present. There is, however, a risk of contaminating the inner parts of the foodstuff in the process. Cooking with several changes of water is the last step in decontamination.

_Table J-1. Decontamination of Food Supplies_

· Decontaminate hard cheeses, margarine, and butter by cutting off the outer layer to a depth of 2.5 to 3 cm.

· Let cooking oils stand for 3 to 5 days, then pour off the contaminated layer; use a funnel to control spillage.

· Nonperishable items that are hard to decontaminate, such as flour, sugar, and salt, can be set aside allowing natural radioactive decay. When supplies are short, dilute the contamination by mixing with uncontaminated food. This will reduce the total amount of radioactive exposure in foods prepared using these contaminated items.

· Decontaminate air permeable, double-sacked goods by removing the outer sack. If the inner sack is free of radiation, double sack the food again to restore protection. However, when contamination is present on the inside bag, the food in contact with the bag is likely to be contaminated. Three methods can be used to handle this type of contaminated product. The easiest method involves spraying the bag of dry goods (except sugar or salt) with water. This will wet a layer of the food inside the bag. The wet layer can be removed when the bag contents are emptied. The uncontaminated contents are scooped back into clean packaging. Another method involves using melted paraffin to uniformly coat the outside of the bag. The paraffin solidifies after 30 to 40 minutes, and then the bag with the radioactive contamination can be removed from the contents. Although this method will seal the radioactive substance in the wax, it probably will not remove the layer of contaminated food product inside the bag. For the third method, form a piece of sheet metal into a cylinder the same height as the bag and 4 to 6 cm smaller in diameter. Insert the cylinder into the bag, then remove the top 3 to 4 cm of the contaminated product. Carefully scoop the remaining product out into a clean sack. With the cylinder still in place, fold the bag down catching the contaminated product on plastic sheeting, or a tarpaulin. When using this method, mixing the contaminated portion with the uncontaminated portion is a problem. Check for contamination remaining in the product.

· Boiling or cooking has no effect on radioactive contamination.

(4) Group IV--Food contaminated through the food chain. It is not practical to decontaminate this food. Meat and milk are the two most common foodstuffs contaminated in this way.

· Milk may be decontaminated to a safe level by a complicated ion exchange process. The I-131 activity will decline rapidly during storage of milk and milk-products, although the Cesium and Strontium activity will remain almost constant for years. In an area with high-level fallout, milk is withdrawn from human consumption. The duration of withdrawal will be dependent upon the type of fallout and levels.

· Meat may be decontaminated to a safe level by soaking in water or brine. Cesium is loosely bound in the meat. By repeated soaking of meat cut in small pieces, most of the Cesium activity will be removed. Traditional meat preserving, such as salting with brine, will remove up to 60 to 70 percent of the Cesium activity. See Table J-2.

· Fruits, vegetables, root crops, and grain products may also contain hazardous amounts of radioactivity if ingested.

(5) Food animals. Food animals that have been exposed to fallout should be considered fit for consumption and slaughtered using routine inspection and slaughter procedures. In those cases where the animal has been exposed to fallout, but is not scheduled for immediate slaughter, the radiation burden can be reduced by moving the animal to an uncontaminated area (barn if available) and washing it with soap and water. Mild radiation sickness does not necessarily mean that the animals cannot be used for food. If the animals have been exposed to an internal radiation hazard, the meat can be eaten if the internal organs are discarded. Chickens that have eaten radioactive material may lay contaminated eggs, but most of the radioactivity will be concentrated in the shells. The white and yolk will be free of harmful amounts of radiation and can be eaten. Chickens will not lay eggs if the radioactive body burden is large enough that their eggs are unfit to eat.

_Table J-2. Traditional Salt Preserving Brine_

====================================================================== MEAT, WHOLE 4-5 KG

25% NaCl (SALT) BRINE 5-LITER BRINE PER KG. KEEP MEAT IN BRINE FOR 3 WEEKS, TEMPERATURE BELOW 10°C. SOAK IN WATER FOR 1-2 DAYS. 65-70% OF CS ACTIVITY WILL BE REMOVED. ---------------------------------------------------------------------- MEAT, CUT 1-2 KG

25% NaCl BRINE 5-LITER BRINE PER KG. KEEP MEAT IN BRINE FOR 4 DAYS. SOAK IN WATER FOR 4 HOURS. 65-70% OF CS ACTIVITY WILL BE REMOVED. ---------------------------------------------------------------------- MUTTON/LAMB RIB

PIECE OF RIB 1-5 KG. 25% NaCl BRINE 5-LITER BRINE PER KG. KEEP IN BRINE FOR 2 DAYS. SOAK IN WATER FOR 2 HOURS. AIR-DRYING FOR 10 DAYS. SOAK IN WATER FOR 2 HOURS. BOIL IN WATER FOR 3 HOURS. 85-90% CS ACTIVITY WILL BE REMOVED. ----------------------------------------------------------------------

DECONTAMINATION OF COARSELY CHOPPED MEAT

0.9% NaCl SOLUTION. 2-LITER SOLUTION PER KG. SOAK IN NaCl SOLUTION FOR 10 MIN. 60-70% CS ACTIVITY WILL BE REMOVED. REPEATED PROCEDURES WILL REMOVE THE SAME PERCENTAGE OF CS ACTIVITY. SIX TIMES REPEATED TREATMENT WILL REMOVE NEARLY 100% OF CS ACTIVITY. ======================================================================

_d._ _Considerations When Decontamination is Not Possible._ When food cannot be decontaminated, sealing the product in a wrapping material or container may be needed. Sealing the product can reduce or shield the emanation of the contamination and/or fix the contamination in place. The hazard from contaminated food is small compared with that from external gamma radiation. Hungry people or animals should not be denied food because of possible fallout contamination. It is not practicable or desirable to preset maximum permissible limits of gross fallout radioactivity as a basis for judging whether or not food should be used. Common sense must be applied in establishing priorities for distribution of available food. For example, use the least contaminated and the most protected food first; hold milk products for 1 to 2 weeks before use.

J-4. Biological

_a. Contamination._ Biological warfare agents exist in the form of toxins and microorganisms. The normal packaging and packing of food (to protect against moisture, dust, and bacterial or other contamination) provides protection against most biological agents. The exception may be toxins and biologically derived substances. However, the protective methods used for chemical agents will also protect against toxins and derived substances. Food in freezers, refrigerators, and in refrigerated trucks or rail cars will be safe if these containers remain sealed until the outer surfaces are decontaminated.

(1) It is unlikely that a biological agent will affect the appearance, taste, or smell of the food enough for the change to be apparent.

(2) Packaging and packing materials are not life supportive to pathogenic agents and are, therefore, self-decontaminating with the exception of spore-forming organisms.

(3) Most operational rations are packaged in metal containers, or encased in heavy aluminum laminated plastics that can withstand boiling water; also, they are impervious to arthropod penetration. This food is highly resistant to biological agents.

