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Training Information
Field Management of Casualties on The Contaminated Battlefield
(
TI17P
)
FIELD MANAGEMENT OF CASUALTIES ON THE CONTAMINATED BATTLEFIELD
The single most important concern for the combat lifesaver/soldier medic during operations on the contaminated battlefield is the timely and proper management of casualties. Providing timely and proper management must begin with preparations long
before deployment
. The required preparations can be divided into several elements.
Training individual unit members to correctly identify chemical agent exposure based on signs or symptoms and to correctly perform self-aid or buddy-aid and decontamination.
Training the combat lifesaver and soldier medic to correctly identify any chemical agent based on observed signs or symptoms experienced by the casualty.
Complete understanding of the severity of exposure based on signs and symptoms.
Correct identification of route(s) of entry of the agent and method of exposure (from liquid and/or vapor) based on signs and symptoms.
Triage chemical casualties or mixed conventionally wounded and chemically contaminated and/or poisoned casualties for mass casualty situations.
Correct treatment of agent effects, proper use of antidotes, and other supportive care that may be required during or after initial treatment (i.e., assisted ventilation or airway suction).
Complete understanding of the various casualty types that can be encountered on the contaminated battlefield.
Identification of required casualty decontamination, both at the initial treatment location and at the MTF.
Complete understanding of ambulatory and litter casualty decontamination operations at the MTF.
Identification of personnel limitations and equipment shortfalls in support of casualty decontamination and treatment.
Understanding the impact of contaminated and/or decontaminated casualties on evacuation operations.
Once deployment is complete, the combat lifesaver/soldier medic must be aware of additional elements that also impact on management operations. These battlefield elements, at a minimum, are as follows:
Current enemy chemical capabilities, enemy chemical employment capabilities (i.e., artillery, rockets, or spray), and anticipated enemy chemical employment.
Tactical intelligence gathered after the verified enemy use of chemical agents.
Current protective posture of the unit and how vigorously it is maintained.
Current status of unit and individual chemical defense readiness.
Morale and confidence of individual unit members, both in the unit and each other.
Complete understanding of current and near-term combat operations.
All of these elements, when considered together, allow the combat lifesaver/soldier medic to take a proactive readiness posture for management operations on the contaminated battlefield. The following sections will expand on these elements.
TRAINING
All individuals, both medical personnel and nonmedical augmentees, who are involved in the patient decontamination effort must be trained in, or show proficiency in the following:
Drink from canteen while wearing your protective mask.
Recognize signs or symptoms of heat injury.
Recognize liquid chemical agent.
Detect and identify chemical agent using M8 Chemical Detection Paper or M9 Chemical Detection Tape.
Evaluate a casualty.
Prepare decontamination solutions.
Recognize signs or symptoms of chemical poisoning.
Administer nerve agent antidote to self (self-aid).
Administer nerve agent antidote and CANA to buddy (buddy-aid).
Transport litter casualties using both two-man and four-man litter carries.
Move casualty using logroll method.
Remove litter casualty’s contaminated clothing.
Perform litter casualty’s skin decontamination.
Use Chemical Agent Monitor (CAM).
Wound or injury management during litter and ambulatory decontamination.
After initial treatment, route casualties to litter patient decon area.
Remove ambulatory casualty’s contaminated clothing.
Monitor litter and ambulatory casualties for residual contamination after completion of decontamination process.
Prepare the M8A1 Automatic Chemical Agent Alarm (ACAA) and/or the M22 ACADA for operation.
Place the M8A1 ACAA and/or the M22 ACADA in operation.
Use the M256A1 Chemical Detection Kit.
Conduct unmasking procedures using the M256A1 Chemical Detection Kit.
Decontaminate open wounds.
Identify chemical agent causing signs or symptoms.
Treat chemical agent poisoning.
Describe and perform emergency medical treatment required to stabilize a casualty for the decon process.
Identify triage requirements based on signs or symptoms.
The list above is suggested as a starting point for a training program to support casualty decontamination operations. The list has obvious tasks that are medical only and should only be taught to medical personnel. However, some tasks are applicable to all and should be taught to all.
EXPOSURE HISTORY
An important informational link between the soldier and the MTF will be the history surrounding the exposure, the soldier's activities since the exposure, and the progression of symptoms. The following questions may be helpful:
At Time of Exposure:
Did M9 Chemical Detection tape react?
Was agent verified in liquid or vapor or a combination of both?
How was the agent identified and verified?
What actions occurred and when did they occur in relation to the time of detection? (i.e., skin decon, flushing eyes, etc.)
What level of MOPP was the casualty wearing at the time of exposure?
If not at any MOPP level, did the casualty don the MOPP over his exposed BDU?
After Onset of Symptoms:
Were MARK I Kits and/or diazepam used, and if so, when in relation to the onset of symptoms?
