Chapter 14 - Field Managment of Chemical Casualties - Pg. 485 - 510

8/3/2019 Chapter 14 - Field Managment of Chemical Casualties - Pg. 485 - 510

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Field Management of Chemical Casualties

Chapter 14

FIELD MANAGEMENT OF CHEMICALCASUALTIES

CHARLES H. BOARDMAN, MS, ORR/L*; SHIRLEY D. TUORINSKY, MSN; DUANE C. CANEVA, MD; JOHN D. MA-LONE, MD, MSPH;ANDWILLIAM L. JACKSON, MD, PHD

INTRODUCTION

HEALTH SERVICE SUPPORT AND MILITARY FORCE HEALTH PROTECTION ONTHE BATTLEFIELD

SERVICE-SPECIFIC OPERATIONS FOR FIELD MANAGEMENT OF CHEMICALCASUALTIES

Land-Based ForcesSea-Based Forces

MANAGEMENT OF CHEMICAL CASUALTIES FROM A CIVILIAN PERSPECTIVE

INTEGRATION OF MILITARY SUPPORT INTO CIVILIAN HOMELANDRESPONSE

THE MEDICAL MANAGEMENT PROCESS IN A CHEMICAL EVENTPreattack, Attack, and Postattack MeasuresPersonnel RequirementsNecessary Medical Equipment and SuppliesZones of ContaminationLevels of DecontaminationMilitary Management Concepts in the Civilian SettingProcessing Patients

SUMMARY

*Lieutenant Colonel, Biomedical Sciences Corps, US Air Force; Air Force Liaison, Instructor, and Occupational Therapist, Chemical Casualty Care Divi-sion, US Army Medical Research Institute of Chemical Defense, 3100 Ricketts Point Road, Aberdeen Proving Ground, Maryland 21010-5400

Lieutenant Colonel, AN, US Army; Executive Officer, Combat Casualty Care Division, US Army Medical Research Institute of Chemical Defense, 3100Ricketts Point Road, Aberdeen Proving Ground, Maryland 21010-5400

Commander, US Navy;; Head, Medical Plans and Policy, Navy Medicine Office of Homeland Security, 2300 E Street, NW, Washington, DC 20372Captain, US Navy; Professor of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814; formerly, Commanding

Officer, Medical Treatment Facility, USNS Mercy

Commander, US Public Health Service; Centers for Disease Control and Prevention Quarantine Station, Honolulu International Airport, 300 RodgersBlvd, Terminal Box 67, Honolulu, Hawaii 96819-1897; formerly, Assistant Chief Medical Officer, US Coast Guard Personnel Command, Arlington,Virginia


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Medical Aspects of Chemical Warfare

INTRODUCTION

ment. First responders, as well as first receivers (thosewho receive contaminated patients at the hospital),must have the training to carry out patient triage andlife saving treatment for contaminated patients before,

during, and after decontamination. This method of ca-sualty management will reduce injury and should sig-nificantly reduce the health impact of a mass casualtyevent caused by the release of hazardous substances.

This chapter compares the current field manage-ment operations of the various military services (land-based and sea-based forces) and the civilian medicalcommunity. Although patient treatment strategies stillvary, there are now many similarities in the decon-tamination procedures used by these various organi-zations, with key differences related to the platformson which field management takes place (eg, on landvs. on sea-going vessels) and the specific equipment

used for medical care, transport, and decontamina-tion. The emphasis in this text is on the managementof chemical casualties; however, these same processesare equally applicable to treating patients affected bybiological and radiological contaminants. Doctrine andtechniques continue to be upgraded, but it is expectedthat any future developments should continue to fol-low the basic principles discussed here.

The management of casualties exposed to chemical,biological, radiological, and nuclear (CBRN) agents haslong been part of military doctrine. Since the eventsof September 11, 2001, interest in the management of

these types of casualties has extended to the civilianresponse network. The military mission has likewiseexpanded beyond the battlefield to include operationsin support of homeland defense and humanitariandisaster relief. This expansion of military roles hasnot significantly changed the procedures for chemicalcasualty care. Although specific medical and decon-tamination equipment has changed with time, thecore principles for managing contaminated casualtiesremain basically unchanged since World War I, whenthe treatment of chemical casualties was conducted ona large scale. These core principles include the earlyremoval of hazardous agent from patients to reduce

injury and contamination spread, and the provision ofearly and effective life-saving treatment.

To save the lives of those contaminated by hazard-ous agents, medical care providers, whether civilianor military, must be capable of a rapid and effectiveresponse. This involves first responders providinginitial medical intervention in the contaminated area,or on the periphery, while wearing protective equip-

HEALTH SERVICE SUPPORT AND MILITARY FORCEHEALTH PROTECTION ON THE BATTLEFIELD

Health service support (HSS) includes all services

performed, provided, or arranged by the military servicesto promote, improve, conserve, or restore the mental orphysical well-being of personnel.1Military doctrine andterminology are rapidly changing to better support jointoperations both on the battlefield and in civil support mis-sions at home and abroad. This brief overview of currentand developing doctrine focuses on its application to themanagement of chemical casualties across the military.

Force health protection (FHP) consists of measurestaken by all military members, from commander tothe individual service member, to promote, improve,conserve, or restore mental and physical well-beingof personnel.1FHP, the medical component of forceprotection, is a comprehensive approach to care thatincludes proactive medical services, striving to preventcasualties instead of focusing only on postcasualtyintervention.1 The basic objectives of military HSSand FHP are to promote and sustain a fit and healthyforce, prevent injury and illness, protect the force fromhealth threats, and sustain medical and rehabilitativecare. The newer, more comprehensive, focus on FHPconsists of three pillars of health protection (Figure14-1), providing a continuum of military health care

before, during, and after military operations.1

On the battlefield, medical care focuses on

minimizing the effects of wounds, injuries,disease, environment, occupational hazards,and psychological stressors on unit effective-ness, readiness, and morale; and

returning to duty as many service membersas possible at each level of care.2

These objectives also apply when the military assistsin homeland defense operations in support of local andstate assets during a national emergency. Military andcivilian HSS planning includes the medical responseto CBRN agent threats.

In any setting, far-forward medical treatment is criticalto reduce injury and save lives. Military medicine focuseson this far-forward care, provided initially by the mili-tary member or a fellow unit member (a buddy), andefficient casualty evacuation to medical facilities offer-ing the appropriate care.2Table 14-1 gives an overviewof the new taxonomy of care capabilities, comparingthem to the current concept of levels (echelons) of careparticular to the management of chemical casualties.1,2


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SERVICE-SPECIFIC OPERATIONS FOR FIELD MANAGEMENT OF CHEMICAL CASUALTIES

number of contaminated casualties can be achievedat the BAS depending on its available resources to de-contaminate the patients before admission to the BAS.Casualties with injuries that require further treatment,or who cannot be managed at the BAS, are evacuated tothe area support medical battalion or to units capableof forward resuscitation care (FRC), which includeforward surgical teams. Forward surgical teams cannotoperate in a chemical environment unless supportedby a unit such as the division clearing station, whichprovides the capability to decontaminate patients.3

The operational tempo may not allow for the thoroughdecontamination of patients by first responders (levelI) or units with an FRC capability (level II); therefore,medical facilities serving in a theater hospital capabil-ity (level III and IV) must be prepared for the triageand decontamination of contaminated casualties whoare transported dirty (without thorough decontamina-tion) to their facilities. The combat support hospital isthe Army theater hospital asset that provides surgicalcare, laboratory services, and stabilization of chemicalcasualties. Army field medical facilities can be chemi-cally hardened with chemically resistant inner tent

Fig. 14-1.The pillars of force health protection.Reproduced from: US Department of Defense. Health Service Support in Joint Operations. Revision, Final Coordination. Wash-ington, DC: DoD; 2005. Joint Publication 4-02: I-9.

Land-Based Forces

Land-based forces are comprised primarily of USArmy and Marine Corps (USMC) personnel, land-based Navy personnel in support of land forces, andAir Force personnel in support of air operations andland forces. Land-based forces include all levels of HSS.HSS units from all services plan and train for chemicalagent incidents in advance. In joint operations,all ofthe services move battlefield casualties through thetaxonomy of care (Figure 14-2), with various servicecomponents having responsibility for particular treat-ment facilities as dictated by the Joint Task Force (JTF)commander.