(4) The use of unpackaged items (unwrapped meats, fresh fruits, and vegetables) should be restricted; use only operational rations. Unprotected fresh food stored in the open and close to the source of dissemination will become contaminated.

_b. Detection._

(1) Rapid identification of agents used is absolutely essential to implement effective countermeasures. Agent identification must be achieved quickly; it is the first step in answering critical management questions. What adjustments must be made in food preparation and distribution? What are the essential countermeasures? What is the expected outcome of the incident?

(2) Samples of food that are suspected of being contaminated are transported to the designated supporting laboratory. Samples must be accompanied by a description of the samples, the sample collection procedures, and the circumstances, which prompted the collection. The designated medical laboratory in the TO will provide a field confirmation identification of the agent(s). Designated CONUS laboratories accomplish definitive identification. See Appendix B for sampling procedures.

NOTE

New biological detection equipment is under development that will enable units to conduct presumptive identification of biological warfare agents. However, samples must also be collected and processed as described in Appendix B.

_c. Decontamination._

(1) Food contaminated with toxins is handled in the same manner as food contaminated with chemical agents. Food contaminated with microorganisms is handled in the same manner as when contaminated with the more common foodborne disease-producing microorganisms.

(2) Several methods are available to decontaminate food items contaminated with biological agents. The following decontamination methods are considered to be the minimum. See Table J-1.

(3) Group II food that is sealed in containers that are resistant to the passage of biological agents requires only that the exterior of the container be decontaminated. Decontamination of these items is as follows:

(_a_) For containers made of metal, glass, plastic, or porcelain:

_1._ Thoroughly wash the container in potable water and soap, or in a disinfectant solution. If the water used for washing is contaminated, the soap and water wash may increase, not reduce, the contamination hazard. After which, the food containers are immersed in a disinfectant solution for 30 minutes (see Table J-3); then rinsed with potable water, if available and time permits. Chlorine solutions are not as reactive or corrosive as DS2.

_2._ Place the containers in boiling soapy water for 15 minutes; then rinse with potable water.

NOTES

1. The chemical field decontamination kits do not meet the requirements to decontaminate food supplies exposed to biological agents.

2. The same procedures should be followed even if there is only suspicion of a biological warfare attack.

(_b_) Thoroughly wipe containers that will not withstand soaking with a cloth soaked in a chlorine detergent solution. Remove the food from the container and place it in Group III.

(_c_) Metal or glass containers determined to have trichothecenes (Yellow Rain) present can be decontaminated using DS2. Allow a contact time of 5 to 30 minutes for the DS2 to neutralize the toxin. Then rinse the container with potable water.

(4) Group III food items that are not protected by the packaging material are decontaminated or disposed of as follows:

(_a_) Decontaminate foods that can be peeled or pared by immersing them in a disinfectant solution for 30 minutes, and then rinsing them with potable water (see Table J-3). Peel or pare the items after decontamination, then wash and, if appropriate, cook before eating.

(_b_) With the exception of certain heat-stable toxins, heat is the most practical means of decontaminating food. Several heating methods may be used, but the method chosen depends upon the type of food to be decontaminated. The key is to apply as much heat as possible without rendering the food unfit.

_1._ Cook in a pressure-type cooker with 15 pounds of pressure at 250°F (121°C) for 15 minutes.

_2._ Cook in a low-pressure cooker at 228°F (109°C) for 1 hour.

_3._ Bake bread or related items at 400°F (204°C) for 40 minutes.

+------------------------------------------------------+ | CAUTION | | | | Bread made with toxin-contaminated flour (especially | | with trichothecenes) is still toxic. | +------------------------------------------------------+

_4._ Bake or roast meat at 325°F (163°C) for 2 hours.

_5._ Boil for at least 15 minutes when no other method is available.

(_c_) Although decontamination methods are provided above, vegetables such as lettuce, broccoli, and cauliflower, or unwrapped meats that have been exposed to biological agents should not be eaten.

(_d_) Foods, such as butter, ice cream, and bread that will not withstand any of the above treatments must be destroyed.

(5) Established meat inspection procedures are followed when animals exposed to biological agents must be used for food. The meat must be thoroughly cooked.

_Table J-3. Chlorine Solutions for Decontamination of Biological Warfare Agents_

============================================================ CHLORINE | MIXTURE TO PRODUCE 200 PPM SOURCE | SOLUTION OF AVAILABLE CHLORINE -------------------------+---------------------------------- HOUSEHOLD BLEACH | 1/2 GAL/25 GAL WATER | HIGH-TEST HYPOCHLORITE | 1/2 LB/25 GAL WATER (CALCIUM HYPOCHLORITE) | | SUPERTROPICAL BLEACH | 1 LB/25 GAL WATER ============================================================

J-5. Chemical

_a. Contamination._

(1) Contamination of foodstuffs by a chemical agent may occur at any point on the battlefield. This contact may render the food unpalatable also. In many cases, decontamination is difficult, thus, emphasis must be placed on protection. Keep food supplies covered at all times. Take special precautions to protect food that is not packed in protective packages. Unprotected food, forage, and grain supplies may be so contaminated that their consumption will produce gastrointestinal irritation, or systemic poisoning. Nerve agents, vesicants, and arsenicals are the most dangerous. Field concentrations of phosgene, hydrocyanic acid, irritants, and smokes will seldom be high enough to cause serious food contamination. The effect of CK on food is not known. As a precaution, foods exposed to CK should be considered toxic.

(2) The effects of chemical agents on food depend on the nature of the agent and the type of the food. The extent to which chemical agents penetrate food also depends on the amount, form of dispersal (liquid [droplet size], or vapor) and duration of exposure. Nerve agents and mustard will penetrate deeply into unprotected fatty foods and will readily penetrate granular products such as grain and sugar. Liquid food products can be completely contaminated. Arsenicals readily hydrolyze to poisonous arsenical oxides in some foods. Foods can be divided into three categories based on their water content, fat content, and crystalline structure:

(_a_) Foods having a high water content, a low fat content, and/or a crystalline structure (fresh vegetables, fruits, sugar, salt, and eggs) will absorb mustard and nerve agents, either as a liquid or as a vapor. Nerve agents will be hydrolyzed slowly.

(_b_) Foods having a low fat content and an irregular (amorphous) structure (flour, bread, grain, rice, cereals, dried fruits, dried vegetables, tea, coffee, peas, and beans) readily absorb mustard and nerve agents in liquid form. As a vapor, these agents are absorbed to some extent, but are easily removed by airing.

(_c_) Foods having a low water content and a high fat content, such as butter, fat, fatty oils, ham, cheese, milk, bacon, fatty meat, and fish, absorb mustard and nerve agents such that removal of the agents is virtually impossible.

(3) Chemical agents can be physically and chemically absorbed into food. In addition to the toxic effect, they often adversely affect taste, smell, and the appearance of the food. However, chemical agents can cause the food to become very toxic without causing any other changes in the food. Table J-4 shows the effects of a number of chemical agents on food. Since food can be contaminated without any outward change in appearance, the possibility of contamination must be assumed in a chemical agent environment. Treat the food with the same precautions as established for known contaminated items.

