CASUALTY MANAGEMENT IN A
In a contaminated environment, casualties enter a medical
treatment facility through the contaminated casualty receiving
area. This occurs at all echelons of medical care that are at
risk for receiving contaminated casualties. The purpose of this
area is to provide for the removal of all chemical contamination
from the casualty before he enters the clean medical treatment
facility and as a result to maintain a contamination free
treatment area where maximal medical care can be provided.
The components of this receiving area are
After crossing the hot line, the casualty enters the clean
treatment area and, after treatment, enters the clean disposition
area. There are two disposition areas. One is for clean
casualties (decontaminated patients from the clean treatment
area). The other is for "dirty" casualties, casualties
who were not decontaminated because they did not need treatment
at this echelon. These latter casualties will come from the
triage area and the contaminated emergency treatment area.
The exact function and staffing and other support of each of
these areas will depend on the size of the medical facility. At a
Battalion Aid Station, for example, staffing is limited and the
same senior medical NCO will usually be both the triage officer
and the emergency treatment care provider, the decontamination
areas will be staffed by a limited number of augmentee personnel,
and very limited medical care can be provided in the clean
treatment area. At a higher echelon of medical care, another type
of medical professional will be the triage officer, a second
medical professional the emergency care provider, and if
augmentee personnel are not plentiful the decontamination team
might be supplemented by non-medical personnel from the hospital
The following is intended as an introduction to each of these
stations. Detailed information can be found elsewhere (Appendix).
THE ARRIVAL POINT
The arrival point is the entrance to the casualty receiving
area. There should be one clearly marked road for incoming
traffic and another clearly marked road for outgoing traffic.
Ambulatory casualties will use the same routes. From this area
ambulatory casualties will walk to the triage area, and litter
bearers will carry litter patients to the triage area.
THE TRIAGE AREA
In this area the triage officer will quickly evaluate each
casualty and place him into one of the triage categories,
immediate, minimal, delayed, or expectant. The triage officer
might be a senior medic in a BAS and a physician or PA in larger
medical units. His ability to evaluate the casualty will be
limited because both he and the casualty will be in MOPP IV.
Those casualties needing immediate care will be sent to the
emergency treatment station (also in the contaminated area).
Casualties classified as minimal might also be sent to this area,
if the care they need can be provided in a contaminated
environment. The purpose of this is to return them to duty
quickly and to lessen the work load on the decontamination teams.
However, the types of injuries that can be treated without
breaking the integrity of the protective garment are small, and
once the integrity of the protective garment is violated the
casualty will need a new protective garment. He might go through
decontamination to don his second battle dress overgarment (BDO)
in the clean area of that facility, or he will be returned to his
unit for reissue of a BDO, in which case he will by-pass the
decontamination area at his current echelon. (Administration of
MARK I's is an example of treatment that can be given without
breaking the seal of the protective garment; however, if the
casualty is ambulatory, the administration of MARK I's is self-
or buddy-aid.) Those casualties classified as delayed will be
sent to a decontamination area if they require care in the clean
treatment area or to the contaminated disposition area for
evacuation without on-site treatment (by-passing the
decontamination area). The expectant will be temporarily set
aside for later reevaluation.
In a BAS, the same senior medic who triages might also provide
emergency treatment. At larger field treatment facilities the
triage and emergency treatment areas will be separate with
The emergency treatment care provider provides assistance to
the immediate casualties and to the minimal casualties.
The care that can be provided in this area is limited because
both the casualty and care provider are completely enclosed in
protective garments and because the time the single care provider
can allocate to a single patient is limited. To some extent care
is limited because this is a contaminated area, but this
limitation is relative, not absolute. This area is downwind of
the clean area; the only vapor hazard is vapor from liquid that
enters the area on the contaminated garments of patients, and the
amount of vapor arising from this small amount of liquid should
be minuscule and it will quickly dissipate in a breeze.
Ventilation of a newly-apneic patient will be limited more by the
lack of personnel to squeeze the Ambu bag than by the risk of
forcing more chemical vapor into the casualty's lungs.
Intravenous injections can be given and intravenous fluids can be
started after thorough decontamination of the skin site and the
care provider's gloves. Minor suturing can be done in this area
using the same precautions. The time needed by the single medical
care provider to perform these procedures is probably the
limiting consideration, not the risk of further contamination.
However, any care or injury that violates the protective
garment will necessitate reissue of the garment, and before
reissue the casualty must be decontaminated at this or a rear
echelon. At a BAS, for example, once any part of the protective
garment is compromised the casualty, who is otherwise able to
return to duty, must be resupplied with new garments. He might go
through the decontamination procedure at his current echelon to
don his own second BDO in the clean area, or he might be
evacuated without decontamination (in a dirty vehicle) for
resupply at his unit.
In some circumstances, an additional task of the medical care
provider at this station will be to irrigate or decontaminate a
wound and surrounding area to wash out or decontaminate any
remaining agent or to decontaminate exposed areas of skin that
seem to be the site of agent exposure. A symptomatic casualty
exposed to nerve agent in a wound or on unprotected skin might
present at a medical facility while still absorbing agent from
the wound or skin surface. It is unlikely that there will be
active agent in a wound (unless a foreign body is present), but
it is good practice to flush the site. Immediate decontamination
will remove this source of further exposure. Because of the
latent period from mustard exposure, when a mustard casualty
presents for treatment it is unlikely that immediate
decontamination of the exposure site will benefit him and it is
equally unlikely that active agent will be present on skin or in
a wound (although he needs to be routinely decontaminated before
he enters the clean treatment area). Amounts of a decontamination
solution suitable for flushing sites of potential contamination
should be among the equipment at the emergency treatment station.
