Section IV. MEDICAL PLANNING GUIDE FOR THE ESTIMATION OF NUCLEAR, BIOLOGICAL, AND CHEMICAL BATTLE CASUALTIES (CHEMICAL)—AMedP-8(A), VOLUME III

D-19. General

a. The primary purpose of Volume III is to assist medical planners, logisticians, and staff officers in predicting CW contingency requirements. Requirements include medical personnel, medical materiel stockpiles, patient transport or evacuation capabilities, and facilities needed for patient decontamination, triage, treatment, and supportive care. An optional purpose is to support medical operational estimates.

b. The guide provides medical worst-case estimates of casualties and remaining operational strength after a single CW attack on a tactically deployed, brigade-sized land force units, with protection available and protection unavailable. These worst-case casually estimates are for personnel located within both the targeted and the downwind hazard areas of the brigade. It is assumed that all targeted personnel will be unsheltered and without medical pre-exposure prophylactic treatment. Tables in the guide are designed to show total numbers of—

Casualties with different types and severities of injury at various times after exposure.
Personnel at different performance levels and times after exposure.
Fatalities at specified times after exposure.

c. The guide presents estimates of personnel status at specific time points. These range from 1 to 3 hours to 7 to 30 days after an attack, depending on the type of agent considered. Such estimates are projected from all possible combinations of the following conditions:

Seven operational scenarios involving three types of units: heavy brigade, support brigade, and light infantry brigade.
Three chemical agents: the nerve agents GB and VX, and the blister agent HD.
Three types of munitions delivering the agents: aerial bombs, tactical ballistic missiles, and rounds from multiple launch rocket systems/artillery batteries—

Three attack intensities for each type of munition: light, moderate, and heavy.
Two postures of individual physical protection against the attacks: unavailable and available.

d. An index to essential information and four sample problems to illustrate use of this information are at the end of the guide (see Section 11). Section 11 provides a planning guide overview, describes applications, and presents a brief explanation of modeling methods used to prepare estimates.

e. The guide is subject to limitations of extent and content. Since there are many more possible attack variables than those considered, the guide presents a limited number of estimates. These estimates are based upon the best available toxicological values, but such values are qualified estimates. Therefore, medical planners and staff personnel should use FM 8-9, NATO Handbook on the Medical Aspects of NBC Defensive Operations, AMedP-6 (B), Part III—Chemical, for more authoritative medical descriptions and information on effects of longer duration.

f. The guide is most value to the user who needs to know what kinds of casualties to expect, relative numbers of each, and the time frames in which they are likely to appear. To assist the user, who lacks experience in actual CW, the guide describes types of injury, relevant factors, general magnitudes of effects, and effects of time courses on chemical casualty numbers. The casualty estimates are appropriate for training exercises. However, this initial attempt to provide complex estimates has limitations for battlefield use. The limitations are described as follows:

The guide provides estimates for a few of many possible chemical attacks. Each estimate is based upon computer modeling of the consequences of specified conditions. This is like saying that the numbers of men who sneeze, after inhaling an allergic flower pollen, might be predicted if specific information (EXAMPLE: The wind speed and direction, the current weather, altitude, time of day, and sites of concentrated flower growth) is known for the specific geographic location of a particular brigade on a given mountain. If such estimates are made for a few widely different mountains, a user of the estimates may be able to guess the numbers of sneezing men in his own brigade, located on a separate mountain. However, if the conditions on both mountains are not nearly identical, the user will need to estimate a scaling factor and apply it to adjust the number predicted for a different environment.
It is unlikely that exactly identical conditions will exist for any two mountains or chemical attacks. The user of the guide must decide which scenario best represents his conditions (or interpolate from two scenarios), then use or adjust the estimates. Therefore, each user must recognize any differences from modeled conditions that might require him to increase, or decrease, an estimate. The user may need to apply a commander's guidance on acceptable risk levels, or consider restrictions of available resources, before accepting, interpreting, or modifying the relevant planning guide numbers. The most difficult problem for the user will be to determine how much to increase, or decrease, planning guide numbers to fit the user's situation. This problem is discussed in paragraph 3.4 of the guide.
The user should be aware that medical worst-case targeting selects for maximal numbers of survivors entering the medical system, not for maximal operational losses. The tabulated estimates are very highly sensitive to the degree of clustering of personnel and their assumed location within a standardized brigade area. Accordingly, use of this targeting method leads to large variations that are based upon the probabilities of hitting clustered personnel, not evenly or widely distributed personnel. Therefore, these estimates do not provide a good basis for estimating the most likely outcomes for a series of "average" attacks, or for comparing a scenario with an actual attack. Although the tabular format of the guide suggests that the listed numbers are exact, the user should understand that different targeting could readily produce other numbers. Selection of a scaling factor Is discussed in paragraph 3.4 of the guide.

