Ch14_pg485-510.pdf

Field Management of Chemical Casualties

Chapter 14

FIELD MANAGEMENT OF CHEMICAL

CASUALTIES

Charles h. Boardman, ms, ORR/L * ; shirley d. Tuorinsky, msn † ; duane C. Caneva, md ‡ ; John d. ma-

lone, md, msPh § ; a n d William l. JaCkson, md, P h d ¥

INTRODUCTION

HEALTH SERVICE SUPPORT AND MILITARY FORCE HEALTH PROTECTION ON

THE BATTLEFIELD

SERVICE-SPECIFIC OPERATIONS FOR FIELD MANAGEMENT OF CHEMICAL

CASUALTIES

Land-Based Forces

Sea-Based Forces

MANAGEMENT OF CHEMICAL CASUALTIES FROM A CIVILIAN PERSPECTIVE

INTEGRATION OF MILITARY SUPPORT INTO CIVILIAN HOMELAND

RESPONSE

THE MEDICAL MANAGEMENT PROCESS IN A CHEMICAL EVENT

Preattack, Attack, and Postattack Measures

Personnel Requirements

Necessary Medical Equipment and Supplies

Zones of Contamination

Levels of Decontamination

Military Management Concepts in the Civilian Setting

Processing 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, 3100

Ricketts 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 20372

§ Captain, 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 Rodgers

Blvd, Terminal Box 67, Honolulu, Hawaii 96819-1897; formerly, Assistant Chief Medical Officer, US Coast Guard Personnel Command, Arlington,

Virginia

485

Medical Aspects of Chemical Warfare

INTRODUCTION

The management of casualties exposed to chemical,

biological, radiological, and nuclear (CBrn) agents has

long been part of military doctrine. since the events

of september 11, 2001, interest in the management of

these types of casualties has extended to the civilian

response network. The military mission has likewise

expanded beyond the battlefield to include operations

in support of homeland defense and humanitarian

disaster relief. This expansion of military roles has

not significantly changed the procedures for chemical

casualty care. although specific medical and decon-

tamination equipment has changed with time, the

core principles for managing contaminated casualties

remain basically unchanged since World War i, when

the treatment of chemical casualties was conducted on

a large scale. These core principles include the early

removal of hazardous agent from patients to reduce

injury and contamination spread, and the provision of

early and effective life-saving treatment.

To save the lives of those contaminated by hazard-

ous agents, medical care providers, whether civilian

or military, must be capable of a rapid and effective

response. This involves first responders providing

initial medical intervention in the contaminated area,

or on the periphery, while wearing protective equip-

ment. First responders, as well as first receivers (those

who receive contaminated patients at the hospital),

must have the training to carry out patient triage and

life 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 casualty

event 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 medical

community. although patient treatment strategies still

vary, there are now many similarities in the decon-

tamination procedures used by these various organi-

zations, with key differences related to the platforms

on which field management takes place (eg, on land

vs. on sea-going vessels) and the specific equipment

used for medical care, transport, and decontamina-

tion. The emphasis in this text is on the management

of chemical casualties; however, these same processes

are equally applicable to treating patients affected by

biological and radiological contaminants. doctrine and

techniques continue to be upgraded, but it is expected

that any future developments should continue to fol-

low the basic principles discussed here.

HEALTH SERVICE SUPPORT AND MILITARY FORCE

HEALTH PROTECTION ON THE BATTLEFIELD

health service support (hss) includes all services

performed, provided, or arranged by the military services

to promote, improve, conserve, or restore the mental or

physical well-being of personnel. 1 military doctrine and

terminology are rapidly changing to better support joint

operations both on the battlefield and in civil support mis-

sions at home and abroad. This brief overview of current

and developing doctrine focuses on its application to the

management of chemical casualties across the military.

Force health protection (FhP) consists of measures

taken by all military members, from commander to

the individual service member, to promote, improve,

conserve, or restore mental and physical well-being

of personnel. 1 FhP, the medical component of force

protection, is a comprehensive approach to care that

includes proactive medical services, striving to prevent

casualties instead of focusing only on postcasualty

intervention. 1 The basic objectives of military hss

and FhP are to promote and sustain a fit and healthy

force, prevent injury and illness, protect the force from

health threats, and sustain medical and rehabilitative

care. The newer, more comprehensive, focus on FhP

consists of three pillars of health protection (Figure

14-1), providing a continuum of military health care

before, during, and after military operations. 1

on the battlefield, medical care focuses on

• minimizingtheeffectsofwounds,injuries,

disease, environment, occupational hazards,

and psychological stressors on unit effective-

ness, readiness, and morale; and

• returningtodutyasmanyservicemembers

as possible at each level of care. 2

These objectives also apply when the military assists

in homeland defense operations in support of local and

state assets during a national emergency. military and

civilian hss planning includes the medical response

to CBrn agent threats.