After treating the casualty the emergency treatment provider
will send the casualty (a) back to duty (if there has been no
violation of his protective encapsulation), (b) to the
contaminated disposition area, by-passing the decontamination
procedure and clean treatment facility, or (c) to the
decontamination area. Casualties who would be sent to the
contaminated disposition area (for "dirty" evacuation)
are those who (a) need treatment (or hospitalization) later, but
do not need immediate care, and (b) those who need resupply at
their unit. These will be evacuated in the contaminated
evacuation vehicle. Those who will be sent to the decontamination
area are casualties who (a) need immediate treatment in the clean
treatment area and (b) can don their own second BDO in the clean
area. For reasons noted below, before he is sent for
decontamination a casualty must be stabilized so that he can
survive for 20-30 minutes without further care.
There are two decontamination areas, one for litter casualties
and one for ambulatory casualties. The relative use of each area
will probably differ from one echelon of medical care to another.
For example, at the BAS stable litter casualties with
non-progressing injuries (a delayed casualty) will by-pass
decontamination and will be sent directly to the contaminated
evacuation area. At higher echelons of care with the capability
to care for these casualties, all litter patients will be
decontaminated. At the BAS attempts will be made to treat walking
casualties and return them to duty.
Decontamination is time and labor intensive. Estimates of the
time required to decontaminate a litter patient range from eight
to 20 minutes. A medic supervises the litter decontamination
area, but he can provide little or no medical care during this
procedure. He cannot support ventilation nor can he assist a
Personnel performing litter decontamination wear butyl-rubber
aprons over their protective garments. The ambient temperature
and humidity dictate their work-rest cycle, but even under
temperate conditions the work period is short necessitating
frequent change of personnel. Three people are needed for litter
patient decontamination, although two might suffice if one is
strong, as patient lifting is necessary.
The litter decontamination area
There are two stations in this area, the clothing removal
station and the skin decontamination station.
At the clothing removal station (litter), two people work
together, one on each side of the litter, to (in order)
decontaminate the mask and hood, remove the hood (but leave mask
in place), decontaminate the casualty's mask and area around the
mask, remove the field medical card, remove gross contamination
from the casualty's protective garment, cut and remove the
protective garment jacket, cut and remove the protective garment
trousers, remove outer gloves, remove the overboots, remove the
combat boots, remove inner clothing and underwear (in the same
order and using the same procedures as with the protective
garments), and check for contamination. At this time, the nude
patient is transferred to the skin decontamination litter using a
three-person roll lift.
During clothing removal, the aidman removes tourniquets after
placing a new one an inch or so higher and cuts away bandages and
irrigates wounds (replacing the bandage only if bleeding recurs).
He also thoroughly decontaminates splints, but does not remove
On the skin decontamination litter, spot decontamination
(only) is done on areas of potential contamination. These include
the neck, lower face, and wrists, and also on areas under breaks
in the protective ensemble including around wound sites.
After final monitoring for contamination, the casualty is
carried on the litter to the shuffle pit and there is moved to a
clean litter provided by a team from the clean side of the hot
line. The mask is removed further upwind, at the entrance to the
clean treatment area.
The ambulatory decontamination area
A member of the decontamination team might help the walking
patient or walking patients might help each other to remove their
garments. The steps in this procedure are to drop the load
bearing equipment, decontaminate and remove the hood,
decontaminate the mask and surrounding skin, place the field
medical card in a plastic bag, remove all gross contamination
from the overgarment, remove the overgarment jacket, remove the
rubber gloves, remove the overboots, remove overgarment trousers,
remove cotton glove liners, check the battledress uniform and
surrounding skin for contamination (and decontaminate any spots
of contamination found), and lift the mask (while the casualty
has his breath held and eyes closed), wipe the face, and replace,
seal, and clear the mask. During this procedure the medic changes
tourniquets and removes bandages as described in the previous
section. The casualty, dressed in his BDU's (including mask),
thoroughly dusts his boots as he procedes through the shuffle pit
(the hot line) to the clean treatment area. The mask is removed
further upwind, at the entrance to the clean treatment area.
If because of the nature of his wounds his BDU is removed, the casualty becomes a litter patient.
THE HOT LINE
The hot line is an arbitrarily established line that
demarcates the area of liquid-agent contamination from an area
that is liquid-agent free. Once established, it should be clearly
marked using engineer tape or another marker to insure that
liquid contamination or a person with potential liquid
contamination does not cross into the clean area. This might
necessitate the use of concertina wire or armed guards. The only
entrance to the clean treatment area is through the
When the medical facility is set up in a clean area (no liquid contamination), all the ground behind the hot line is clean except the holding area for contaminated casualties waiting to be evacuated and the routes traversed by the contaminated evacuation vehicles; these should be far to the side of the contaminated triage and treatment areas. In other circumstances, the clean treatment area will be an oasis surrounded by the hot line.