(4) The protective properties of packaging materials are dependent upon a number of factors. The factors include the form of the agent (liquid versus vapor); concentration and exposure time; weather (temperature, wind speed, and humidity); and packaging material (the type of material, thickness, and the presence of folds, tears, and small holes). Even the thinnest material will offer some protection and is better than nothing at all. Therefore, always cover food supplies with whatever material is available. Table J-5 summarizes the protection values of various packaging materials against vapors and liquids.

(_a_) Operational rations are substantially protected while contained in the shipping cases and especially if stored in the original palletized unit load with an overlay of fiberboard, shrink wrap, or film wrap. The worst case is pallets of subsistence contaminated by liquid droplets during an attack. After the attack, high vapor concentrations will exist in the vicinity of the palletized loads. If the outer barrier is permeable such as fiberboard, it is possible that a liquid agent can seep through the overlay fiberboard and contact the shipping containers in liquid form. Normally, with seepage resistant materials, such as shrink wrap as the outer barriers, only the vapors of the agent are found within the pallet.

(_b_) While MREs are stored, the food is protected by up to six layers of material. Multilayer barriers result in a complex diffusion process of the agent from the outside towards the interior. Vapor penetration into nonhermetically sealed spaces is a simple gaseous diffusion process. Permeation through packaging is a much more complex process regardless of whether the challenge is a liquid or a vapor.

_1._ Liquid is adsorbed into permeable materials such as fiberboard or chipboard. With permeation-resistant materials (such as shrink wrap), the agent dissolves into, seeps through, and then desorbs from the barrier material. Shrink wrap provides adequate protection. Fiberboard sheathing provides adequate protection against mustard agents, but not against nerve agents.

_2._ The low-density polyethylene used to construct the menu bag can absorb chemical agents and possibly toxins. If the menu bag is removed from the shipping container and is exposed to liquid contamination, enough agent may pass through the bag to create a health hazard. Keep MREs in the shipping container until issued to the soldier. The menu bags should then be kept under the same degree of protection as the soldier.

_3._ The aluminum-laminated materials used to construct the MRE (retort and nonretort) pouches protect food from chemical contamination if hermetically sealed. The only item in the MRE meal bag that is not adequately protected is the spoon.

(5) Mylar and cellophane are resistant to chemical agents.

_Table J-4. Effects of Chemical Agents on Food_

======================================================================= | INFLUENCE ON | +--------+-------+-----------------------+ RESIDUAL AGENT | TASTE | SMELL | COLOR | TOXICITY ----------------+--------+-------+-----------------------+------------- MUSTARD | BAD | BAD | DISCOLORS MEAT | + N-MUSTARDS | BAD | BAD | DOESN'T DISCOLOR MEAT | + ARSENICALS | ACID | BAD | DISCOLORS MEAT AND | +, ARSENIC | | | VEGETABLES | NERVE AGENTS | BAD | NONE | NONE | + PHOSGENE | ACID | NONE | ? | - AFTER | | | | WEATHERING CYANOGEN AGENTS | BITTER | BAD | NONE | - AFTER | | | | WEATHERING IRRITANTS | ACID | BAD | NONE | + SMOKE | ACID | BAD | ? | - WHITE | ? | ? | ? | + PHOSPHOROUS | | | | ----------------+--------+-------+-----------------------+-------------

+ INDICATES THE PRESENCE OF RESIDUAL TOXICITY. - DENOTES THAT RESIDUAL TOXICITY IS NOT PRESENT. ? THE INFLUENCE HAS NOT BEEN DETERMINED. =======================================================================

_Table J-5. Protection from Chemical Contamination by Packaging Methods and Materials_

_b. Detection._

(1) Currently, a field method for detecting chemical agent contamination in food does not exist. Contamination is not always spread evenly throughout food; this makes it impossible to take a single sample and determine the presence or absence of chemical agents in the entire lot. Additionally, standardized laboratory tests have not been developed for determining levels of chemical agents in food. Until a specific method to detect chemical agents in food is available, reliance will have to be made upon determination of contamination, or lack thereof, on the packaging material; the integrity of the packaging material; the protective qualities of the packaging material; and the penetration characteristics of the suspected chemical agents.

(2) Food may become toxic without any change in outward appearance. Never taste or smell food to determine if contamination is present in food.

(3) Veterinary and subsistence units have the following equipment available to detect chemical agents in the field:

(_a_) The M8 Automatic Chemical Agent Alarm System consists of the M43 detector unit and the M42 alarm unit. The detector unit is a portable, automatic, point-monitoring device that is designed to be hand carried from point to point. The M8 is used to provide early warning of a toxic agent position and detects the presence of chemical vapors and aerosols. The M43 detects all nerve, blood, and choking agents, and some blister agents. The M43A1 (the replacement for the M43) only detects nerve agents.

(_b_) The M256 Chemical Agent Detector Kit detects and identifies nerve, blood, and blister agents. The M256 is the most sensitive of the chemical agent vapor detectors available. However, it is not a continuous, real-time monitoring system. It requires 15 to 20 minutes for sampling and analysis.

(_c_) The ABC-M8 VGH Chemical Agent Detector Paper can detect and differentiate between nerve and blister agents by color change. It is intended to be used by blotting and wiping surfaces suspected of contamination. The M8 paper will respond with a visual color change in 10 seconds or less.

(_d_) The M9 Chemical Agent Detector Paper will detect liquid nerve (G & V) and blister agents (H & L), but will not identify the specific agent or differentiate between nerve and blister agents. The M9 tape is sensitive to droplets as small as 100 μ, and will respond with a visual color change in 10 seconds or less.

(4) All subsistence in a chemical attack area are considered contaminated until a survey can be conducted, preferably by veterinary and chemical personnel. Personnel must be at MOPP Level 4 while conducting the survey. Concentrate the initial portion of the survey on the adequacy of the storage facility and other protective measures in preventing chemical agent contact with subsistence items. The area surrounding the storage facility is examined for the presence of animals, rodents, birds, and arthropods acting unusual, or dead in unusual numbers. If animals are present and assistance is required in identifying the NBC agent, specimens can be collected and submitted to the area medical laboratory. Damage such as broken windows, holes, or loss of structural integrity of the storage facility is noted. This information combined with knowledge of the agent form (liquid or vapor), type of agent (which will indicate the degree of persistency), and approximate time of attack will provide a risk assessment. Liquid agents should not significantly penetrate an intact facility, but may produce vapor contamination by off-gassing.