The first responder capability (level I) for Armyland-based forces at the point of injury incorporatesself and buddy aid care. Units also have combat medicsor treatment squads that provide first aid. Unique tothe Army at this level is the combat life saver, a soldierwith first-aid training. These individuals are capable ofassisting the medic in field care of injured soldiers. Thebattalion aid station (BAS) is also part of this capability.Stabilization and emergency treatment for a limited


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TABLE 14-1

COMPARISON OF TAXONOMY OF CARE CAPABILITIES WITH LEVELS (ECHELONS) OF CAREPARTICULAR TO CHEMICAL CASUALTY MANAGEMENT*

Care Capability/ Level of Care Care Rendered Care Particular to Chemical Casualties

First Responder Capability

Compares to level I care at the unitlevel.Prepares patient for return to duty ortransport to the next level of care.

Initial essential stabilizing medical carerendered at the point of injury.

Self aid, buddy aid, examination, emer-gency lifesaving (eg, maintain airway,control bleeding, prevent shock). Useof IV fluids, antibiotics, applying splintsand bandages.

Same as care rendered plus: Decontamination of the skin and

equipment. Providing antidotes (atropine/2

PAM/diazepam) to chemical

agents.

Forward Resuscitative Care Capability

This compares to level II physician-di-rected emergency care at a small medicalfacility in the theater of operations.Treat patient for RTD or stabilize for

movement to a larger medical treatmentfacility capable of providing care.

Forward advanced emergency medicaltreatment performed as close to the point oninjury as possible, based on current opera-tional requirements.

Resuscitation and stabilization, can in-

clude advanced trauma management,emergency medical procedures, andforward resuscitative surgery.May have capability (depending onmilitary service) for basic laboratory,limited radiograph, pharmacy, type O

blood transfusion, and temporary hold-ing facilities.

Same as responder capability (level I)plus: Emergency contaminated shrap-

nel removal. Intubation. Ventilatory support (though lim-

ited). Wound debridement. Informal stress counseling.

En Route Care Capability Involves the medical treatment of injuriesand illnesses during patient movementbetween capabilities in the continuum ofessential care.

New term not used in former doctrine.Includes support of airway, controlling

bleeding, and administration of anti-dotes and seizure medications, if neededand available during transport.

Theater Hospitalization Capability

Compares to level III and IV capabilities

Facility in theater that is larger thanFRC (level II). Care requiring expandedclinical capabilities such as restorativesurgery. Treat patient for RTD or beginrestorative surgery and prepare formovement to a higher level of care.

Includes theater hospitals with modularconfigurations to provide in-theater supportand includes the HSS assets needed to sup-

port the theater.

Resuscitation, initial wound surgery,and postoperative treatment. This is thefirst level that offers restorative surgeryand care rather than just emergencycare to stabilize the patient. Has largervariety of blood products than level II.

Same as for FRC (level II) plus: Exploratory surgery. Initial burn care . Bronchoscopy. Intubation. Ventilatory support (more as-

sets than level II). More extensive wound debri-

dement. Eye care. Respiratory therapy.

Formal stress counseling.

Level IV

Largest facility found in mature the-aters. Rehabilitates those who can RTDin theater and prepares more seriouscasualties for movement to level V.

Provides restorative surgery, like level

III, and also rehabilitative and recov-ery therapy.

Same as for level III plus:

Physical and occupationaltherapy rehabilitation for thosewith limited vesicant burns.

Full respiratory therapy . Ventilatory support (more as-

sets than level III). More extensive eye care. Psychological counseling.

(Table 14-1continues)


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Definitive Care Capability

Compares to a stateside level V.

Definitive care, which is normally pro-vided in the continental United States,Department of Veterans Affairs hospi-tals, or civilian hospitals with committed

beds for casualty treatment as part of theNational Defense Medical System. Mayalso be provided by overseas allied orhost nation MTFs

Care rendered to conclusively manage apatients condition, includes the full rangeof acute, convalescent, restorative, andrehabilitative care sites outside the theaterof operations.

Includes the full range of acute conva-lescent, restorative, and rehabilitativecare.

Same as for level IV plus: Longer term respiratory

therapy. Full rehabilitative services

for mental health, cognitive/

memory retraining, retrainingin activities of daily living/lifeskills, prevocational services,and post traumatic stress coun-seling. This incorporates a teamof rehabilitation professionssuch as physical, occupational,speech, and mental healthservices as needed based onthe severity of exposure and

resulting disability, if any.

*Taxonomy of care terms are in italics.FRC: forward resuscitative care

HSS: health service supportIV: intravenous2-PAM: 2-pyridine aldoxime methyl chlorideRTD: return to dutyData sources: (1) US Department of Defense. Health Service Support in Joint Operations. Revision, Final Coordination. Washington, DC: DoD;2005. Joint Publication 4-02. (2) US Department of Defense. Doctrine for Health Service Support in Joint Operations. Washington, DC: DoD;2001. Joint Publication 4-02.

Table 14-1continued

liners and fitted with air filtering units.Land-based Naval units are divided into broad

warfare areas including expeditionary warfare, forcesthat move to a theater of operations, and naval installa-tions.4Expeditionary units include construction forces,

logistic support personnel, special warfare units,and fleet hospitals. Expeditionary forces on land aretypically deployed in support of USMC units. Theseusually include land-based FRC (level II) capability,which may initially contain as few as 10 beds but canbe expanded to 500 beds with a theater hospitaliza-tion capability (ie, a combat zone fleet hospital).1

Casualties from these facilities can then be evacuatedto land-based facilities of other services or to hospitalships. Expeditionary medical units deploy as part of alanding force, with CBRN defense capabilities for in-dividual protection, self-decontamination, and limitedequipment decontamination.

Naval installations such as fleet hospitals, on theother hand, are more permanent, fixed facilities thatoffer FRC capabilities at level III or greater. Installationplanning at these facilities involves disaster prepared-ness, including coordination with local authorities.Plans for operations in a contaminated environmentinclude using shelter-in-place procedures, individualprotective gear, and various types of detection equip-ment. The installation disaster officer directs emer-

gency-response teams, coordinates decontaminationoperations, and assists in the command and controloperations center.4In addition to triage and treatingcasualties from an incident, the medical departmentalso organizes medical supplies; provides food and

water inspection; conducts disease monitoring; distrib-utes antidotes and medications as needed for CBRNincidents; and provides training on CBRN hazards,self aid, and first aid as part of FHP.4

The approximately 175,000-member USMC is anintrinsic part of the Department of the Navy; medicalsupport to the Marine Corps is provided by the NavyMedical Department. USMC personnel may augmentNavy medical patient decontamination operations.First responder capability (level I) is provided throughself aid and buddy aid as well as by Navy corpsmenassigned to USMC units. The Marines, at this level,also utilize their intrinsic BASs, or USMC wing supportsquadron aid stations, staffed by Navy medical person-nel. Unique to the USMC is the Chemical/BiologicalIncident Response Force (CBIRF) with first respondermedical capabilities. CBIRF deploys domestically, par-ticularly in the National Capital Region of Washington,DC, or overseas to pre-position or respond to a CBRNincident. Composed of USMC and Navy personnel,CBIRF has the capability to monitor, detect, identify,and analyze toxic industrial chemicals (TICs), toxic

liners and fitted with air filtering units.


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industrial materials, and other CBRN hazards. The

force has casualty extraction teams, technical searchand rescue teams, and patient/responder decon-tamination assets to support a mass casualty incident.CBIRF medical personnel are trained to conduct triageand provide emergency medical care to stabilize largenumbers of contaminated casualties extracted from theincident site, then decontaminate them for transfer tolocal medical facilities.4

Air Force first responder capability (level I) consistsof self aid and buddy care.5First responders then re-trieve the patient and form a casualty collection pointfor transport to the base medical facility. The Air Forceincorporates the split mission-oriented protectiveposture (MOPP) concept, dividing an air base into sec-tors or control zones, each operating under a differentMOPP level depending on its contamination threat.Under this plan, one area of the base may be contami-nated without affecting the operations of the entirebase.6Casualties are retrieved from the contaminatedzones by medical first responders in protective en-semble and transported to the base medical facility orbase casualty holding area. Depending on the maturity

of the base, the medical support can consist of a small

portable expeditionary aeromedical rapid responsepackage, a basic Expeditionary Medical Support(EMEDS) package, or a larger EMEDS plus 10- or 25-bed package, which evolves into an Air Force theaterhospital. Casualty care includes patient decontamina-tion, triage, clinical care, movement or quarantine onthe air base, and aeromedical evacuation.7EMEDS canbe configured to have an FRC capability (level II) ora theater hospital capability (level III or IV) based onthe number of air-transportable medical equipmentand personnel packages deployed to meet operationalrequirements. EMEDS equipment packages consist oftentage and medical equipment that can be added toan EMEDS basic package to increase service and bedcapacity. The EMEDS basic package can be deployedas a collectively protected Air Force medical facilityto provide shelter in a chemically or biologically con-taminated environment.7In these collective protectionconfigurations the EMEDS facilities are fitted withchemical protective liners and air handling units thatfilter hazardous agents. An EMEDS facility is designedto remain in operation for days after a chemical attack

Fig. 14-2.Taxonomy of care capabilities.Reproduced from: US Department of Defense. Health Service Support in Joint Operations. Revision, Final Coordination. Wash-ington, DC: DoD; 2005. Joint Publication 4-02: I-4.