in any setting, far-forward medical treatment is critical

to reduce injury and save lives. military medicine focuses

on this far-forward care, provided initially by the mili-

tary member or a fellow unit member (a “buddy”), and

efficient casualty evacuation to medical facilities offer-

ing the appropriate care. 2 Table 14-1 gives an overview

of the new taxonomy of care capabilities, comparing

them to the current concept of levels (echelons) of care

particular to the management of chemical casualties. 1,2

486

Field Management of Chemical Casualties

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.

SERVICE-SPECIFIC OPERATIONS FOR FIELD MANAGEMENT OF CHEMICAL CASUALTIES

Land-Based Forces

number of contaminated casualties can be achieved

at 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 to

the area support medical battalion or to units capable

of forward resuscitation care (FrC), which include

forward surgical teams. Forward surgical teams cannot

operate in a chemical environment unless supported

by a unit such as the division clearing station, which

provides the capability to decontaminate patients. 3

The operational tempo may not allow for the thorough

decontamination of patients by first responders (level

i) 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 triage

and decontamination of contaminated casualties who

are transported dirty (without thorough decontamina-

tion) to their facilities. The combat support hospital is

the army theater hospital asset that provides surgical

care, laboratory services, and stabilization of chemical

casualties. army field medical facilities can be chemi-

cally hardened with chemically resistant inner tent

land-based forces are comprised primarily of us

army and marine Corps (usmC) personnel, land-

based navy personnel in support of land forces, and

air Force personnel in support of air operations and

land forces. land-based forces include all levels of hss.

hss units from all services plan and train for chemical

agent incidents in advance. in joint operations, all of

the services move battlefield casualties through the

taxonomy of care (Figure 14-2), with various service

components having responsibility for particular treat-

ment facilities as dictated by the Joint Task Force (JTF)

commander.

The first responder capability (level i) for army

land-based forces at the point of injury incorporates

self and buddy aid care. units also have combat medics

or treatment squads that provide first aid. unique to

the army at this level is the combat life saver, a soldier

with first-aid training. These individuals are capable of

assisting the medic in field care of injured soldiers. The

battalion aid station (Bas) is also part of this capability.

stabilization and emergency treatment for a limited

487

Medical Aspects of Chemical Warfare

TABLE 14-1

COMPARISON OF TAxONOMY OF CARE CAPABILITIES wITH LEVELS (ECHELONS) OF CARE

PARTICULAR TO CHEMICAL CASUALTY MANAGEMENT *

Care Capability / Level of Care

Care Rendered

Care Particular to Chemical Casualties

First Responder Capability

Initial essential stabilizing medical care

rendered at the point of injury.

same as care rendered plus:

• Decontaminationoftheskinand

equipment.

• Providingantidotes(atropine/2

PAM/diazepam)tochemical

agents.

Compares to level i care at the unit

level.

Prepares patient for return to duty or

transport to the next level of care.

self aid, buddy aid, examination, emer-

gency lifesaving (eg, maintain airway,

control bleeding, prevent shock). use

of iv fluids, antibiotics, applying splints

and bandages.

Forward Resuscitative Care Capability

Forward advanced emergency medical

treatment performed as close to the point on

injury as possible, based on current opera-

tional requirements.

resuscitation and stabilization, can in-

clude advanced trauma management,

emergency medical procedures, and

forward resuscitative surgery.

may have capability (depending on

military service) for basic laboratory,

limited radiograph, pharmacy, type o

blood transfusion, and temporary hold-

ing facilities.

same as responder capability (level i)

plus:

• Emergencycontaminatedshrap-

nel removal.

• Intubation.

• Ventilatorysupport(thoughlim-

ited).

• Wounddebridement.

• Informalstresscounseling.

This compares to level ii physician-di-

rected emergency care at a small medical

facility in the theater of operations.

Treat patient for rTd or stabilize for

movement to a larger medical treatment

facility capable of providing care.

En Route Care Capability

Involves the medical treatment of injuries

and illnesses during patient movement

between capabilities in the continuum of

essential care.

new term not used in former doctrine.

includes support of airway, controlling

bleeding, and administration of anti-

dotes and seizure medications, if needed

and available during transport.

Theater Hospitalization Capability

Includes theater hospitals with modular

configurations to provide in-theater support

and includes the HSS assets needed to sup-

port the theater.

resuscitation, initial wound surgery,

and postoperative treatment. This is the

first level that offers restorative surgery

and care rather than just emergency

care to stabilize the patient. has larger

variety of blood products than level ii.

same as for FrC (level ii) plus:

• Exploratorysurgery.

