1. Purpose. This chapter provides medical support considerations for planning and conducting joint NBC defense operations.

2. Overview. Medical support for NBC defense operations will be performed during any phase of military operations. The combatant commander should plan for these medical aspects in the portions of campaign plans and orders that address NBC defense in the theater.

3. Health Service Support (HSS). HSS remains a Service responsibility, as outlined in Joint Publication 4-02, "Doctrine for Health Service Support in Joint Operations." As more nations develop and use WMD, the probability of US forces encountering these weapons will increase. Medical planning is one aspect of meeting this challenge. Because of the large number of casualties resulting from the use of such weapons, and the special handling required that can drain medical resources, the combatant commander must plan to use directive authority to ensure the proper coordination of health service to the force, to include adequate shelter, food, medical prophylaxis, and fluids.

a. Defensive Measures. There are a number of interrelated defensive measures that should be included in the planning aspects associated with HSS in an NBC environment. These include military surveillance of key sectors to deter an attacker disseminating chemical and/or biological agents from a ship-, aircraft-, or ground-based source; medical defensive measures to protect personnel at risk against exposure, infection, or intoxication; physical defensive measures to reduce the risk of personnel inhaling any chemical agent or biological aerosol that may be present; and early detection. Although the detection of a biological aerosol is not itself a countermeasure, effective detection plays a key role in enabling other countermeasures to be used efficiently.

b. Medical Management. The medical management of casualties resulting from use of WMD and, in particular, biological agents, is a problem of managing large numbers of individuals with infectious disease or exposure to chemical agents and/or toxins and injuries resulting from nuclear weapons. Medical units will require augmentation to decontaminate incoming casualties. Each element of the medical treatment and evacuation process must be evaluated, especially as it pertains to coalition and HN interrelationships. The fact that the source of the exposure may have been artificially created by deliberate, hostile means will not change the basic principles of treatment. For instance, in the event of a biological attack, the most important factor in providing operationally relevant information and adequate medical management will be the rapid establishment of an accurate, specific identification of the agent. In contrast to naturally occurring epidemics in which the disease incidence increases over a period of weeks or months, an artificially induced epidemic will peak in a few hours or days. Since a biological attack may be silent or nearly so, the first indication of a problem may well be the appearance of a wave of casualties in which medical personnel are unable to differentiate natural disease epidemics from overt or covert enemy attacks. Onset of illness following exposure to toxic agents may range from minutes or as long as 3 weeks. Some potential biological agents are transmissible among humans, so spread after the initial attack may become an important planning consideration.

(1) There are unique aspects of medical management after biological attack that require special alertness and training. Timely identification and communication of the threat is essential for the theater force survival. Casualties may not occur at the same time as they would in the case of saturation bombing or a massive surprise attack with nerve agents. The degree of exposure to the agent and host resistance causes the onset of illness to be spread over a number of hours or days. An increasing casualty load is anticipated with relatively few initial casualties and a greater number over successive hours or days until a peak is reached. An exception to this aspect would be an attack with biological toxin(s) that might create an immediate and dramatic mass casualty situation.

(2) Decontamination and collective protection for NBC attacks are particularly important if the situation necessitated a prolonged stay in a presumptively infected area. Medical management must provide reasonably adequate shelter, establish uncontaminated food and water intake, and ensure specific treatment is available. Demands for military medical support to neighboring civilian populations following such an attack will probably be intense, especially if the attack contaminated neighboring civilian populations with concentrations of very young, very old, and those already suffering from underlying disease or other forms of weakening stress. Medical facilities security must also be planned.

5. Preventive Medicine Principles. In an NBC environment, preventive medicine services will be in great demand. There is a possibility that many deaths would occur if an effective biological agent attack occurred. Demands for military medical support to both military and civilian populations will probably be intense. Preventive medicine personnel must assist the commander in determining the health hazards associated with nuclear fallout and biological contamination, such as safe food and water sources, and in determining when to use prophylaxis, immunization, and other preventive measures associated with NBC warfare. Preventive medicine personnel must be aware of the NBC threat in the theater and continually update the informational data base on diseases, potential disease vectors, and the susceptibility of troops to these diseases. In NBC conditions, diseases known to exist in the area may be manifested but not transmitted to our forces. The appearance of a disease or vector not known to exist in the theater is an indication that biological warfare agents are being introduced into the area. Following an effective NBC attack, the application of general preventive medicine principles will be important.