D-20. Medical Planning Considerations

a. The guide provides medical planners and staff personnel with a systematic means for estimating chemical casualties in various-sized units, without regard to composition. This document provides more accurate and detailed estimates and is based upon detailed operational scenarios for brigade-sized units. Both chemical planning guides support estimates of combat performance from individuals remaining in the unit.

b. Effective mass casualty management requires careful planning. The guide is designed to support such planning by providing medical planners and staff personnel with a systematic means for estimating the number, type, and time-related status of chemical casualties.

NOTE

Each user is advised to consult any available national military NBC defense doctrinal publications of similar nature.

c. Medical requirements during CW may be substantially different from those for the usual combat situation. There may be no indication of the presence of chemical agents in some tactical situations. Unprotected units downwind from an attack area, or those entering contaminated areas in an unprotected posture, may be unexpectedly exposed to chemical agents. However, casualty management also involves practice of self-aid and buddy aid, on-site medical triage and emergency care, transport to medical facilities, communications, health services, logistics, and evacuation by ground or air transportation.

d. The signs and symptoms of chemical agent exposure may be sudden and intense, or delayed and subtle, depending on the agent used and the level of exposure. Individuals may not reach the first level of care for 15 to 60 minutes after the onset of effects. Decontamination may delay medical treatment. Stabilization should occur before casualties leave emergency care areas, but contamination of these areas may delay the stabilization process. However, effects of decontamination or secondary contamination on estimated doses and effects are not considered in the guide. For medical planning, users of the guide need to consider the various qualifications of its casualty estimates, as discussed in paragraphs 3.4 and 3.4.2 of the guide.

e. A chemical burn caused by HD can require more care than a same-sized burn induced by conventional munitions. Therefore, the initial prognosis may require revision after treatment is underway, and estimates of percent capable by performance band may require adjustment.

D-21. Triage

Since a chemical attack may produce mass casualties, preparations for a triage system should be in place before the attack. Paragraph 2.5.1 of the guide describes patient categories by injury severity. For a particular described operational scenario, this information may be used to estimate the number of patients with specified levels of injury. The guide does not provide estimates of the number of patients by triage classification or usual medical and toxicological descriptions.

D-22. Evacuation

a. An efficient and flexible evacuation plan is essential for adequate casualty treatment and to retain mobility of forward medical resources. For assessment of a potential mass casualty situation, the full range of evacuation assets, limitations, and obstacles should be considered by the medical planner. After an attack, the medical staff may need to estimate the number of casualties that require evacuation resources at given postexposure times.

b. Evacuation requirements will vary with the type of chemical agent used. Nerve agent casualties may not be evacuated because the time course of severe effects is relatively short. Depending upon exposure conditions, HD casualties may or may not require evacuation to a facility where they can receive care for several days, or possibly 6 to 9 months. Estimates provided in the guide can be used as a starting point from which to plan for evacuation resources.

D-23. In-Unit Care

The casualty estimates in the guide are presented with no allowance for in-unit care such as self-aid or buddy aid. Soldiers trained in first aid procedures may be the first to see chemical injuries. The guide can provide an estimate of the numbers of injured personnel who will require first aid. However, there may be need for rapid augmentation, support, or other intervention. Delays in obtaining medical care may occur because of physical damage or contamination of the surrounding area. The tables described in paragraphs 3.3.2 and 3.3.3 of the guide give the time courses of effects that may apply to estimation of in-unit and delayed medical requirements.