Has the soldier been taking the Nerve Agent Pretreatment Pill (NAPP)? When did he take the last one?
How long since the last onset of symptoms?
What symptoms has the casualty experienced?
What activities has the individual engaged in since the initial exposure?
What was the casualty doing when the symptoms began?
What level of MOPP was the casualty in when symptoms began?
Knowing the soldier's protective posture at the time of exposure, the time taken to react to the exposure, and the actions taken by the soldier in response to the exposure will assist the triage effort and subsequent treatment effort at the MTF. Obtaining as complete a history as possible, coupled with unit chemical survey data, will enhance the triage and treatment effort for the casualty at the MTF. Providing too much information on the field medical card is far better than not providing enough.
The combat lifesaver/soldier medic must also be aware of the various factors influencing production of the casualty types. These factors are as follows:
The protective posture of the unit at the time they encountered the chemical agent.
To what extent was the unit surprised by the encounter, regardless of how the encounter happened?
Was the encounter a result of movement through the chemical contamination or a result of direct attack on the unit?
Was movement through the chemical contamination deliberate or unintentional?
Was the unit in contact with enemy forces at the time of the encounter?
Did the unit encounter chemical agents in vapor form only, liquid form, or a combination of both?
Has the unit’s chemical survey team verified the agent?
Understanding the circumstances surrounding the production of the casualty will help the combat lifesaver/soldier medic in the casualty's triage, treatment, and evacuation.
CASUALTY EVALUATION
The combat lifesaver/soldier medic will encounter seven general categories of casualties on the contaminated battlefield. They are listed below.
Poisoned and contaminated
Poisoned and not contaminated
Conventionally wounded, poisoned, and contaminated
Conventionally wounded, poisoned, and not contaminated
Conventionally wounded, not poisoned, and contaminated
Conventionally wounded, not poisoned, and not contaminated
Psychological
This list may seem obvious at first, but it is presented for a reason. The proper management of casualties must begin with an in-depth understanding of the various types of casualties and the specific treatment needs of each.
When the combat lifesaver/soldier medic is confronted with one or more casualties on the contaminated battlefield, a deliberate decision-making process must begin. Taking deliberate steps to evaluate the casualty, regardless of condition, will allow him to be triaged into the correct category. This, in turn, will optimize the casualty's care and his chance of eventual return to duty.
At times, the combat lifesaver will need to decide which course of action to follow. The deciding factor will always be to treat the condition that poses the most immediate threat to life and limb. The most critical step of the decision-making process is triage.
TRIAGE ON THE CONTAMINATED BATTLEFIELD
Triage is defined as the classification of patients according to type and seriousness of injury in order to provide the most orderly, timely, and efficient use of medical resources while providing maximal casualty care. Triage is necessary during a mass casualty situation or when the casualty load overwhelms medical resources. Under this circumstance, it is necessary to sort and prioritize patients for care. When the number of casualties does not overwhelm medical resources, triage is not necessary.
During a mass casualty situation, the goal is to provide the best care for the most casualties. Ideally, care would be provided first for those who are in immediate danger of dying because of their wounds. However, this can be done only if resources to provide this care are available
and
if the care will not require an undue amount of time that might be spent caring for other casualties.
Guidelines for surveying a chemical casualty prior to triage are provided below. Chemical casualties may also have conventional wounds, and standard guidelines for the initial survey of a casualty must also be followed. These guidelines should be discussed with the medical officer in your unit and modified accordingly.
Surveying the Casualty
Observe the self-aid or buddy-aid rendered for both conventional wounds and/or chemical agent poisoning
Question the casualty’s buddy regarding the following:
-- Type of agent and how it was identified
-- Initial signs/symptoms
-- Conventional wounds noted in casualty by buddy and buddy-assisted first aid rendered
-- Prior treatment for suspected chemical poisoning and/or conventional wounds
-- Use of nerve agent pretreatment drug (pyridostigmine)
Observe the casualty’s protective clothing and equipment for signs of liquid chemical contamination.
Observe the casualty’s M9 Chemical Agent Detector Paper for pink, red, reddish brown, or purple color changes. The generation of a wound at the time of chemical agent exposure may also result in liquid agent being deposited into the wound, in which case the liquid chemical agent probably has begun to absorb into the tissue. Exposed skin may also be absorbing agent.
Observe the casualty closely for small liquid droplets on butyl rubber surfaces (protective boots, gloves, mask hood, and helmet cover). Survey the casualty’s weapon for liquid droplets. Place M8 Chemical Detection Paper on the liquid. Refer to the M8 booklet cover for liquid agent identification based on color change.
(Perform this step
only
if evidence of liquid chemical agent contamination is observed on the M9 paper, BDO, or equipment and has not been identified by the section or platoon chemical survey team. This step can wait until triage action on the casualty is complete and must be performed by the combat lifesaver/soldier medic. Results must be written on the Field Medical Card.)