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on the base. When collectively protected, a small-shelter patient decontamination system package isadded to provide the capability to decontaminate largenumbers of patients before they enter the collectivelyprotected EMEDS.8,9

For all services, evacuation of land casualties is per-

formed by the facility at the next higher level of care,which sends evacuation assets forward to retrieve thepatient. Patient movement is typically carried out byrotor-winged aircraft or ground vehicles. In theater thisis normally the responsibility of either the service com-ponent command that operates the particular facilityor Army rotor-wing medical evacuation (MEDEVAC)units.1,5These units may have to designate certainassets to transport contaminated casualties from achemical battlefield to an FRC or theater hospital.Fixed-wing Air Force aeromedical assets used for in-tertheater evacuation are usually reserved for patientswho have been decontaminated.1,5

Sea-Based Forces

Sea-based forces are comprised primarily of Navyand Coast Guard assets. Medical evacuation to Navalvessels operating offshore must certainly be consid-ered for chemical casualties with airway compromiseor significant trauma. Army air ambulance, Navy, orUSMC casualty evacuation helicopters provide therotor-wing assets for these vessels (Figure 14-3).1Inthe Navy, the major designated casualty receiving andtreatment ships are the dozen multipurpose large-deckamphibious landing helicopter dock assault ships of

the USSWaspclass, such as the USSBon HommeRichardor USS Kearsage.10These large, 40,000-ton vessels, 823feet long, are designed to operate offshore in supportofamphibious operations and can serve as FRC (levelII) facilities.5They support intense helicopter activitiesand are designed around large, self-contained well

decks for small boat transfers within the protectedhull of the ship. Extensive command, control, com-munication, and computer capabilities allow forMEDEVAC coordination and patient regulating.Thenewly commissioned landing platform dock 17, SanAntonio-class amphibious ships have similar capabili-ties but a smaller size.10These Naval platforms, con-nected locally with helicopter assets, can be combinedwith the extended 1,500-mile range of the V-22 Ospreyvertical takeoff and landing aircraft to bring multiplecapabilities for medical response to the severely in-jured, whether they have chemical or physical trauma.The medical facilities on Navy aircraft carriers provide

FRC (level II) capability, although their space is lim-ited compared with that of the casualty receiving andtreatment ships.5The casualty receiving and treatmentamphibious assault vessels are large floating facilities,with FRC (level II) capability available to land-basedforces or civilian casualties during presidentially au-thorized military support to civil authorities.

Although they lack an enclosed well deck for ef-ficient small boat transfers, the two 70,000-ton hospitalships USNS Comfort and USNSMercy (Figure 14-4)have large helicopter landing pads and offer completetertiary care capabilities, including 12 operating rooms,80 intensive care beds, and 50 ventilators, providing the

services of a theater hospital (level III). Naval facilities

Fig. 14-3.Unloading a patient from Army MEDEVAC to aNavy ship for treatment.Reproduced from: US Department of Defense. Health ServiceSupport in Joint Operations. Revision, Final Coordination.Washington, DC: DoD; 2005. Joint Publication 4-02.

Fig. 14-4.Hospital ship USNSMercy.Reproduced from: US Department of Defense. Health ServiceSupport in Joint Operations. Revision, Final Coordination.Washington, DC: DoD; 2005. Joint Publication 4-02: III-12.


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capable of providing a definitive care capability (levelIV and V) are located outside the theater of operationsin large land-based installations.1,11,12

In contrast, the Coast Guard has limited capabili-ties to receive casualties. Coast Guard personnel canprovide first aid for victims rescued from ships or the

water. The primary Coast Guard role is to offer forceprotection and safety regulation for vessels and ports,to minimize the possibility of a chemical attack ormajor toxic industrial chemical incident. Their muchsmaller 300-foot Coast Guard cutters are staffed byindependent duty corpsmen and physicians assistantscapable of providing first aid for chemical casualties,including administration of atropine autoinjectorsand basic decontamination with water, soap, andhypochlorite solutions. These medical assets can alsoparticipate as part of requested federal resources inresponse to a mass casualty event. The Coast Guarddeep-draft vessels scheduled to enter operation in 2007

will have capabilities to operate in a chemical hazardenvironment for up to 72 hours.13

Medical response planning and evacuation of casu-alties to ships is the responsibility of the JTF surgeon,a physician of any specialty, usually embarked on the

lead ship and a staff member of the JTF Commander.The JTF Commander, usually at least a one-star ad-miral, is responsible for coordination of Naval assetsin support of land-based objectives of the operationaltheater commander. During shore-to-ship operations,the Army is usually responsible for medical rotary-

wing support for patient transport; otherwise the Navyand USMC perform this service. The Air Force is theprincipal fixed-wing air asset for the transportation ofpatients from the theater of operations to the continen-tal United States (ie, to level V) during joint operations.5

By doctrine, patients must be decontaminated be-fore transport to Naval vessels; however, a thoroughdecontamination of patients may not be possiblewith a high operational tempo. Navy documentsprovide detailed instruction for the decontaminationand processing of patients brought on board ship byrotor-winged aircraft and landing craft before theyare brought below decks.14Large Navy vessels at sea

have extensive water supplies for decontaminationpurposes. Their evaporators daily produce thousandsof gallons of fresh water. Additionally, appropriatelyprotected personnel can quickly use fire hoses to washdown external areas with salt water.

MANAGEMENT OF CHEMICAL CASUALTIES FROM A CIVILIAN PERSPECTIVE

The accidental release of toxic substances occursregularly in the United States from fixed storage andindustrial facilities and from containers during trans-portation. Most common among these substances areammonia, pesticides, volatile organic compounds, ac-

ids, and petroleum products.15US hazardous materials(HAZMAT) response teams have gained experiencein managing these accidental releases. Events suchas the 1984 release of the carbaryl pesticide precursormethylisocyanate, in Bhopal, India, which killed andinjured thousands, and the more limited yet lethal at-tacks by the Aum Shinrikyo cult in Matsumoto (1994)and later Tokyo (1995), Japan, killing less than a dozenbut injuring scores more, demonstrate that intentionalacts of sabotage and terrorism can create large numbersof casualties in unprotected civilian populations.1618

Until recently, no effort had been made to standard-ize guidelines for the management of mass casualtiesfrom such events. In February 2003, Homeland Secu-rity Presidential Directive-5 was signed into law byPresident George W Bush, initiating the developmentof the National Incident Management System.19Thissystem serves as the template for the management ofmass casualty events in the United States, whether theyare caused by a terrorist attack, accident, or naturalevent (such as a hurricane). It provides a frameworkto coordinate the response of the government, private-

sector, and nongovernmental organizations. Structureis added to this framework through the National Re-sponse Plan (NRP), which provides the actual coordi-nation mechanisms for various agencies, including fire,rescue, and emergency medical services, for effective

communication and teamwork.20 These documents,along with others developed by the Department ofHomeland Security, Department of Health and HumanServices, Occupational Safety and Health Adminis-tration (OSHA), Joint Commission on Accreditationof Hospital Organizations, and other agencies, havesought to foster more standardization in the disasterand medical response to mass casualty events fromall hazards. This entire response plan was first fullyimplemented in response to Hurricane Katrina, whichdevastated the US Gulf Coast in August 2005, and isundergoing further modification based on the manylessons learned from the disaster.