D-24. Patient Bed Requirements

Requirements for patient beds and hospitalization time may be greater after chemical exposures than after a conventional attack. Such increases are particularly important for agents, such as HD, that produce injuries followed by a long recovery period. Bed requirements can be estimated using the tables described in paragraphs 3.3.2 and 3.3.3 of the guide. Casualties Occurring by Time Period tables (see paragraph 3.3.3) in the guide are useful after an attack since they show gains and losses of casualties over time. Personnel by Injury Category tables (as described in paragraph 3.3.4) in the guide may be more useful in long-range planning. They show maximum numbers of personnel by injury severity category. The tables in the guide only provide estimates for the first 30 days after attack. Depending upon the theater evacuation policy specified for the operation, hospital days may be either in theater or in the national area.

D-25. Medical Logistics

The estimates provided in the guide are intended to support projections of medical materiel and logistical requirements. Increased demands may occur for certain types of medical and general supplies. These may include specific equipment, kits, dressings, antibiotics, and other critical medical materiel. Demands may also increase for items unique to the chemical battlefield (such as nerve agent antidote autoinjectors), as well as items adapted to chemical environments (including IV systems and special self-contained intensive care units). Tables showing maximum numbers of personnel by injury severity category (see paragraph 3.3.4 in the guide) can provide useful input for logistical planning.

D-26. Medical Force Planning

a. The assignment of medical support is normally based upon the total military population and the expected conventional casualty rate. The guide may be used to assess requirements for additional medical units. The use of chemical weapons in tactical situations could be one indication of an increased tempo of warfare and need for additional personnel.

b. Although a unit may be targeted for chemical attack, that unit might not be located where the highest number of casualties could occur (as in a downwind hazard area). Accordingly, another unit might have priority for support. The tables presented in the guide can be used in planning for either situation. Some tables (see paragraph 3.3.4 in the guide) show estimated maximum numbers of personnel by injury severity category. Such estimates should be combined with a comprehensive array of other available information to increase the effectiveness of medical force planning.

c. The guide is organized into 11 sections. Section 1 introduces the guide and presents background and medical planning considerations. Section 2 provides information on the methodology used to develop the estimates of fatalities, casualties, and effectiveness of individuals remaining in the unit. Section 3 explores the use of the casualty prediction tables based on combat effectiveness decrements and estimates of the number of casualties categorized by insult level. Sections 4 through 10 contain tables of casualty estimates. Section 11 is a tutorial on use of the tool.

d. These medical worst-case casualty estimates (see paragraph 2.1.2 through 2.1.7 in the guide) are for personnel in the chemical-targeted and downwind hazard areas of the brigade sector. The actual areas presenting chemical agent hazards to personnel are relatively small and localized when compared to the entire brigade sector. These estimates are not valid for acute effects from repeated exposures, possible delayed effects of low dosage exposures, operational worst-case targeting, targets with different numbers or distributions of exposed personnel, or attacks involving different conditions (of meteorology, terrain, protective status, and so forth) than are modeled. Although the guide is primarily designed to support medical force planning for future CW defense, it may be used to anticipate short-term requirements. For example, delayed requirements of HD victims for care or evacuation resources may be predicted from tables that give estimates of casually numbers by injury type at given times after a CW attack (see paragraphs 3.3.2 and 3.3.3 in the guide).

[APPENDIX E]
Example X-, ANNEX, TO HSS PLAN/OPERATION ORDER__, MEDICAL NBC STAFF OFFICER PLANNING FOR HSS IN AN NBC ENVIRONMENT

1. PURPOSE. Establish standardized procedures for medical NBC staff officers planning, preparing for, detecting, reporting, and providing preventive/protective measures for NBC/TIM hazards. Establish planning procedures for conducting HSS in NBC/TIM environments. Also, establish procedures for providing technical guidance/support to leadership before, during, and after an NBC/TIM event.