(_a_) Upon entering the storage facility, the M8 can be used to determine the presence of chemical vapors. However, precautions must be taken. The M42 alarm is not to be used inside shelters, vehicles, vans, or other interior modes. Therefore, when checking food storage facilities, the alarm unit must be left outside, turned off, or disconnected. Do not tilt the M43 detector more than 45 degrees (because of the liquids it contains). This is not a problem with the improved M43A1, but the M43A1 requires attachment of an exit port filter when used indoors. The M256 Chemical Agent Detector Kit can be used to sample the air.

(_b_) Pre-position M9 chemical agent detector paper in food storage areas; especially on the least protected pallets and in areas where droplets may enter, such as near doors or windows. Examine the M9 paper for indications of liquid chemical agents. If the M9 paper is positive, or if the packaging materials show the presence of liquids or stains, use the M8 detector paper to determine the type of the agent. If an agent is not indicated by the detector paper, then the amount of agent present will be insufficient to cause secondary contamination when the outer package is removed.

(5) Detection procedures become more complicated if a chemical agent has penetrated or permeated through the packaging and packing materials. Unless liquid has seeped through the cardboard, any agent in the interior of the shipping case will be in a vapor form. Liquid seeping should be obvious. The sampler-detectors in the M256 Chemical Agent Detector Kit do not have an aspirator for sampling the interior of the case. However, there are several procedures that can be used. One is to open the case, place the activated sampler-detectors inside the case, and then reclose the case. Another is to punch holes in the case, place the activated sampler-detector over the holes, and cover the sampler-detector with an empty box or can (open end down) to concentrate the vapors escaping from the case. Alternatively, remove the food from the case and place it in a plastic bag with the sampler-detectors to concentrate the vapors. These procedures require two sampler-detectors; one for blood agents and one for nerve and blister agents. Neither method is very sensitive in low concentrations of vapor as is expected to be present inside shipping containers. A better method is to modify the M43 detector with a field expedient probe of Teflon tubing attached to the detector's air inlet. Insert the open end of the tubing into a hole in the case or package to sample the interior air. When available, the improved chemical agent monitor (ICAM) can be used; its design will allow aspiration of air from inside shipping cases. The ICAM can also be used to detect and identify liquid agents on a surface provided the agent is vaporizing in sufficient quantity. The ICAM gives a visual representation of a hazard evaluation.

_c. Decontamination._

(1) Decontamination is only required for contamination remaining 10 minutes or longer. Decontamination efforts on subsistence items will normally be limited to removal of the containers and carton overwrap material.

(2) The need for decontamination is primarily dictated by the type of chemical agent used. The method of decontamination selected will depend upon the type of packaging material used and the urgency with which the food is required.

(3) Food supplies in storage are not likely to be seriously contaminated if reasonable protection precautions are taken. For this reason, large supplies of food are not to be condemned as a whole simply because they have been exposed to possible chemical contamination. A prompt and careful survey of the supplies may reveal that only a few items have been contaminated to a level that decontamination is required. Prompt segregation of the heavily contaminated portions will prevent, or minimize, contamination of the remainder. Foods without protective packages constitute the major difficulty.

(4) Individual decontamination is performed by each soldier on those subsistence items in his possession at the time of the attack. Individual decontamination is limited to operational rations that are in original, intact containers. Unit-level decontamination is performed by unit personnel under the supervision of unit NBC personnel. Support decontamination is attempted at major subsistence storage facilities. Again, decontamination is limited to packing material. Decontamination of food itself is only attempted in emergency situations when alternative supplies are not available.

(5) Start decontamination operations with the easiest method and proceed to the most difficult. This allows for the removal of a relatively large portion of the contamination in a minimum of time. The simplest procedure is to allow the materials to age and air ("weather"). Substantial self-decontamination will occur with most agents. Exceptions are thickened mustard, thickened GD, and VX. Table J-6 provides the length of time for which contaminated subsistence supplies may present a contact hazard. Weather elements that affect decontamination are--

(_a_) Warm temperatures speed liquid agent off-gassing and hasten the dispersion of chemical agents into the air.

(_b_) High winds rapidly disperse chemical agent vapors and speed off-gassing from surfaces.

(_c_) Moisture causes chemical agents to react with water to form nontoxic or less toxic chemicals. Heavy rain or rain of long duration can aid decontamination by mechanically removing chemical agents.

(_d_) Even in cold weather, direct sunrays warm surfaces above the air temperature and hasten the off-gassing and decomposition of chemical agents.

_Table J-6. Persistency of Selected Liquid Chemical Agents_

(6) Active decontamination is attempted only when weathering will not decontaminate the packaging material in sufficient time. Decontamination procedures can be enhanced by using heat to vaporize the chemical agent; by reaction with decontaminants; or by removing with hot soapy water.

(_a_) The simplest (standard) decontamination materials are water and detergents. An effective decontaminant is hot water used with the addition of soap or detergent and scrubbing. Commercial abrasive powdered cleansers are effective decontaminants for many surfaces (metal, glass, Formica), but not wood or soft plastics.

(_b_) Water can be used to flush chemical agents from surfaces. High-pressure application produces a better cleansing action than low pressure. If the surface has absorbed the agent, flushing will remove the surface contamination, but will not affect the agent that is absorbed.

(_c_) Soaking contaminated items in boiling water is an excellent decontamination method for some agents. Water alone will not be sufficient to decontaminate all chemical agents. Soaking in warm or cold water may reduce the contamination slightly; however, the hazard may not be reduced sufficiently even after prolonged soaking. If hot water is not available, or if it might cause damage to the item, other methods of decontamination should be considered, such as decontaminating solutions or a caustic solution followed by thorough rinsing.

(_d_) Fibrous materials such as cloth and canvas are best decontaminated by washing and scrubbing.

(_e_) Glass, metal, porcelain, and plastic surfaces are best decontaminated by using hot water or hot soapy water. Some toxic materials are readily removed with no more than slight abrasion or brushing.

(_f_) Painted, varnished, and waxed surfaces are generally smooth and nonporous. Dust and liquids are readily removed by wiping, brushing, or vacuuming. Absorbed materials are removed by hot water, detergent, or complexing agents. None of these surfaces stand up well to heavy abrasive techniques. Agents can be attacked and removed by caustics, acids, and organic chemicals. Some of these surfaces readily absorb agents, so weathering following decontamination is advisable.

(_g_) Rubber is a porous material that can absorb agents. It is not easily decontaminated by abrasive techniques. Warm, soapy water used with brushing is effective since it removes some absorbed contamination. Strong acids, alkalies, and organic solvents may deteriorate and decompose rubber articles.

(7) Operational rations are the primary rations issued; always issue uncontaminated stocks first. This allows for decontamination of contaminated stocks without interrupting supply support. Normally, contaminated stocks are not issued. The decision to issue contaminated items is based on the tactical situation, criticality of the items, type and extent of contamination, and the time and resources available for decontamination. Decontamination efforts on subsistence items are limited to the containers and carton overwrap material.

(_a_) The MRE retort and nonretort food pouch may be decontaminated with soap and water wash. The chemical agents will be removed by the solutions.

