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 as follows:
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. The 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 (BAS), 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 augmented 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 augmented personnel are not plentiful, the decontamination team might be supplemented by nonmedical personnel from the hospital staff.
The following is intended as an introduction to each of these stations. Detailed information can be found elsewhere (Appendix).
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.
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 physician's assistant 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 appropriate care can be provided in a contaminated environment. The purpose of this is to return them to duty quickly and to lessen the workload 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 bypass the decontamination area at his current echelon. (Administration of MARK I Kits 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 Kits 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 (bypassing the decontamination area). The expectant casualty will be temporarily set aside for later re-evaluation.
EMERGENCY TREATMENT AREA
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 different staffs.
The emergency treatment care provider provides assistance to the immediate and 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 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. 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 supplied 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 supply 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 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. 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 (1) back to duty (if there has been no violation of his protective encapsulation), (2) to the contaminated disposition area, bypassing the decontamination procedure and clean treatment facility, or (3) to the decontamination area. Casualties who would be sent to the contaminated disposition area (for "dirty" evacuation) are those who need treatment (or hospitalization) later, but do not need immediate care, and those who need supply at their unit. These will be evacuated in the contaminated evacuation vehicle. Those who will be sent to the decontamination area are casualties who need immediate treatment in the clean treatment area and 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 20 to 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 nonprogressing injuries (a delayed casualty) will bypass decontamination and 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 8 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 suddenly apneic casualty.
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.
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):
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 them.
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 areas under breaks in the protective ensemble, including areas 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.
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 as follows:
During this procedure the medic changes tourniquets and removes bandages as described in the previous section. The casualty, dressed in his BDU (including mask), thoroughly dusts his boots as he proceeds 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 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 ensure 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 decontamination stations.
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.
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Introduction |
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