a. The tendency of individuals in an emergency situation to become careless regarding food and water sanitation, general hygiene, and other common disease control measures could be a significant cause of secondary spread of disease. The problems of maintaining safe water and food conditions will differ for military personnel deployed throughout the operational area and for the civilian population.

b. Following an NBC attack, all food except canned or otherwise well-protected food should be thoroughly inspected to ensure adequate protection was provided. Foods determined to be safe must be protected against secondary contamination. Protective measures must be practiced by those who transport, store, prepare, and serve food, as well as by those who consume the food. In addition, consideration must be given to applying control measures necessary to prevent contamination of food stuffs by insects, rodents, and other vectors.

c. It is difficult to maintain satisfactory personal and area field sanitation, particularly in unfamiliar climates. Strict measures are required for waste treatment and sewage. Water surveillance and area water sanitation control measures must be instituted. The best insurance of water sanitation is water purification or boiling. However, water purification tablets and military systems for boiling or purifying large amounts of water for consumption and hygiene purposes are not effective against certain biological agents such as viruses, spores, or toxins.

d. Washing with soap and water is the most effective simple personal hygiene measure for the control of communicable diseases. It is the responsibility of each person to apply standard individual protective and sanitary measures as appropriate.

7. Patient Decontamination and Triage. The management and treatment of contaminated casualties will vary with the tactical situation and the nature of the contaminant. Each medical unit must have a plan that can be put into effect immediately. Decentralization is necessary-- casualties must not be forced to wait at a central point for decontamination. All medical units should have comparable sets of medical items and decontamination equipment for treatment of contaminated patients originating in their area. Decontamination of the patients serves two purposes: a. It prevents the patient's system from absorbing additional contaminants and b. It protects medical personnel treating the patient and other patients from contamination.

a. Medical treatment facilities (MTF) will establish decontamination areas. When casualties arrive at the MTF, they must be seen at a triage point and directed to the proper area. The triage officer must determine if the patients have a surgical or medical condition that requires priority over decontamination.

b. Ninety to ninety-five percent of all decontamination can be accomplished by removing the outer clothing and shoes. This can usually be accomplished before admission without interfering with medical treatment. Actions should be taken immediately to ensure all personnel suspected of being contaminated by a biological agent are cleaned and kept free of disease-producing organisms.

a. WMD are capable of producing mass casualties. Even though few chemical casualties become fatalities, they require intensive HSS. In the first few hours after an NBC attack, medical facilities can be swamped with casualties who require lengthy hospitalization.

b. At the same time the patient load is increasing, other factors combine to complicate HSS operations. Operations in MOPP gear reduce individual and collective efficiency at a time when manpower requirements increase. Patient decontamination requires manpower and will reduce the number of personnel available to treat casualties. Heat stress in MOPP will require more frequent rest breaks, further reducing care capability. Establishing and maintaining a facility with collective protection shelter (CPS) and continuously monitoring the air inside the shelter for contaminants calls for additional personnel. These procedures decrease the ability to treat patients as efficiently and effectively.

a. Contamination may be transferred to the medical treatment facility if patients are evacuated to MTFs without being decontaminated. Patients must be decontaminated before they are admitted into the collective protective system. This is required to prevent the medical staff from becoming casualties; ordinarily, the medical staff works without protective equipment.

b. Many HSS assets are fixed or possess limited mobility. They are often located near C3 activities and main supply routes; hence, they must continue to operate within the contaminated environment. Treatment cannot cease while the unit relocates.

c. Oxygen Production and Resupply. Production of liquid and gaseous oxygen normally will not occur in an NBC contaminated environment. Although newer production plants have been designed for potential operation in such a state, generally production will be stopped until air quality improves. Product transfer operations (gaseous and liquid) will also be curtailed unless medical and flight line requirements demand such. Supply and medical units must develop plans to resupply critical gases and cryogenic liquids in the contaminated area from primary and alternate sources. These sources include production and storage organic to the unit, from other Services, from HN support, and from commercial contracts.

07-10-1996; 10:42:28