(_b_) Semipermeable materials (polyethylene menu bag, shrink wrap, and film wrap) may have chemicals deposited not only on the surface, but also dissolved into the matrix of the material. The chemicals can be removed from the surface by washing with hot soapy water, but contaminant dissolved in the material is not removed. The remaining agent can only be removed by weathering which can be accelerated through the use of heat and sweeping the surface with air.

(_c_) Fiberboard is both sorbent and permeable and acts like a blotter. Liquid decontaminants can force the contaminant further into the fiberboard. Any attempt to decontaminate fiberboard would be futile. The only alternatives are to remove the fiberboard, or to allow it to weather.

(_d_) Palletized unit loads of MRE and UGR outerwraps can be decontaminated through the aid of a forced clean air sweep in 4 to 5 days, compared to 3 weeks or more under natural conditions without a forced air sweep.

(8) Contaminated food supplies are only handled by personnel trained in decontamination methods and in MOPP Level 4. Contaminated food items are divided into three groups as described below (see Table J-1 for additional information).

(_a_) Group 1 consists of canned and unopened packaged items which have been exposed only to agent vapors. Most items in this group will be safe to issue after a brief period of outdoor airing to remove clinging vapors. Table J-7 lists the decontamination procedures for packaging materials contaminated with nerve agents, mustards, and arsenicals.

_Table J-7. Chemical Decontamination of Packaged Material_

====================================================================== PACKAGING MATERIAL CONTAMINATION DECONTAMINATION PROCEDURES ---------------------------------------------------------------------- AIRTIGHT METAL VAPOR AND AIR FOR 24 HOURS. WASH CONTAINERS, GLASS LIQUID WITH HOT SOAPY WATER, BOTTLES, FOIL SODA, OR BLEACH SOLUTION. ALUMINATED LAMINATED RINSE WITH WATER. MATERIALS.

POLYESTER, PVF. VAPOR REMOVE CONTAMINATED WOODEN BOXES, CRATES, PACKAGE. AIR CONTENTS FOR BOARD, MULTILAYER 24 HOURS. BAGS.

CARDBOARD, LIQUID CONTAMINATED CONTENTS--TREAT POLYETHYLENE. AS UNPACKAGED FOOD. =======================================================================

(_b_) Group II consists of canned and unopened packaged items which have been contaminated with a liquid chemical agent.

_1._ Attempts to decontaminate porous packaging materials, such as cardboard or wood, are likely to be unsuccessful and may result in spreading the contamination. The best procedure in handling such items is to strip off the outer contaminated coverings and examine the inner layer to see if penetration of the agent has occurred. If it has, continue stripping off layers until an uncontaminated layer is reached and place it in Group I. If the agent has penetrated to the food, place it in Group III.

_2._ Food in cans or in other sealed, impermeable containers is not in danger of chemical contamination. Because contamination is confined to the outer surface of the sealed container, decontamination is accomplished by: immersion in boiling, soapy water for 30 minutes and rinse; immersion in boiling water for 30 minutes; spray with DS2; or to wash in hot soapy water, rinse, and aerate. Under no conditions should contaminated containers be opened before they have been decontaminated and monitored.

_3._ Supertropical bleach and DS2 can be used on the polyethylene menu bag for up to 24 hours without a significant change in appearance, tensile properties, and size of the plastic. The use of DS2 will cause significant degradative changes to most other plastics, while STB will cause little or no change. Also, DS2 may cause false positive readings when using M8 or M9 paper, or the M256 Detector Kit to check completeness of decontamination.

(_c_) Group III will consist of unpackaged or poorly packaged items which have been exposed to an agent in either vapor or liquid form. Foodstuffs in this group should be decontaminated only when absolutely necessary. =The decision to use foods that have been contaminated is to be made by the commander.= Decontamination procedure to be followed, in order, is: trim surface fat and grossly contaminated areas; wash with water or 2-percent sodium bicarbonate solution; then boil in water.

_1._ Boiling in water may be eliminated when the contamination has been only with the vapors of irritant agents. When such an exposure has been light, aeration for a short time may be used for decontamination.

_2._ Frying, roasting, or broiling will not remove traces of blister agents from meats. In general, salvage of foods heavily contaminated with droplets of the blister agents, especially the arsenical blister agents, is not practical. Foods of high water or fat content are unfit for consumption and reclamation is not practical when contaminated with liquid mustard or a liquid nitrogen mustard.

_3._ When foods have been exposed to blister agent vapor, they can be reclaimed by washing with sodium bicarbonate solutions and rinsing with clear water, by intensive cooking, or in the case of dry provisions, by 24 to 48 hours of aeration. Lean meat contaminated with mustard vapor can be reclaimed by boiling in water for 30 minutes or more. With nitrogen mustard vapor contamination, the meat should be boiled in a 2-percent sodium bicarbonate solution. Discard the water used to boil the meat.

_4._ Nerve agent contamination is treated the same as blister agent contamination.

_5._ Foods, such as potatoes and hard-skinned fruits and vegetables, can be decontaminated by washing or scrubbing, followed by peeling or scraping, then washing again.

_6._ Prepared food in open containers will be contaminated; it must be temporarily isolated, or disposed of (bury or as directed by commander).

_7._ A food Item that is contaminated with irritants can be decontaminated by airing. Consumability is determined by taste rather than toxicity.

_8._ Phosgene is rapidly hydrolyzed, therefore, washing the food with water or airing it will usually suffice.

_9._ Food contaminated with white phosphorous should be destroyed.

_10._ Normally, hydrocyanic acid will have little effect on food supplies. The exposures will most likely be as a vapor. However, foods with a high water content may become unfit for consumption after exposure to high concentrations.

_11._ The effect of CK on foods is not known. Foods exposed to CK vapors are considered toxic.

_12._ Table J-8 lists the decontamination procedures for unpackaged food contaminated with a chemical agent.

(9) Decontaminating cattle, poultry, and other livestock is only attempted when other sources of food are not available. Heavily contaminated animals should be destroyed. Livestock contaminated lightly by phosgene, nerve agents, mustards, and arsenicals (such as vapor or liquid) may be slaughtered in the early stages of poisoning before the full effects of exposure are shown. If these animals are slaughtered in the preliminary stages of poisoning and all tissues exposed to the agent (the head, blood, lungs, organs, and local areas) are discarded, there is no danger in consumption of the meat, provided the animal passes a pre-slaughter and slaughter inspection. This is true even of animals poisoned by arsenical agents since the edible tissue will contain amounts of arsenic too small to be toxic. Organs (liver, brain, heart, kidney, and lungs) will contain more arsenic than the musculature and are discarded. The meat must be well cooked. Personnel involved in slaughtering procedures must be careful to prevent spreading contamination to the meat and to themselves.

(10) Decontaminating forage and grain exposed to only chemical agent vapors is by aeration. Aerated supplies, especially if mixed with larger amounts of uncontaminated supplies, produces no ill effects when fed to animals. Forage or grain heavily contaminated by liquid vesicants, especially arsenicals, should not be used.