Local responses to chemical releases vary. Typi-cally, when a casualty-causing chemical event occurs,those who can flee the scene on foot or by privateor commercial vehicle are the victims first seen atthe nearest medical facility. As demonstrated inTokyo, their arrival may be the first indicator for amedical facility, and a community, that an event hasoccurred.21,22When the event is reported to authori-ties, local fire departments and HAZMAT teams, if


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available, respond. Response time can range from 5 to30 minutes from initial release.23,24Once these teamsrespond, the area is cordoned off. Decontaminationunits are established by the fire department at theperiphery of the contaminated area (the hot zone).The initial processing of patients through decon-

tamination can be 30 minutes or more after the initialtoxicant release.23In some communities, particularlyin rural areas, medical personnel do not have level IIemergency medical service (EMS) or hazardous ma-terials operations training, so they cannot accompanyHAZMAT crews into contaminated areas. Frequently,local EMS personnel are not proficient in treatingcontaminated patients while wearing personal pro-tective equipment (PPE), which relegates them totreating patients after decontamination.25Wearing ap-propriate self-protection ensemble while stabilizingpatients before decontamination procedures is a dif-ficult challenge for first responders. Victims are often

decontaminated and only then seen by unprotectedEMS personnel, who place them on ambulances fortransport to hospitals. Because HAZMAT teams musttake time to secure the area and muster equipmentbefore they can begin decontamination, victims whodo not flee the scene before the arrival of HAZMATand fire department teams may not receive medicalcare for 30 minutes or more after their exposure.23Asequence of events similar to this occurred after pas-sive release of dilute sarin nerve agent in the 1995 To-kyo attack.17Authors such as Okumura who studiedthis event closely believe that a more forward medicalpresence, as incorporated by the military, may save

more lives in the event of a chemical release creatingmass casualties, particularly if a potent warfare agentis used in the attack.17

Currently, many larger metropolitan fire depart-ments are training their emergency medical techni-cians (EMTs) to provide life saving medical care in the

contaminated area or at its periphery. This training stilldoes not occur in many smaller rural departments, orin most private emergency services, which providecare only after patient decontamination. Withoutadequate first responder training in the provisionof medical care while wearing PPE, first responderEMTs are relegated to the contamination-free area; inthis situation medical intervention will be too late formany victims.26The Department of Health and HumanServices is considering policy and recommendationsto encourage appropriately trained and equipped firstresponders from all agencies to provide medical carein contaminated areas. The National Fire Protection

Association has published standards for the profes-sional competence of EMS responders in hazardousmaterials incidents.25Hospitals that receive contami-nated patients now have guidance through the OSHABest Practices for Hospital-Based First Receivers of Victimsfrom Mass Casualty Incidents Involving the Release ofHazardous Substances, released in January 2005. Thisdocument establishes the baseline for medical facilityresponse to the arrival of contaminated casualties.Its purpose is to insure that the triage, stabilization,decontamination, and treatment of contaminated ca-sualties is successfully conducted while first receiversafety is maintained.27

INTEGRATION OF MILITARY SUPPORT INTO CIVILIAN HOMELAND RESPONSE

The role of the US military in national strategies fordefense and homeland security is undergoing rapiddevelopment. Specific capabilities within the Depart-ment of Defense (DoD) are driven by doctrine andpolicy promulgated from the Office of the Secretary ofDefense and operational orders from regional combat-ant commanders. These directives shape the forces thatare organized, trained, and equipped by the servicesto support national strategic policies.

The primary role of military medicine, to preservethe fighting force, provides a robust, capable, HSS in-frastructure that is mobile, responsive, and trained andequipped for operations in austere environments. Thisforce, which during peacetime provides routine healthcare for its DoD beneficiaries, must also incorporatethe needs and requirements for the postSeptember 11homeland defense, the global war on terrorism strate-gies, and response to requests through the NRP emer-gency support functions. As the policy and doctrine

drives development of specific capabilities, a balance isrequired between the goal of smaller, leaner forces withincreased operational tempos engaged in supportingthe strategies, and a repository of medical response inthe homeland for CBRN mass casualty incidents.

Currently, military installations are required to de-velop and implement CBRN capabilities for responseand recovery from terrorist incidents involving weap-ons of mass destruction (DoD Instruction 2000.18).28Capabilities developed for these requirements in-clude detectors; warning and reporting technologies;decontamination equipment; triage and treatmentprocedures; and command, control, and communica-tion operations. Multiple programs with overlappingcapability requirements, including force protection, an-titerrorism, and all hazards emergency managementdetermine specific capabilities. As all military hospitalssubscribe to the Joint Commission for Accreditationof Healthcare Organizations, local coordination for


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disaster planning is routinely required.29 Local andstate public health requirements, as well as operationalorders from regional combatant commanders, alsodrive this interactive planning process. The militaryhealth system participation in disaster planning forthe homeland occurs at city and other local, county,

state, federal, and national levels.After validation of requests by local authorities,commanders may immediately respond to local di-sasters to save human lives, reduce human suffering,and/or prevent significant property loss.3032Althoughcommanders must notify their chain of command ofsuch actions as soon as reasonably possible, they do notneed to seek higher authority before responding.

Medical support to the NRP, emergency supportfunction #8, occurs through defense support of civilauthority. Through a bureaucratic process, requestsfrom state governors proceed to the president, then,upon presidential approval, to the coordinating fed-

eral agency, generally the Department of HomelandSecurity for most federally declared emergencies.Requests for DoD assistance are filtered through the

Joint Defense Office of Military Support to ensurethat requests are valid and cannot be reasonablymet by non-DoD capabilities. The Joint Task Forcefor Civil Support then serves as the command andcontrol element to match requirements to specificcapabilities within the DoD. These assets or units are

then chopped or change operational command fromthe service component to the respective regional com-batant commander, usually under a specific responsetask force under the Joint Task Force for Civil Support.These federal assets, such as decontamination teamsor medical assistance teams, then operate in supportof the local incident commander under the unifiedcommand system.3032

Northern Command in Colorado Springs, Colorado,and Pacific Command in Honolulu, Hawaii, representthe regional combatant commanders whose area ofresponsibility covers the United States and its ter-ritories. Operational orders from these commanders,

through the service components, determine and influ-ence readiness and response postures for installationsunder their direction.

THE MEDICAL MANAGEMENT PROCESS IN A CHEMICAL EVENT

Whether on the chemical battlefield, or in supportof homeland defense in response to a terrorist masscasualty event, key measures must be taken to preparefor, manage, and recover from a chemical incident.Although not inclusive, the list below is adapted fromguidelines found in several military publications.3,4,33

Preattack, Attack, and Postattack Measures

Preattack, or preparatory, measures include

understanding potential local chemical threatsand specific TICs, their location, specific com-pounds, and effects;

preparing plans and equipment to address achemical agent release, both warfare agentsand TICs;

developing policies to enhance patient fieldmanagement in the event of a CBRN release;

training first responders and medical pro-viders in triage and emergency medical carewhile wearing protective equipment;

training medical providers in the medicaltreatment of chemical casualties;

rehearsing teams in patient decontaminationmethods and practicing workrest cycles;

acquiring appropriate decontamination equip-ment and PPE;

designating shelters and practicing collective

protection measures, or sheltering in place,including the use of shelters, recognition ofalert states, procedures to disperse assets,and the use of appropriate levels of PPE formedical workers;

developing and practicing communicationwith supporting and supported agencies;

developing and rehearsing logistics to sup-port the management of mass casualty events;and

developing and rehearsing recovery plans in-cluding the management of hazardous wastefrom patient decontamination operations.

Attack measures, or measures to take during theevent, include

instituting plans for the evacuation and pro-cessing of casualties;

securing medical treatment facility (MTF)entrances to maintain a contamination-freehospital environment;

practicing individual protection and collectiveprotection for medical and other MTF person-nel in potentially contaminated areas;

performing patient treatment and decontami-nation;

instituting workrest cycles for staff wearingprotective equipment;


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providing mental health assets specific tochemical casualties and PPE utilization;

instituting waste recovery plans for decon-tamination operations; and

coordinating with supported and supportingagencies.

Postattack, or recovery, measures consist of

practicing medical team recovery and stafftechnical decontamination;

monitoring for chemical contamination; continuing patient evacuation if needed; properly disposing of hazardous waste from

patient decontamination operations; inventorying supplies and equipment and

arranging for replacements; and coordinating with supported and supporting

agencies.

The key for effective field management of chemicalcasualties is to develop a workable plan and train forthe event using real equipment and realistic scenariosappropriate for the location. In reality, MTFs must as-sume an influx of mass casualties and develop plansto effectively stabilize patients at smaller facilities andthen promptly evacuate them to larger facilities withgreater resources. Proper preparation for mass casualtyevents will ensure a smaller number of serious casual-ties through successful management.

Casualties may sustain additional conventionalinjuries; for example, blast injuries may occur when an

explosive device is used to disseminate the chemicalagent. The following key objectives, which also relateto military HHS and FHP, should be the focus of anyfield management process:

Minimize chemical agent injuries. Prevent aggravation of conventional injuries

during care and decontamination. Control the spread of chemical contamination

through decontamination. Continue with the primary mission of caring

for patients not involved with the release.

Personnel Requirements

The process of field management can be person-nel intensive, requiring between 12 and 50 workersto operate triage areas, emergency treatment areas,and decontamination lines. Personnel requirementsdepend on a variety of the following factors: ambienttemperature in which field management operations aretaking place, number of casualties, type of chemical

agent, level of fitness of medical and decontamina-tion personnel wearing PPE, and decontaminationequipment used.