• Initialburncare.

• Bronchoscopy.

• Intubation.

• Ventilatorysupport(moreas-

sets than level ii).

• Moreextensivewounddebri-

dement.

• Eyecare.

• Respiratorytherapy.

• Formalstresscounseling.

Compares to level iii and iv capabilities

Facility in theater that is larger than

FrC (level ii). Care requiring expanded

clinical capabilities such as restorative

surgery. Treat patient for rTd or begin

restorative surgery and prepare for

movement to a higher level of care.

level iv

largest facility found in mature the-

aters. rehabilitates those who can rTd

in theater and prepares more serious

casualties for movement to level v.

Provides restorative surgery, like level

iii, and also rehabilitative and recov-

ery therapy.

same as for level iii plus:

• Physicalandoccupational

therapy rehabilitation for those

with limited vesicant burns.

• Fullrespiratorytherapy.

• Ventilatorysupport(moreas-

sets than level iii).

• Moreextensiveeyecare.

• Psychologicalcounseling.

( Table 14-1 continues )

488

Field Management of Chemical Casualties

Table 14-1 continued

Definitive Care Capability

Care rendered to conclusively manage a

patient’s condition, includes the full range

of acute, convalescent, restorative, and

rehabilitative care sites outside the theater

of operations.

same as for level iv plus:

• Longer term respiratory

therapy.

• Fullrehabilitativeservices

formentalhealth,cognitive/

memory retraining, retraining

inactivitiesofdailyliving/life

skills, prevocational services,

and post traumatic stress coun-

seling. This incorporates a team

of rehabilitation professions

such as physical, occupational,

speech, and mental health

services as needed based on

the severity of exposure and

resulting disability, if any.

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 the

national defense medical system. may

also be provided by overseas allied or

host nation mTFs

includes the full range of acute conva-

lescent, restorative, and rehabilitative

care.

* Taxonomy of care terms are in italics.

FrC: forward resuscitative care

hss: health service support

iv: intravenous

2-Pam: 2-pyridine aldoxime methyl chloride

rTd: return to duty

data 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.

liners and fitted with air filtering units.

land-based naval units are divided into broad

warfare areas including expeditionary warfare, forces

that move to a theater of operations, and naval installa-

tions. 4 expeditionary units include construction forces,

logistic support personnel, special warfare units,

and fleet hospitals. expeditionary forces on land are

typically deployed in support of usmC units. These

usually include land-based FrC (level ii) capability,

which may initially contain as few as 10 beds but can

be expanded to 500 beds with a theater hospitaliza-

tion capability (ie, a combat zone fleet hospital). 1

Casualties from these facilities can then be evacuated

to land-based facilities of other services or to hospital

ships. expeditionary medical units deploy as part of a

landing force, with CBrn defense capabilities for in-

dividual protection, self-decontamination, and limited

equipment decontamination.

naval installations such as fleet hospitals, on the

other hand, are more permanent, fixed facilities that

offer FrC capabilities at level iii or greater. installation

planning at these facilities involves disaster prepared-

ness, including coordination with local authorities.

Plans for operations in a contaminated environment

include using shelter-in-place procedures, individual

protective gear, and various types of detection equip-

ment. The installation disaster officer directs emer-

gency-response teams, coordinates decontamination

operations, and assists in the command and control

operations center. 4 in addition to triage and treating

casualties from an incident, the medical department

also organizes medical supplies; provides food and

water inspection; conducts disease monitoring; distrib-

utes antidotes and medications as needed for CBrn

incidents; and provides training on CBrn hazards,

self aid, and first aid as part of FhP. 4

The approximately 175,000-member usmC is an

intrinsic part of the department of the navy; medical

support to the marine Corps is provided by the navy

medical department. usmC personnel may augment

navy medical patient decontamination operations.

First responder capability (level i) is provided through

self aid and buddy aid as well as by navy corpsmen

assigned to usmC units. The marines, at this level,

also utilize their intrinsic Bass, or usmC wing support

squadron aid stations, staffed by navy medical person-

nel.UniquetotheUSMCistheChemical/Biological

incident response Force (CBirF) with first responder

medical capabilities. CBirF deploys domestically, par-

ticularly in the national Capital region of Washington,

dC, or overseas to pre-position or respond to a CBrn

incident. Composed of usmC and navy personnel,

CBirF has the capability to monitor, detect, identify,

and analyze toxic industrial chemicals (TiCs), toxic

489

liners and fitted with air filtering units.

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