_Table J-8. Chemical Decontamination of Unpackaged Food_

======================================================================== FATTY FOODS NONFATTY FOODS, NONFATTY FOODS, (BUTTER, BACON, High WATER CONTENT LOW WATER CONTENT, CHEMICAL AGENT MILK, CHEESE, CRYSTALLINE (FRUITS, AMORPHOUS (FLOUR, HAM). VEGETABLES, SALT, CEREALS, BREAD, SUGAR). PEAS). ------------------------------------------------------------------------ =NERVE AGENTS=

VAPOR, HEAVY DESTROY DESTROY, UNLESS AIR FOR 48 HOURS, POSSIBLE TO BOIL THEN BOIL. AFTER AIRING 48 HOURS.

VAPOR, LIGHT DESTROY AIR FOR 48 HOURS, AIR FOR 48 HOURS, THEN BOIL. THEN BOIL.

LIQUID DESTROY DESTROY DESTROY

=MUSTARDS=

VAPOR REMOVE 1-3 cm WASH WITH WATER. WASH WITH WATER. OF OUTER LAYER AIR FOR 48 HOURS. AIR FOR 48 HOURS. AND WASH WITH 2% SODIUM BICARB- ONATE SOLUTION. BOIL FOR AT LEAST 30 MINUTES. DESTROY MILK.

LIQUID DESTROY DESTROY DESTROY

=ARSENICALS= DESTROY DESTROY DESTROY ========================================================================

GLOSSARY

ABBREVIATION, ACRONYMS, AND DEFINITIONS

=ABCA= American, British, Canadian, and Australian

=ABO= agents of biological origin

=AC= hydrogen cyanide

=AFJMAN= Air Force Joint Manual

=amb= ambulance

=AMEDD= Army Medical Department

=AMEDDC&S= Army Medical Department Center and School

=AMedP= Allied Medical Publication

=AML= area medical laboratory

=AN/PDR27= radiac meter

=AN/PDR77= radiac meter

=AN/VDR2= radiac meter

=AO= area of operations

=AR= Army regulation

=ATM= advanced trauma management

=ATTN= attention

=AXP= ambulance exchange point

=BAS= battalion aid station

=BAT= Biological Augmentation Team

=BC= blood culture

=bde= brigade

=BDU= battle dress uniform

=BI= battle injury

=BIDS= Biological Integrated Detection System

=Biological Warfare Agent Field Confirmation Identification= Identification of a suspect biological warfare agent by means of devices/materials/technologies that are based on detecting biological markers using two or more independent biomarker results. Examples might include the findings of the presumptive biomarker identification with the addition of a positive PCR, ELISA, or electrochemiluminescence (ECL) results, using specific target nucleic acid sequences for the organism and antibody recognition of agent-specific antigen sites, respectively. (Field sample/ specimen identification by forward deployed or forward positioned laboratories [such as the US Air Force Biological Augmentation Team (BAT), theater army medical laboratory, or forward deployed preventive medicine unit (US Navy) and homeland security Laboratory Response Network (LRN) Level B or C, US Army Community Hospitals or Medical Centers].)

=Biological Warfare Agent Definitive Identification And Confirmation= The specific identification of a suspect biological agent as to genus and species, serological type, or toxin. This level of identification is by means of devices/materials/technologies that are based on two or more independent biomarker results and using different methodologies. This level of identification is performed in a reference laboratory with a broader variety of methodologies available and highly skilled testing personnel, thus providing the highest levels of accuracy. (Sample/specimen identification is accomplished by homeland security LRN Level C and D and nationally recognized laboratory such as the US Army Medical Research Institute of Infectious Disease or Centers for Disease Control and Prevention.)

=Biological Marker= Characteristics of a biological agent (organism, virus, toxin, or product) that are specific to the agent. This includes (1) recognition of specific nucleic add sequences (DNA or ribonucleic acid [RNA]) unique to the bacteria or virus by a technique such as PCR; (2) identification of specific ECL assay; (3) specific growth properties as seen on selective media such as characteristic colony morphology on culture along with phage inhibition; (4) Identification using specific microscopic characteristics such as Gram stain, fluorescent antibody stain, immunohistochemical stain, or cytopathic effects.

=Biological Warfare Agent Presumptive Identification= Identification of a suspect biological warfare agent by means of devices/materials/technologies that are based detecting biological markers (biomarkers) using a single methodology. The biomarkers and/or methodologies used at this level of testing have significant limits to their accuracy. Agent identification to species level, or differentiation among a family of similar agents, may not be possible. This is equivalent to the LRN Level A and the US Army BIDS. (EXAMPLES: Identification by sensor triggering, hand-held devices [hand-held assays] or initial systems, or laboratory analysis employing one screening methodology [such as microscopic morphology, antibody/protein, or nucleic acid-based test].)

=bot/pkg= bottle/package

=BSA= brigade support area

=BW= biological warfare

=BZ= an incapacitating chemical warfare agent

=C= Centigrade/Celsius

=C2= command and control

=C4I= Command, Control, Communications, Computers, and Intelligence

=CaCl= calcium hypochlorite

=cal/cm^2= calories per square centimeter

=cal/cm^2/sec= calories per square centimeter per second

=CAM= chemical agent monitor

=CANA= convulsant antidote for nerve agent (diazepam)

=CB= chemical/biological

=CBDA= Chemical Biological Defense Agency

=CBPS= chemically biologically protected shelter

=CBRNE= chemical, biological, radiological, nuclear, and high-yield explosive

=CBSCC= Chemical-Biological Sampling Control Center

=CBSCE= Chemical-Biological Sampling Control Element

=cc= cubic centimeter

=CG= phosgene

=cGy= centigray

=CIS= Commonwealth of Independent States (Russia)

=CK= cyanogen chloride

=Cl= chlorine

=CLASS VIII= Classification of medical supplies and equipment within the Federal Stock Classification System

=CLS= combat lifesaver

=cm= centimeter

=cm^2= square centimeter

=CNS= central nervous system

=CO_{2}= carbon dioxide

=CONUS= continental United States

=COSC= combat operational stress control

=CP= chemically protected

=CP DEPMEDS= chemically protected deployable medical system

=CPS= collective protection shelter

=CREST= Casualty Requirements Estimation Tool

=CS= combat support

=Cs-137= Cesium 137

=CSF= cerebrospinal fluid

=CSH= combat support hospital

=CSS= combat service support

=CW= chemical warfare

=CX= phosgene oxime

=DA= Department of the Army

=DAP= decontamination apparatus, portable

=DCS= division clearing station

DD Department of Defense

decon decontamination

DEPMEDS Deployable Medical System

DNA deoxyribonucleic acid

DNBI disease and nonbattle Injury

DOD Department of Defense

DP diphosgene

DS2 decontaminating solution Number 2

DTF dental treatment facility

E EDTA

EAC echelons above corps

ECL electochemiluminescence

ECP entry control point

ECU environmental control units

EDTA ethylenediaminetetraacetate

EEE eastern equine encephalitis

ELISA enzyme-linked immunosorbent assay

EM electron microscopy

EMP electromagnetic pulse

EMS emergency medical services

EMT emergency medical treatment

EOD explosive ordnance disposal

EPW enemy prisoner of war

ER emergency room

evac evacuation

F Fahrenheit

F-1 Fraction-1

FA fluorescent antibody

FDECU field deployable environmental control unit

FH field hospital

FLOT forward line of own troops

FM field manual

FMC Field Medical Card

FSOP field standing operating procedures

FST forward surgical team

g gram

G1 Assistant Chief of Staff (Adjutant)