Temperature

A critical factor in the ability to sustain decontamina-tion operations is temperature, ambient temperature,and, most importantly, wet-bulb globe temperature(WBGT). The WBGT is a composite temperature usedto estimate the effect of temperature, humidity, andsolar radiation on humans. It is used by industrialhygienists, athletes, and the military to determine ap-propriate exposure levels to high temperatures. TheWBGT index combines air temperature, humidity, airflow, and radiant heat data to provide a measure forthe risk of heat stress. Typically WBGT readings arebelow simple thermometer readings. For example, a78.9F (26.1C) WBGT could roughly be equivalent

to an outdoor temperature of 95F (35C) in the sunor 98F (36.7C) in the shade.34 WBGT measures bothradiant and evaporative temperatures. A variety ofWBGT devices can be purchased. Most units are light-weight, easily transportable, and have digital displays.An example of a WBGT is shown in Figure 14-5.

Wearing protective ensemble increases the WBGTindex by 10F (5.6C).3,4,33 Body armor (a possible re-quirement for the military, but not normally for civilianmedical personnel) increases the index by another 5F(2.8C).3,4,33 Protective clothing increases the heat loadon an individual because sweat from the skin is unableto contact air and dissipate heat through evaporation.

The risk of dehydration, heat cramps, heat stroke, andother heat-induced injuries is greatly increased by thehot encapsulating protective gear, and water consump-tion wearing a protective mask is cumbersome, if notimpossible. Many civilian protective masks lack anoral rehydration tube.

A safety monitor should be appointed to preventinjury, especially heat-related injury, for teams wear-ing PPEs.27Handheld heat stress calculators are com-mercially available to assist in calculating the time thatindividuals should remain in PPE.35,36Both OSHA andthe military joint manual covering patient decontami-nation emphasize the importance of preventing heatinjury. OSHA recommends periodically taking theblood pressure of workers wearing protective gear ormeasuring core body temperature; both are difficultto accomplish while the worker remains adequatelyencapsulated in protective ensemble in a contami-nated, or potentially contaminated, area.27The militaryincorporates a program of workrest cycles based onthe WBGT index reading (Table 14-2). During the restcycle, team members wearing PPE rest in a shaded area


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and drink water. Masks that allow team members todrink without mask removal should be used. Hydra-tion units, such as Camelbaks (Camelbak, Petaluma,Calif), can be worn under hooded masks and suits.

Casualty Number and Agent Characteristics

Current technology to thoroughly decontaminatepatients is linear in design, and critical narrowing pointbottlenecks are inevitable as patients are processedthrough a decontamination line. To reduce congestion,more decontamination lanes are added, which requiresmore personnel. Larger numbers of casualties alsorequire more medical personnel to provide adequatecare. Other novel ideas to hasten decontamination,particularly in a civilian setting, are to distributepersonal decontamination solutions to casualties, al-lowing them to decontaminate themselves and others,as is done by military service members conductingimmediate decontamination on the battlefield. The

aim is to readily reduce the amount of contaminant onthose exposed until a more through decontaminationcan be performed.

The type of agent encountered dictates the im-mediate hazard to life and limb as well as the level ofdecontamination necessary before a patient can enter

an MTF. Many people believe that all patients exposed,or potentially exposed, to a chemical agent must bethoroughly washed. Ideally, if it does not delay life sav-ing medical care, a comprehensive shower with warmwater and soap (liquid castile soap or baby shampoo)should be performed if time and circumstances permit.Situations where clothing removal alone might suf-fice include (a) exposure to vapor only, when agent istrapped in clothing and hair but is not on the skin; (b)cold weather situations when individuals are wearingthick clothing and the ambient temperature is 35F(1.6C) or below, creating a significant risk of freez-ing, or even below 65F (18.3C), when hypothermia

is a greater possibility in injured people, especially ifwarm water is not available. In these cases the indi-vidual should be moved promptly to a warm area for amore thorough wash after clothing removal, or decon-tamination should be provided for exposed skin areasonly.37,38An appreciation of these facts and knowledgeof agent characteristics listed in Table 14-3 are criticalfor medical and decontamination personnel.

Fitness Level

Workers who are not physically fit will fatiguefaster and require more periods of rest. They may also

be more prone to musculoskeletal injury. The medi-cal management of chemical casualties can be verylabor-intensive when patient lifts and litter carriesare performed, especially while patient handlers arewearing PPEs or when no special ergonomic equip-ment (eg, roller systems, wheeled litter carriers) isavailable. Those who do not have adequate musclestrength will quickly fatigue after the movement ofonly a few litter patients. Moderate and heavy work,as is done by medical and decontamination workers,dramatically increases the strain on the cardiovascularsystem, and individuals who are not physically fit areat a greater risk for cardiovascular events. Those whoare more physically fit will be able to wear their pro-tective ensembles longer while incurring less cardio-pulmonary risk. Personnel who are fit have enhancedpulmonary function compared to those who are lessfit, allowing better oxygen exchange during exertionin protective masks. Personnel who have suffered heatstroke in the past are likely to be more susceptibleto recurrence. OSHA mandates that all individualsdesignated to wear personal protective gear receive

Fig. 14-5. An example of a wet-bulb globe thermometer(WBGT).Photograph: Courtesy of US Army Medical Research Insti-tute for Chemical Defense, Chemical Casualty Care Division,Aberdeen Proving Ground, Md.


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an occupational health assessment, which usually in-cludes basic pulmonary function testing for respiratorutilization and determination of their physical abilityto complete assigned duties while wearing protectiveensemble.27

Decontamination Equipment

The equipment used for patient decontaminationranges from simple hoses, buckets, and sponges,to quickly erected pop-up decontamination tents(Figure 14-6) with intrinsic showers, to permanent de-contamination systems built into hospitals. Typically,simply equipped decontamination stations are more la-bor intensive because water buckets and patient littersrequire frequent lifting. Pop-up decontamination tentsand permanent hospital decontamination facilities thatincorporate roller systems and integrated plumbing forlitter patient decontamination help conserve energy,speed the process, and potentially reduce musculoskel-etal injury in personnel. North Atlantic Treaty Organi-zation litter carriers (Figure 14- 7), or wheeled gurneysthat can be decontaminated, reduce the frequency ofpatient lifting; sharp, long-handled seat belt cutters(Figure 14-8) reduce the repetitive opening and clos-ing of scissors for cutting patient garments. These andother ergonomic adaptations help reduce worker strain

and subsequent risk of musculoskeletal injury. Someenclosed systems, such as pop-up tents, are frequentlyheated, but rarely air-conditioned. These environmentsin warm climates, if not air-conditioned, can becomeheat intense for personnel, which will necessitate more

frequent workrest cycles.

Necessary Medical Equipment and Supplies

Critical to the emergency care of chemical casualtiesare adequate supplies of life saving medications forindividuals exposed to rapidly lethal chemicals suchas nerve agents and cyanide. Initial antidotes for nerveagents are carried by all military members, in the formof three Mark I kits (Meridian Medical TechnologiesInc, Bristol, Tenn; kits contain atropine and 2-pyridinealdoxime methyl chloride) and diazepam, when thereis a threat of an enemy using chemical agents.4Militarymedics, corpsmen, and EMTs typically carry more ofthese items. Most civilians, of course, do not carrythese items with them, but civilian emergency re-sponders should have adequate supplies immediatelyavailable. Emergency airway supplies are also criticalfor the management of chemical casualties becausemost chemical agent deaths are caused by respira-tory compromise. Chemical monitors can be used atdecontamination stations to check for the presence of

TABLE 14-2

WORKREST CYCLES AND WATER CONSUMPTION (WITHOUT PROTECTIVE ENSEMBLE)*

Easy Work Moderate Work Hard Work

Heat WBGT Index WorkRest Water Intake WorkRest Water Intake WorkRest Water Intake

Category (F) (Min) (Qt/h) (Min) (Qt/h) (Min) (Qt/h)

1 (White) 7881.9 NL NL 4020 2 (Green) 8284.9 NL 5010 3030 1 3 (Yellow) 8587.9 NL 4020 3030 1 4 (Red) 8889.9 NL 3030 2040 1

5 (Black) > 90 5010 1 2040 1 1050 1

*Notes:Wearing protective overgarments adds 10 F (5.6 C) to the WBGT index, and wearing body armor increases this by another 5 F (2.8 C).The workrest times and fluid replacement volumes will sustain performance and hydration for at least 4 hours of work in the specifiedheat category.Hourly fluid intake should not exceed 1 quart and daily fluid intake should not exceed 12 quarts.Rest means minimal physical activity while sitting or standing, accomplished in the shade if possible.NL: No limit to work time per hourQt: quartWBGT: wet-bulb globe temperatureData sources: (1) US Departments of the Army, Marine Corps, Navy, and Air Force. Health Service Support in a Nuclear, Biological, and ChemicalEnvironment. Draft. Washington, DC: DoD; 2004. FM 4-02.7, MCRP 4-11.1F, NTTP 4-02.7, AFTTP (l) 3-2.47. (2) US Department of the Army.Health Service Support in a Nuclear, Biological, and Chemical Environment. Tactics, Techniques, and Procedures . Washigton, DC: Headquarters,DA; 2002. FM 4-02.7.