Survey casualty for conventional injuries.
Survey casualty for continued signs/symptoms of chemical agent poisoning.
Determine whether or not the casualty can respond to a command.
-- Ask the casualty to describe signs and symptoms.
-- Observe whether or not the casualty responds in an orderly fashion when following simple directions. Suspect shock or CNS involvement if he cannot.
Observe the casualty for the following symptoms:
-- “Sweating” through the overgarment or through exposed skin; this could indicate a skin exposure to liquid nerve agent under the ”sweat.”
-- Labored breathing
-- Coughing
-- Vomiting
Check pulse by placing fingers on carotid. This might be done by feeling through the hood. If no aerosolized agent is still in the air, the triage officer, wearing the
tactile
chemical protective gloves, might reach under the hood and feel for the pulse on bare skin. After unfastening the arm strap of the hood and unzipping the hood, the
tactile
gloves and the skin on the neck should be decontaminated before feeling for the carotid pulse.
Check for pupil reactivity by covering both eye lenses with gloved hands, then uncovering and observing for pupil reaction.
Triage the patient.
Triage categories are immediate, delayed, minimal, and expectant.
IMMEDIATE
A casualty classified as immediate has an injury that will be fatal if he does not receive immediate care. In a non-mass casualty situation, he would be the first casualty to receive care. However, in a mass casualty situation, particularly in a far-forward medical treatment facility, he may not receive this care. The required care may not be available at that echelon (e.g., a casualty may need major chest surgery, and that cannot be done at a BAS) or the time needed to provide that care may be so prolonged that other casualties would suffer. Examples of immediate casualties are provided below.
-- Casualties who are not displaying signs and symptoms of chemical agent poisoning but have a life-threatening conventional injury (i.e., gross external bleeding, sucking chest wound, flail chest, airway obstruction, tension pneumothorax, maxillofacial wounds in which asphyxia exists or is likely to occur).
-- Severe nerve agent casualties with or without conventional wounds. This would include those who have labored breathing or just stopped breathing but still have adequate circulation (a good blood pressure) and those who are convulsing or have convulsed.
-- Casualties from cyanide poisoning who are gasping or just stopped breathing, but still have adequate circulation.
-- Casualties in respiratory distress from phosgene, a phosgene-like substance, or a vesicant. The care required for these casualties exceeds that at the lower echelon medical treatment facilities. They should be triaged as immediate only if they can be quickly evacuated to a pulmonary treatment facility for intensive care.
DELAYED
A
delayed
casualty is one who needs further medical care but can wait for that care without risk of compromising his successful recovery. He may require extensive surgical procedures and long-term hospitalization, but he is presently stable and requires no immediate care. A casualty with a leg wound or fracture is an example of a conventional casualty who would be delayed. A casualty recovering from severe nerve agent poisoning will be delayed. Most casualties with vesicant burns will be delayed.
MINIMAL
A casualty who would be classified as
minimal
is one who (1) can be treated by a medic and does not need to see a physician or physician’s assistant, (2) will not be evacuated, and (3) will return to duty within a day or so. Such casualties might be as follows:
-- Casualties with moderate to mild nerve agent poisoning who have taken the antidote, are recovering, and are not in distress.
-- Casualties who have minor conventional wounds.
-- Blister agent casualties with a small amount of erythema or a few small blisters in noncritical areas.
EXPECTANT
The
expectant
casualty is one for whom medical care cannot be provided at the medical treatment facility and cannot be evacuated for more advanced care in time to save his life. This category is used only during mass casualty situations. This category does not mean that these casualties will not receive medical care.
Transfer casualties for treatment/evacuation based on established priorities for treatment.
-- Casualties who have been classified as “IMMEDIATE” are transferred to the contaminated medical treatment area for stabilization. After stabilization, these casualties are taken to the litter patient decontamination area.
-- Casualties who have been categorized as “DELAYED” may or may not require treatment in the collective protection treatment area before evacuation. If they need to enter this clean area for treatment, they are sent to the ambulatory or litter decontamination line, whichever is appropriate. If they do not need treatment in this area, they are sent directly to the evacuation holding area.
-- Casualties who have been categorized as “MINIMAL” may receive treatment in the collective protection treatment shelter or the contaminated emergency treatment area. If they can be treated in the contaminated emergency treatment area and they have no break in their BDO, they will be returned to duty from this area. If they require treatment in the clean treatment area, they will need to be sent to one of the decontamination areas before entry into the area. If there is a break in their BDO, they will need resupply. They must go through decontamination to the clean treatment area for resupply (resupply will be their own second BDO; if they do not have a second BDO, they will require evacuation for resupply).
-- Casualties who have been categorized as “EXPECTANT” will be transferred to designated contaminated holding areas. These casualties will be constantly monitored while in this area and provided with available comfort measures.
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