G2 Assistant Chief of Staff (Intelligence)

G3 Assistant Chief of Staff (Operations and Training)

G4 Assistant Chief of Staff (Logistics)

GA Tabun

gal gallon

GB Sarin

GD Soman

=GF= a nerve agent

=GH= general hospital

=gm= gram

=GP= general purpose

=GVO= green vinyl overboots

=Gy= gray (100 cGy)

=H= heparin

=HD= sulfur mustard (a blister agent)

=HG= chemical symbol for mercury

=HL= mustard and Lewisite mix

=HMMWV= high mobility multi-purpose wheeled vehicle

=HN= nitrogen mustard

=HPLC= high-pressure liquid chromatography

=HSL= health service logistics

=HSS= health service support

=HUB= hospital unit base

=HUH= hospital unit holding

=HUM= hospital unit medical

=HUS= hospital unit surgical

=HTH= high test hypochlorite (70% available chlorine)

=I-131= Iodine-131

=IATA= International Air Transportation Association

=IAW= in accordance with

=IC= intensive care

=ICAM= improved chemical agent monitor

=ICC= incident command center

=ICU= intensive care unit

=ICW= intensive care ward

=ID= Incapacitation dose

=IgG= immunoglobulin class G

=IgM= immunoglobulin class M

=IMA= installation medical authority

=ISO= International Organization for Standardization

=IV= intravenous

=J2= Joint Intelligence Directorate

=J3= Joint Operations Directorate

=kg= kilogram

=km= kilometer(s)

=kph= kilometers per hour

=KT= kiloton

=L= Lewisite

=LAB= laboratory

=lb= pound

=LCE= load-carrying equipment

=LD= lethal dose

=LD 50/60= lethal dose for 50 percent of exposed persons within a period of 60 days

=LRN= Laboratory Response Network

=LSD= d-lysergic acid diethylamide

=LZ= landing zone

=µ= micron

=m= meters

=m3= milligrams per minute

=MCRP= Marine Corps Reference Publication

=MEDEVAC= medical evacuation

=Medical Countermeasures= Those measures taken to maintain soldier sustainability through the prevention and pretreatment of injury from NBC agent hazards; and following injury those measures taken to treat NBC casualties and improve medical capability for diagnosis, physiological resuscitation and continued medical management of NBC casualties.

=MES= medical equipment set

=MF2K= Medical Force 2000 (Army of Excellence Organizations)

=mg= milligram

=mg/kg= milligrams per kilogram

=MILVAN= military-owned demountable container

=ml= milliliter

=mm= millimeter

=MOPP= mission-oriented protective posture

=MOS= military occupational specialty

=MRE= meal ready-to-eat

=MRI= Medical Reengineering Initiative

=MSR= main supply route

=m/sec= meters per second

=MT= megaton

=MTF= medical treatment facility

=NaCl= sodium chloride (salt)

=NATO= North Atlantic Treaty Organization

=NAVMED P= Naval Medical Publication

=NBC= nuclear, biological, and chemical

=NBCC= nuclear, biological, and chemical control

=NBCWRS= nuclear, biological, and chemical warning and reporting system

=NCO= noncommissioned officer

=NL= no limit

=NTTP= Navy Tactics Techniques and Procedures

=O_{2}= oxygen

=OEG= operational exposure guide

=OPLAN= operation plan

=OPSEC= operations security

=Patient Decontamination=--The removal and/or the neutralization of hazardous levels of nuclear, biological, and chemical contamination from patients at a medical treatment facility. Patient decontamination is performed under the supervision of medical personnel to prevent further injury to the patient and to maintain the patient's health status during the decontamination process. Patient decontamination serves multiple purposes; it protects the patient from further injury, it prevents exposing medical personnel to the contamination, and it prevents contamination of the medical treatment facility.

=PCR= polymerase chain reaction

=PDS= patient decontamination station

=pH= symbol relating the hydrogen ion activity in gram equivalents per liter used in expressing the acidity and alkalinity on a scale whose values run from 0 to 14 with 7 representing neutrality. Numbers less than 7 indicate increasing acidity, and numbers greater than 7 indicate increasing alkalinity.

=PMM= preventive medicine measures

=pnt= patient

=ppm= parts per million

=PPW= patient protective wrap

=PS= chloropicrin

=PVF= polyvinyl fluoride

=PVNTMED= preventive medicine

=QSTA= Quadripartite Standardization Agreement

=RDD= radiological dispersal device

=recon= reconnaissance

=RES= radiation exposure status

=RNA= ribonucleic acid

=ROWPU= reverse osmosis water purification unit

=RT= red top

=RT-PCR= reverse transcriptase/polymerase chain reaction

=RTD= return to duty

=S1= Adjutant (US Army)

=S2= Intelligence Officer (U.S. Army)

=S3= Operations and Training Officer (U.S. Army)

=S4= Supply Officer (U.S. Army)

=SCUD= ballistic missile

=SDK= skin decontaminating kit

=SFG= Special Forces Group

=SMART= special medical assistance response team

=SOF= Special Operations Forces

=SOP= standing operating procedure

=Sr-89= Strontium-89

=Sr-90= Strontium-90

=STANAG= Standardization Agreement (NATO)

=STAT= statim

=STB= supertropical bleach

=Sv= Sievert

=T2= trichothecene

=TAML= theater Army medical laboratory

=TC= training circular

=TEU= technical escort unit

=TEMPER= tent, expandable, modular, personnel

=Toxic Industrial Biological (TIB)= Biological materials (bacteria, viruses, and toxins) found in medical research, pharmaceutical, and other manufacturing processes that are toxic to humans and animals, or cause damage to plants.

=Toxic Industrial Chemical (TIC)= Chemical compounds used or produced in industrial processes that are toxic to humans and animals, or cause damage to plants. EXAMPLES include fuels, solvents, heavy metals, and chemicals used in manufacturing processes.

=Toxic Industrial Material (TIM)= Toxic industrial materials may be toxic industrial chemical (TIC), toxic industrial biological (TIB) and toxic industrial radiological (TIR) materials.

=Toxic Industrial Radiological (TIR)= Radiation-emitting materials used in research, power generation, medical treatment, and other non-weapon developmental activities that are harmful to humans and animals if released outside their controlled environment.