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contamination on casualties when they arrive, or afterthe cleaning process to check for completeness of de-contamination. This equipment includes the improvedchemical agent monitor, its nonmilitary equivalents,and M8 paper. The improved chemical agent monitortests for vapor coming from liquid contaminants onpatients and their clothing, and M8 paper is for direct

testing of nonvolatile liquid chemical warfare agentcontaminants. In decontamination systems with largequantities of soap and water available, use of thesedetection devices is often not warranted because ofthe thoroughness of the washing process. These de-tectors are also limited to the types of agents and theconcentration levels they are designed to detect, and

may not be appropriate for all TICs and toxic industrialmaterials.

Zones of Contamination

In interagency operations, a contaminated area isdivided into zones of contamination (Figure 14-9).25,39To more effectively manage the contaminated area, avariety of control lines and points are designated de-pending upon the level of contamination. These sameareas hold true on the battlefield.

Hot Zone

The hot zone is the area of chemical release. Ex-amples include a chemical munitions impact area oran area of contamination created by an accidental orintentional TIC release from a factory storage tank. Thearea is determined to be contaminated with chemicalagents (dry solid, liquid, or vapor). This determina-tion is usually performed through the use of chemicalmonitoring devices. Individuals entering this area

TABLE 14-3

MINIMAL DECONTAMINATION PROCEDURES BASED ON AGENT CHARACTERISTICS

Agent Characteristics Suggested Minimal Decontamination Procedure Before Admission To MTF

Vapors Remove all clothing and equipment to reduce vapor trapped in cloth fibers. Wash or briskly brush

hair, if exposed. Wash skin areas that were exposed to the vapor if time allows.

Liquid Remove all clothing and equipment to reduce liquid and vapor hazard to medical staff. Decontami-nate areas where liquid agent is on the skin and the protective mask.

Solid Carefully cut off (with sharp cutting tool) and roll back overgarments to contain the solid dust par-

ticles. Patients underclothing may need to be removed in a different area, upwind, if it is coveredwith solid agent. If available a HEPA-filtered vacuum can be used to vacuum garments. (Someresources suggest that an insect sprayer or mister can be used to lightly mist garments with water

before removal to reduce particle aerosolization prior to protective ensemble removal.To date, thisconcept has not been thoroughly evaluated. Caution must be used in this process because fine agent

particles could be reaerosolized with a direct flow of air or water when misting the dry material, ordry chemicals could become activated with the addition of small amounts of water). Outer clothingshould always be carefully removed, followed, if possible, by a thorough washing of the skin using

copious amounts of water.

HEPA: high-efficiency particulate airMTF: medical treatment facility

Fig.14-6.Decontamination inside a plumbed tent. The rollersystem supports the litter or backboard. There are manytypes of systems available.Photograph: Courtesy of US Air Force.


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must be in a high level of protection, OSHA level Aor B (see Chapter 17, Chemical Defense Equipment,for a description of these protective levels), at leastuntil the agent is known, after which lower levels maybe appropriate. MTFs located in this area typicallycease operations, shelter in place, and do not receivepatients. The exception is the military collectively

protected MTF which, although initially set up ina clean area, can continue to operate for a limitedamount of time if the area it is in becomes contami-nated. These structures have protective, chemicallyresistant liners and environmental control units thatfilter contaminated air.

Warm Zone

The warm zone is outside the hot zone. The levelof contamination here is significantly lower than thatfound in the hot zone. Contamination in the warmzone is only that which is on the unprotected skin,clothing, and equipment of those entering from the hotzone. If the event was a release of chemical vapors (agas plume or other passive release of vapors as in theTokyo subway attack), the primary hazard is from theoff-gassing of vapors trapped in patient clothing andhair. If the event is from a dry solid or liquid chemicalrelease, then the contamination hazard would be fromsolids and liquids on clothing, equipment, and skin,as well as vapors coming from any liquid residue. As

Fig. 14-7. North Atlantic Treaty Organization wheeled littercarrier. This device allows a litter to be easily handled byone or two individuals, which reduces staffing requirementsand worker fatigue.Photograph: Courtesy of US Army Medical Research Insti-tute for Chemical Defense, Chemical Casualty Care Division,Aberdeen Proving Ground, Md.

Fig. 14-8.A variety of cutting tools are available for the rapidremoval of clothing. These include (from bottom to top) thetwo-bladed seat belt cutter and bandage scissors.Photograph: Courtesy of US Army Medical Research Insti-tute for Chemical Defense, Chemical Casualty Care Division,Aberdeen Proving Ground, Md.

Fig. 14-9.Zones of contamination after a chemical release. (1)Hot zone: contaminated area of chemical release; (2) warmzone: contaminated individuals enter from the hot zone;(3): evacuation corridor: contains patient decontaminationstations; (4) cold zone: area free of solid, liquid, and vaporcontamination.MTF: medical treatment facilityDiagram: Courtesy of US Army Medical Research Institutefor Chemical Defense, Chemical Casualty Care Division,Aberdeen Proving Ground, Md.

noted previously, an event involving a solid or liquidhazard would require a more intense decontamina-tion effort.

Once an MTF begins to receive patients, the areawhere contaminated patients are received would bedesignated as part of the warm area. In the warmarea medical and decontamination team members

MTF MTF patienttriage & decon

GrossDecontamination

WARM ZONE (2)COLD ZONE (4)

(3)

HOTZONE

(1)


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working with the contaminated patients wear anOSHA level C protective ensemble to protect themagainst the limited, but still dangerous, amounts oftoxic materials on the patients. This area is referredto as the contamination reduction zone, decon-tamination zone, or protective action zone in some

references.25,27,39

Evacuation Corridor

The evacuation corridor, which is within the warmzone, incorporates land evacuation routes from thehot zone for casualties who may still be contaminated.Patient decontamination stations, whether locatedimmediately outside the hot zone or near the door ofa receiving MTF, are within this corridor. In some in-stances, particularly in a military battlefield situation,seriously injured contaminated patients who are stillwearing their protective gear and have undergone only

operational decontamination (see Levels of Decon-tamination, below) may be evacuated by rotor-wingaircraft to an MTF well outside the warm zone. Inthese cases a separate warm zone would be created toinclude the aircraft landing area and the MTF patientdecontamination area.

Cold Zone

Areas free of solid, liquid, and vapor contaminationare in the cold zone. All military MTFs are initially es-tablished in contamination-free areas. Before being al-lowed into the cold zone, individuals must go through

decontamination and be determined contamination-free; this requirement applies not only to patients butalso to medical workers and decontamination teammembers in protective ensemble. Individuals in thecold zone do not need to wear any type of protectiveequipment, except in the event of a nosocomiallytransmitted biological agent such as plague (Yersiniapestis) or smallpox. In these cases, respiratory and con-tact precautions must be followed by those in contactwith the patient. The cold zone may also be referredto as the postdecontamination zone, support zone, orclean zone.25,27,39

Levels of Decontamination

Various stages of patient decontamination aredescribed in the processing of a CBRN casualty.3,14,33

The military uses the following three levels of decon-tamination (the official names for these levels maychange, but the order of performance will remain theimportant focus).

Immediate

Immediate decontamination is performed by theindividual who is exposed to the hazardous agent,or provided by a buddy partner immediately afterthe exposure event. Military members are trained to

decontaminate themselves using the M291 skin decon-tamination kit and M295 equipment decontaminationkit or reactive skin decontamination lotion, if available,as soon as possible after exposure to a chemical agent.This is the most effective time to perform decontami-nation to lessen the dose on the skin and significantlyreduce future medical complications.

Patient Operational Decontamination

Patient operational decontamination is performedbefore loading a contaminated patient onto a dirtyevacuation asset. The patient remains in a protective

mask and overgarment, and any gross contaminationis removed. Plastic sheeting may also be used insidethe vehicle to help minimize contaminant spread dur-ing transport. This procedure would more likely befollowed under operational tempos that do not allowfor the removal of the patients protective clothinguntil arrival at an MTF with appropriate resources tocare for the individual. For example, the situation of acontinued chemical threat with no replacement cloth-ing is quite possible on the battlefield.