2. PROCEDURES

a. Medical NBC staff officers prepare list of equipment and procedural guidelines for HSS operations under NBC/TIM conditions. (Provide a list of radiological detection devices, chemical agent detection/identification kits/devices, components of biological sample/specimen collection, and shipping containers. Provide guidelines/references for operating detection/identification devices.)

b. Planning actions for use before an NBC/TIM event. (Provide preventive/protective measures that the leadership can employ to reduce the health effects of a NBC/TIM event. Also, provide preventive/protective measures that leadership can employ to reduce the health effects of existing NBC/TIM hazards/contamination in an AO. Provide HSS leadership with procedures that can be employed to protect their unit and patients.)

c. Planning action for use during an NBC/TIM event. (Provide preventive/protective measures that the leadership can employ to reduce the health effects of a NBC/TIM event. Provide HSS leadership with procedures that can be employed to protect their unit and patients.)

d. Planning actions for use after an NBC/TIM event. (Provide preventive/protective measures that line leadership can employ to reduce/mitigate the health effects of an NBC/TIM event on the force. Provide HSS leadership with procedure that can be employed to mitigate the effects on their unit and patients.)

e. Planning actions for preventive medicine support for NBC/TIM events. (Provide types and numbers of PVNTMED units/personnel required to perform PVNTMED missions during such events. Describe mission requirements for units/personnel preparing for and reacting to the event. Describe types of samples required and how samples must be collected, preserved, packaged, and shipped to supporting medical laboratory for analysis. Describe detection/monitoring equipment required for the event; such as AN/PDR77, AN/VDR2 radiac meter, chemical agent monitor (CAM), and M272 water test kit.)

f. Planning actions for veterinary support for NBC/TIM events. (Provide types and numbers of veterinary units/personnel required to perform the veterinary service missions during such events. Describe mission requirements for units/personnel preparing for and reacting to the event. Describe types of samples/specimens required and how samples/specimens must be collected, preserved, packaged, and shipped to supporting medical laboratory for analysis. Describe food contamination and decontamination procedures. Describe detection/monitoring equipment required for the event; such as AN/PDR77, AN/VDR2 radiac meter, and CAM.)

g. Planning actions for medical laboratory support for NBC/TIM events. (Provide requirements for medical laboratory support for an NBC/TIM event. Describe types of laboratory test/procedures required to provide command verification on the use of an NBC device/weapon. Provide medical laboratory reporting requirements; example: provide report to command surgeon; Joint Task Force/theater commander; senior commander in affected operational area.)

h. Planning actions for combat health logistics support for NBC/TIM events. (Provide requirements for combat health logistics support units and personnel. Describe types of Class VIII supplies required to support HSS response to an event. Examples: Numbers of chemical agent patient decontamination MESs, chemical agent patient treatment sets, number of packets of chemical agent pretreatment tablets required, and chemoprophylaxis required for personnel exposed to a biological agent.)

i. Planning actions for combat stress control/mental health support for NBC/TIM events. (Provide requirements for COSC/mental health support units/personnel. Describe where and how COSC/mental health personnel will provide their support in response to the event.)

j. Planning for medical treatment of NBC/TIM event casualties. (Provide requirements for medical evacuation and treatment (including emergency dental care) support units/personnel. Provide requirements for nonmedical personnel to perform patient decontamination at the MTF. Describe where and how evacuation and treatment personnel will provide their support in response to include supervision of patient decontamination procedures.)

3. COORDINATION REQUIREMENTS. (Provide requirements for support such as who should transport/escort samples/specimens from unit of origin to support medical laboratory and on to the CONUS gold standard laboratory. Example: The Technical Escort Unit normally provides transportation and escort for suspect NBC samples, in their absence describe who will provide this service. Provide requirements for numbers of personnel required to perform patient decontamination at supporting MTFs. Describe decontamination support requirements for medical units; especially hospitals and major combat health logistics facilities.)

4. REPORTS. (Describe types of reports required and frequency of reporting on HSS aspects of NBC/TIM events. Reports should provide, at a minimum, aspects of event and recommended preventive/protective actions needed to prevent or minimize casualties.)