=TIR= toxic industrial radiological

=TM= technical manual

^{=TM=} trademark

=TOE= table of organization and equipment (US Army organizational structure document)

=TO= theater of operations

=trmt= treatment

=TSOP= tactical standing operating procedures

=TT= tiger top

=µ= microns

=UGR= unit group rations

=UN= United Nations

=US= United States

=USAF= United States Air Force

=V-agent= a nerve agent

=VEE= Venezuelan equine encephalitis

=VX= a persistent nerve agent

=WBGT= wet bulb globe temperature

=WEE= western equine encephalitis

=WMD-IST= weapons of mass destruction--installation support team

REFERENCES

=NATO=

_NATO Emergency War Surgery Handbook._ 1988.

=NATO STANAGs=

These agreements are available on request (using DD Form 1425) from the Standardization Documents Order Desk, 700 Robins Avenue, Building 4, Section D, Philadelphia, Pennsylvania 19111-5094.

2002. _Warning Signs for the Marking of Contaminated or Dangerous Land Areas, Complete Equipments, Supplies and Stores. Edition 8._ 29 January 1999.

2047. _Emergency Alarms of Hazard or Attack (NBC and Air Attack Only). Edition 7._ 24 July 1998. (Latest Amendment, 7 February 2000.)

2068. _Emergency War Surgery. Edition 4._ 28 October 1986. (Latest Amendment, 17 October 1991.)

2083. _Commander's Guide on Nuclear Radiation Exposure of Groups. Edition 5._ 19 September 1986. (Latest Amendment, 26 June 1994.)

2103. _Reporting Nuclear Detonations, Biological and Chemical Attacks, and Predicting and Warning of Associated Hazards and Hazard Areas--ATP 45(A). Edition 8._ 31 August 2000.

2104. _Friendly Nuclear Strike Warning. Edition 7._ 28 June 1994. (Latest Amendment, 28 June 1995.)

2112. _Nuclear, Biological, and Chemical Reconnaissance. Edition 4._ 6 March 1998.

2475. _Medical Planning Guide for the Estimation of NBC Battle Casualties (Nuclear)--AmedP-8(A), Volume I._ December 2000.

2476. _Medical Planning Guide of NBC Battle Casualties (Biological)--AmedP-8(A), Volume II._ March 2001.

2477. _Planning Guide for the Estimation of NBC Battle Casualties (Chemical)--AmedP-8(A), Volume III._ March 2001.

2500. _NATO Handbook on the Medical Aspects of NBC Defensive Operations--AMedP-6(B). Edition 4._ 11 February 1997.

2873. _Concept of Operations of Medical Support in Nuclear, Biological, and Chemical Environments--AmedP-7(A). Edition 3._ 16 October 1996.

2879. _Principles of Medical Policy in the Management of a Mass Casualty Situation. Edition 3._ 7 September 1998.

2941. _Guidelines for Air and Ground Personnel Using Fixed and Transportable Collective Protection Facilities on Land. Edition 2._ 19 June 1992. (Latest Amendment, 30 October 1995.)

2954. _Training of Medical Personnel for NBC Operations. Edition 1._ 28 December 1987. (Latest Amendment, 6 June 1995.)

=ABCA QSTAGs=

These agreements are available on request (using DD Form 1425) from the Standardization Documents Order Desk, 700 Robins Avenue, Building 4, Section D, Philadelphia, Pennsylvania 19111-5094.

183. _Emergency Warning Signals and Alarms for NBCD Hazards or Attacks (NBC and Air Attacks Only). Edition 3._ 12 August 1991.

187. _Reporting Nuclear Detonations Biological and Chemical Attacks and Predicting and Warning of Associated Hazards and Hazard Areas. Edition 5._ 21 May 1998.

189. _Friendly Nuclear Strike Warning. Edition 3._ 12 August 1991.

501. _Warning Signs for the Marking of Contaminated or Dangerous Land Areas, Complete Equipment, Supplies and Stores. Edition 2._ 11 May 1982.

608. _Interoperable Chemical Agent Detector Kits. Edition 3._ 13 December 2000.

816. _Medical Aspects of Mass Casualty Situations. Edition 1._ August 1990.

1330. _Medical Aspects of NBC Defensive Operations._ Draft.

2000. _Guidelines on Entry and Exit Procedures for Using Collective Protection Facilities._ 17 December 1996.

=JOINT OR MULTISERVICE PUBLICATIONS=

AR 40-535. _Worldwide Aeromedical Evacuation._ AFR 164-5; OPNAVINST 4630.9C; MCO P4630.9A. 1 December 1975. (Reprinted with basic including Change 1, 10 May 1979.)

AR 40-562. _Immunizations and Chemoprophylaxis._ AFJI 48-110; BUMEDINST 6230.15; CG COMDTINST M6230.4E. 1 November 1995.

AR 40-656. _Veterinary Surveillance Inspection of Subsistence._ NAVSUPINST 4355.10; MCO 10110.45. 15 October 1986.

AR 40-657. _Veterinary/Medical Food Inspection and Laboratory Service._ NAVSUPINST 4355.4F; MCO P10110.31G. 6 November 1997.

FM 3-3. _Chemical and Biological Contamination Avoidance._ FMFM 11-17. 16 November 1992. (Change 1, 29 September 1994.)

FM 3-4. _NBC Protection._ FMFM 11-9. 29 May 1992. (Reprinted with basic including Changes 1-2, 21 February 1996.)

FM 3-5. _NBC Decontamination._ MCWP 3-37.3. 28 July 2000.

FM 3-6. _Field Behavior of NBC Agents (Including Smoke and Incendiaries)._ AMF 105-7; FMFM 7-11 H. 3 November 1986.

FM 3-9. _Potential Military Chemical/Biological Agents and Compounds._ NAVFAC P-467, AFR 355-7. 12 December 1990.

FM 3-11.34. _Multiservice Procedures for Nuclear, Biological, and Chemical (NBC) Defense of Theater Fixed Sites, Ports, and Airfields._ MCWP 3.37.5; NTTP 3-11.23; AFTTP(I) 3-2.33. 29 September 2000.

FM 3-19. _Nuclear, Biological and Chemical Reconnaissance._ FMFM 11-20. 19 November 1993.

FM 3-100. _Chemical Operations, Principles and Fundamentals._ MCWP 3-3.7.1. 8 May 1996.

FM 4-02.33. _Control of Communicable Diseases Manual._ 17th Edition. NAVMED P-5038. 31 December 1999.

FM 4-02.283. _Treatment of Nuclear and Radiological Casualties._ NTRP 4-02.21; AFMAN 44-161(I); MCRP 4-11.1B. 20 December 2001.

FM 6-22.5. _Combat Stress._ MCRP 6-11C; NTTP 1-15M. 23 June 2000.

FM 8-9. _NATO Handbook on the Medical Aspects of NBC Defensive Operations AMedP-6(B), Part I--Nuclear, Part II--Biological,