Patient Thorough Decontamination

Patient thorough decontamination is performed atthe MTF or a consolidated troop and patient decon-tamination area in close proximity to the incident site,if possible. Personnel remove the patients clothingand thoroughly clean them using either soap and wa-ter or another decontaminant. The patients are thendetermined to be free of contamination before beingbrought into the MTF.

Military Management Concepts in the CivilianSetting

The civilian setting is quite different from the militarybattlefield scenario. The civilian scenario described be-low would probably apply to the military in a situationin which service members were exposed to chemicalagents while wearing their duty uniform, which offersno protection, such as in an unexpected terrorist attackon a military installation or the sudden release of toxicfumes from a nearby industrial accident. See Table 14-4for a comparison of casualty care and decontamination


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in the military and civilian setting.The majority of civilians are not aware of the char-

acteristics of chemical agents or the steps to take forimmediate decontamination. Many, appropriately,would probably attempt immediate decontamina-tion of a visible or symptomatic agent by washing orwiping. They might effectively perform immediatedecontamination by washing with copious amounts ofwater from a sink or hose, or by using bottled water.Wiping could be performed using frequently carriedmoistened disposable baby wipes. Liquid agent couldbe wiped from the skin using any nontoxic absorbentmaterial such as clean dry sand, bread, flour, or babypowder, followed by wet wipes.40If the individualdoes not perform any of these procedures, then de-contamination may not take place until the arrival offirst responders, who may be delayed. Also, civiliancasualties, unlike military personnel, would not haveimmediate access to nerve agent antidotes (or wouldnot know how to use them). The casualties wouldneed to wait until treated by appropriately suppliedfirst responders.

In the civilian sector, HAZMAT crews and fire de-

partments can take 15 minutes or longer to assess thehot zone and establish patient decontamination lanes

in the warm zone23; during this time civilian casualtieswould remain contaminated and untreated. If the toxinis an organophosphate nerve agent, then antidoteswould be provided, if available, by the civilian firstresponder. Under the best of situations in a civiliansetting, casualty treatment is often administered onlyafter the patient is evacuated by HAZMAT crews tothe warm zone triage area. Local civilian EMTs couldbe trained to provide stabilizing patient care whilewearing PPE in the warm zones patient collection areabefore decontamination. In an optimal situation, firstresponder EMTs in PPE could accompany HAZMATcrews into a contaminated area and begin triage andtreatment of victims as they are being evacuated.26Inthe military battlefield scenario, of course, initial careand decontamination is provided at the incident site, inthe hot zone, before and during patient evacuation.

Patient operational decontamination would probablynot be done in the civilian sector because most contractambulance services will not take contaminated patientson their vehicles. Some semblance of operational decon-

TABLE 14-4

COMPARISON OF MILITARY BATTLEFIELD AND CIVILIAN CASUALTY CARE ANDDECONTAMINATION

Process Military on Chemical Battlefield Civilian or Unprepared Military

Immediate Immediate decontamination takes place upon Casualties may wash contaminated areas ifdecontamination contamination using M291, RSDL, or other kit. knowledgeable, otherwise they must wait for

HAZMAT crews and first responders

Operational patient Contaminated patients, wearing protective gear, Local vehicles may have to be used if available.decontamination can be transported on designated vehicles to Ambulance services may be hesitant to

decontamination facilities. transport contaminated patients.

Emergency medical Care can begin on the battlefield. Initiated by the Medical care is delayed in all instances bycare individual or a buddy. Unit medics can also minutes. Care may not be initiated until the provide lifesaving care while they are wearing patient is moved from the incident site and protective equipment. then decontaminated. Care may be initiated

earlier if medical personnel are trained toprovide assistance while wearing protectiveequipment.

Thorough patient Performed before patient enters the MTF, whether a Performed before patient enters the MTF,decontamination small or large facility. May have gross contam- whether a small or large facility. May haveinants removed at a centralized facility outside gross contaminants removed at a centralizedthe hot zone with continued decontamination at facility outside the hot zone with continuedthe hospital decontamination area if indicated. decontamination at the hospital decontam-

ination area if indicated.

HAZMAT: hazardous materialsMTF: medical treatment facilityRSDL: reactive skin decontamination lotion


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using any available materials such as bottled water,baby wipes, or reactive skin decontamination lotion.

For more thorough decontamination, civilian casu-alties are provided with gross decontamination in thewarm zone by the fire department, using fire enginewater spray or water from plumbed decontamination

tents (Figure 14-11), and more complete decontamina-tion at the MTF prior to entry into the facility. For themilitary casualty, thorough decontamination occurs atthe patient decontamination station, which is locatedoutside the military MTF. In both the civilian and mili-tary decontamination station, a patient moves througha sequence of substations to account for valuables,remove clothing, and wash. These same stations areestablished whether decontamination takes place inan area with limited resources, such as an Army BASor civilian fire department decontamination line,or a facility with more robust capabilities, such as amoderate sized or larger military or civilian hospital

(Figure 14-12). OSHA documents refer to the areaoutside an MTF, where contaminated patients arriveand are triaged and decontaminated, as the hospitaldecontamination zone.27

Once the patients are decontaminated, they moveacross the hot line into the hospital postdecontamina-

tion zone. Name designations for each area may differdepending on the setting, but the sequence of steps inthe process is similar. The areas described below areadopted from several sources.3,7,8,14,27,33,42,43

Entry Control Point and Arrival Area

The entry control point is the doorway to the decon-tamination area. This entrance is typically barricadedin some way to regulate traffic flow and is usuallystaffed by security personnel wearing protective en-semble. Ambulances, other vehicles, and ambulatorycasualties go through this control point on their way

Fig. 14-11. This is one example of the layout of a civilian hazardous materials incident patient decontamination area at theperiphery of the hot zone or at the entrance to the medical facility. This model takes into consideration a 10-minute lag time

between incident occurrence and the self-reporting of patients. It follows the same sequence of steps noted in Fig. 14-12.EMS: emergency medical serviceDiagram: Courtesy of Commander Duane Caneva, US Navy.

Wind

Downslope

First Responder Flow

Casualty Flow

Triage and Treatment Groups

WaterHeater

Waste Water

Reconstitution ofsupplies/equipmentand personnel

Entry/ExitControlPoint

Hazardous MaterialsIncident Site

EMS

StagingArea

CasualtyCollection

&

IncidentEmergencyOperations

Center (EOC)

ConfirmedClean

HazMat Incident Medical Treatment Site Setup

(> 10 minute)

Ambulatory

Decon

Non-amb

Decon

(> 10 minute)

Self Reporting

IncidentCommand Post

Post-DecontaminationTriage, Treatment, &Patient Admission

Deconedonscene

EMS Transport

WaterSource

Decon

Triage

Decontamination

Zone

Hospital Incident Command Post&

Emergency Operations Center (EOC)

Post-DecontaminationZone

SecurePerimeter

1st ReceiverDecon Lane


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to the arrival area. On land the entry control pointwould be located well in front of the decontaminationarea, and at sea it would be at the transport aircraft orwatercraft casualty loading area located on land. Atthe arrival area vehicles are unloaded and patientsare brought to the adjacent triage area. Maintainingtraffic discipline in this area is critical to ensure un-impeded flow of patients and vehicles. The arrivalpoint on land must be large enough to accommodateever expanding numbers of casualties; at sea the ar-rival point would be the aircraft or watercraft landingarea. At this point monitoring devices may be used tocheck for contamination on patients. All personnel inthese areas wear a MOPP level 4 or level C equivalentprotective ensemble.

Triage Area (Warm Side)

Patients are moved to the triage area from the arrivalpoint, where a triage officer (trained physician, nurse,

EMT, physicians assistant, dentist, or veterinarian)quickly triages the patient, who is then moved to arespective immediate treatment area (also known asthe warm side emergency medical treatment station).Patients are triaged according to their priority formedical treatment (immediate, delayed, minimal, orexpectant); level of decontamination (high or low);and further medical evacuation required (urgent, pri-ority, or routine). See Chapter 15, Triage of ChemicalCasualties, for more detailed information. Medicalworkers in this area wear a level C equivalent protec-tive ensemble.

The immediate treatment area should be locatednear the entrance to the litter decontamination lanesto allow direct access for patients who will be litter-borne. Expectant patients are located adjacent to thedirty side emergency treatment station, but fartheraway from the litter decontamination lanes, so thatthese patients can be retriaged and stabilized fordecontamination when the dirty side no longer has

Fig. 14-12.Another, more detailed, example of the layout of a patient decontamination site at a medical treatment facility(military or civilian). Note the relative positioning of specific triage areas, the waste dump, rest/rehydration points, areasfor storage of personal effects, hot line, and vapor control line.EMT: emergency medical treatmentMTF: medical treatment facilityDiagram: Courtesy of the US Army Medical Research Institute for Chemical Defense, Chemical Casualty Care Division,

Aberdeen Proving Ground, Md.

Contaminated Weapons/Personal Effects

Temporary Storage Area

Dirty Side

ArrivalPoint

Arrival Point 50-75 Meters from Hot Line Hot Line

Clean Side

Wind Direction

TriageMinimal/Delayed

TriageImmediate

ContaminatedEMT

TriageExpectant

ContaminatedTemporary

Morgue

Dump

Contaminated Dump 75-100 Meters

Clean Evacuation

CleanDisposition

MTF

Hot LineResupply

Point

MTF 30-50 Meters

20x25Overhead

CoverClean SideTreatment

ContaminatedDisposition

AmbulatoryDecon

DecontaminationCheck

DecontaminationCheckLitter

Decon

WaterStorage

Rest/Re-hydration Point50 Meters perpendicular todecon area 5 meters from

Hot Line

Shuffle Pit

Shuffle Pit

Vapor ControlLine


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patients. The delayed treatment area is located nearthe entrances of both the litter and ambulatory pa-tient decontamination lanes; delayed patients can beprocessed through either lane when available. Finally,the minimal patient triage treatment area should bepositioned nearer to the ambulatory decontamina-

tion lane because these patients can walk throughthe lane with minimal assistance. In the military,minimal patients are typically sent back to their unitsafter receiving medical care without needing to bedecontaminated or crossing to the clean side, wherethe MTF is located. In the civilian sector, the move-ment of these patients should not interfere with theprocessing of more serious casualties through thedecontamination line.

The warm side emergency treatment station (orimmediate patient treatment area) is where life savingcare is provided to stabilize the patient for decontami-nation or transport. Care given at this station includes

the administration of antidotes, quick decontaminationof contaminated skin areas, intubation, and intrave-nous administration of fluids. Medical staff in thisarea are trained in these procedures and capable ofperforming them while wearing OSHA level C protec-tive ensemble.

Decontamination Area

Lanes are established in the decontamination areafor litter and ambulatory patients. The number of staffrequired for a decontamination team is dictated, asdiscussed earlier, by ambient and WBGT temperature

in the field management operations area, number ofcasualties, type of chemical agent, level of fitness ofpersonnel wearing protective ensemble, and decon-tamination equipment used. Minimum staffing levelsare two decontamination workers per litter patient,who must have their clothing cut off, and one perambulatory patient, who can undress and decon-taminate themselves under supervision. If only oneor two patients need decontamination, it can be donewith a garden hose, buckets and sponges, or built-inshower. Larger numbers of casualties require moreefficient decontamination procedures. More specificsuggestions for personnel are found in Chapter 16,Decontamination of Chemical Casualties.

In the Army and Navy (in support of USMC units),decontamination is carried out by nonmedical person-nel from the supported military units who are super-vised by medical personnel. In Air Force and someNavy shipboard decontamination teams, all the teammembers come from the medical unit. These personnelwear OSHA level C PPE or the military equivalent. Iftheir garments are not completely water resistant, theyalso wear water repellent toxicological agent protective

aprons to keep the protective overgarments dry andallow for apron decontamination before performingpatient lifts.

The decontamination process usually takes up to 10to 20 minutes for a litter patient and 5 to 10 minutesfor an ambulatory patient, depending on the type of

decontamination equipment and the team traininglevel. Plumbed equipment that dispenses soap andwater and roller systems for litter patients are moreefficient than the more labor-intensive processes usingminimal equipment such as buckets and sponges.

A final check for thoroughness of contamination isoften incorporated at the end of the decontaminationprocess. This check is more critical when water-con-servative methods, such as washing with buckets andsponges, are used. In these situations, some areas of theskin might remain incompletely washed. Decontamina-tion equipment that incorporates a large volume but alow-pressure flow of water provides a more thorough

wash and can reduce the necessity for a final check.Warm water, and warm decontamination areas, aremore likely to ensure thorough patient compliance andminimize the development of patient hypothermia.

Hot Line

The hot line is located at the end of the decontamina-tion line, before the clean area. At this point, all liquidcontamination has been removed from patients anddecontamination team (it is sometimes referred to asthe liquid control line). Patients are typically nude atthis point, and decontamination station workers have

removed their protective overgarments. In the civiliansector, patients undergoing gross decontamination bya fire department might still have on their undergar-ments. If clean covering garments are available, vic-tims should be strongly encouraged to doff their wetundergarments, which could hold agent, particularlyif exposed to liquid or potent aerosol. Patients enter-ing an MTF should be nude but covered by a hospitalgown, to insure that contamination does not enter thefacility and allow for patient privacy.

Vapor Control Line

The vapor control line delineates the location whereno vapor hazard remains from clothing that has beenremoved in the decontamination area. Although notrequired for biological and radiological contamination,this line is critical for chemical contamination. Thevapor contol line is approximately 10 feet beyond thehot line as the patient proceeds toward the clean side.In the military, the air in this area may be monitoredby a stationary vapor monitor such as the automaticchemical agent detector alarm.


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Triage and Treatment Area (Clean Side)

The triage and treatment area (clean side) is partof the cold zone, located near the vapor controlline (OSHA refers to this area as the hospital post-decontamination zone). The recently decontami-

nated patients are retriaged in this area, and waitfor processing into an ambulance, if this occurs at adecontamination station separate from an MTF, orto await movement into an MTF from an adjacentdecontamination station.

Additional Areas

Other areas that may be necessary, but not in allsituations, include the following:

contaminated waste dump to store contami-nated waste until proper removal;

fresh and waste water bladders if decontami-nation tent systems are used;

warm side disposition areas used by the mili-tary, where casualties in protective gear havebeen provided operational decontaminationand await dirty evacuation;

a warm side temporary morgue for storage ofthe contaminated remains of those who die

during field management; a warm side weapons and contaminatedpersonal affects storage area for storage andeventual disposition of patient items;

litter decontamination area for military decon-tamination operations with minimal equip-ment;

a warm side rest area for decontaminationcrews and medical team members;

a clean side supply point where medical anddecontamination supplies can be apportionedas necessary; and

a clean side disposition area for staging de-

contaminated patients for transport to anotherlocation.

SUMMARY

Field management of chemical casualties involvesongoing triage, treatment, and patient movementthrough the medical system to obtain the most ap-propriate care available given the situation and re-sources. Conducting field management in a chemicallycontaminated environment requires that medical anddecontamination personnel wear the equivalent ofOSHA level C protective ensemble for protection from

contaminants on patients and hazardous vapors emit-ted by the contaminants.

The militarys immediate medical response to achemical event on the battlefield is identical acrossthe services, using self and buddy aid. This responsediffers from the civilian response, because of lack oftraining in self-decontamination and treatment andlack of readily available resources. Unprotected mili-tary personnel (without PPE and individual decon-taminants or antidotes) exposed to a chemical releasewould encounter some of the same challenges as thecivilian population.

Civilian casualties unable to flee the scene of a chem-ical release must wait until HAZMAT teams and firedepartments arrive on the scene. This initial responsetypically takes 10 minutes or longer, and victims maynot encounter a medical care provider for 30 minutesor more after their initial exposure. Typically medicaltreatment is not provided until after the victim has

undergone decontamination. This process is changingfor civilian medical responders, particularly in largermetropolitan communities; many fire departmentmedical responders wearing PPE are now preparedto provide early life saving medical triage and care tocontaminated casualties before decontamination. Thisalignment of civilian and military medical responseshould improve response capabilities and patient out-

comes in the event of a mass casualty incident.Although the positioning of up-front medical care

in the warm zone may differ, the process of patientdecontamination is similar for civilian and military.It includes the following: accounting for patientvaluables, clothing removal, washing, and movementacross the hot line; evidence recognition and properchain of custody procedures; recognition of second-ary explosive devices; clean side triage and treatment;and patient disposition from the decontaminationsite. The procedures may vary slightly dependingon the decontamination platform (land vs sea) andtype of equipment used (eg, buckets and sponges vsrobust plumbed systems or designated permanentdecontamination facilities). Decontamination typicallytakes from 5 to 20 minutes, depending on the medicalcondition of the casualty, the type of decontaminationequipment, and the level of training of the decontami-nation team.


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Documents

Chapter 14 - Field Managment of Chemical Casualties - Pg. 485 - 510