APPENDICES

1. Patient Decontamination
2. Casualty Receiving Area
3. Personnel Decontamination Station
4. Toxicity Data
5. Physicochemical Data
6. Medical Equipment Set Contents
7. Summary Chart
8. Glossary of Terms

Patient decontamination is personnel, time, and equipment intensive. Nevertheless, with a little ingenuity and attention to just a few basic principles, an effective litter decontamination procedure can be accomplished with minimal cost. The first part of this appendix briefly discusses considerations in establishing a decontamination site, followed by step-by-step procedures.

The decontamination site is part of the medical treatment facility, and the same considerations for establishing the treatment facility apply to the decontamination area. The decontamination area is located about 50 yards downwind from the treatment area (i.e., wind blowing from the clean treatment area to the dirty decontamination area).

• Wind direction
• Security of the decontamination site
• Area control of the decontamination site
• Litter patient decontamination
• Ambulatory patient decontamination

The important considerations of personnel and equipment requirements are discussed in other publications.

Wind direction is important because a vapor hazard may be present downwind from a liquid contaminated area (i.e., patient arrival/triage area). Patient decontamination is always performed upwind, or at least not downwind, from the patient arrival area.

The decontamination site will initially be set up to take advantage of the prevailing wind; however, setup should be adaptable to allow for quick rearrangement when the wind comes from another direction.

If the wind changes direction by more than 45^o, the decontamination site will need to be adjusted accordingly. A wait of 15 to 20 minutes to determine if the change is permanent should precede the move. When the site is moved, it must be moved at least 75 meters upwind from any contaminated area. Personnel working in the old "clean" area when the wind shifts must ensure that all casualties remain masked. This scenario points out that the ideal decontamination setup should include 2 separate decontamination sites approximately 75 meters apart, when possible.

When choosing a decontamination site, the same security considerations must be given as for any other site chosen for medical operations. The decontamination site is at the same potential risk from attack as is the actual medical treatment facility.

An entry control point (ECP) can be established to control movement of clean and contaminated vehicles to the Medical Treatment Facility (MTF) or the Decontamination Site. The ECP should be located at a distance far enough from the MTF to keep vapor hazard from contaminated vehicles to the minimum.

Traffic control at the decontamination site involves routing a clearly marked, one-way course from the ECP to the decontamination site.

Control of personnel movement is necessary to ensure that contaminated walking personnel do not accidentally contaminate clean areas. The hot line must be secured. Concertina wire works well to keep personnel in the desired areas, and a clearly marked, one-way route helps to ensure that correct entry and exit points are used.

Two people are required per litter patient. These two augmentees will link up with one litter patient in the triage area and work with that same litter patient until hand-off at the "hot line." These two people conduct both clothing removal and any required skin decontamination. To assist these two augmentees, two other augmentees will be needed, one to assist the first two augmentees in picking up the patient from the clothing removal litter, and the second to remove the contaminated clothing and litter and replace it with a clean litter. These four augmentees will conduct all patient decontamination and movement of the patient while in MOPP level IV and the Toxicological Agent Protective (TAP) apron.

Personnel working in the patient decontamination area will be at MOPP level IV plus the Toxicological Agent Protective (TAP) apron. At least two people from this area will move to the triage area and carry the patient from this area to the first decontamination station.

Two different concentrations of chlorine solution are used in the patient decontamination procedure. A 0.5% chlorine solution is used for all patient washing procedures and for the mask decontamination. The 5% chlorine solution is used to decontaminate the scissors, the TAP aprons, and the gloves on personnel working in the patient decontamination area and the casualty's hood. The chlorine solutions are placed in buckets for use in this area. The buckets should be distinctly marked because it is very difficult to tell the difference between the 5% and 0.5% chlorine solutions. These solutions may be made using the 6-ounce Calcium Hypochlorite (HTH) containers that come with the Chemical Agent Decon Set. The 0.5% solution can be made adding one 6-ounce container of calcium hypochlorite to 5 gallons of water. Adding eight 6-ounce containers of calcium hypochlorite to 5 gallons of water can make the 5% CL solution. These solutions evaporate quickly at high temperatures, so if they are made in advance, they should be stored in closed containers.

1. Decontaminate the mask and hood. Sponge down front, sides, and top of hood with 5.0% calcium hypochlorite solution, or wipe off with the M258A1 or the M291 Decon Kit.

2. Remove hood.

1. Dip scissors in 5% HTH solution.
2. Cut off hood.

1. Release or cut hood shoulder straps.
2. Cut/untie neck cord.
3. Cut/remove zipper cord.
4. Cut/remove drawstring under the voicemitter.
5. Unzip the hood zipper.
6. Cut the cord away from the mask.
7. Cut the zipper below the voicemitter.
8. Proceed cutting upward, close to the inlet valve covers and eye lens outserts.
9. Cut upward to top of eye lens outsert.
10. Cut across forehead to the outer edge of the next eye lens outsert.
11. Cut downward toward patient's shoulder staying close to the eye lens outsert inlet valve cover.
12. Cut across the lower part of the voicemitter to the zipper.
13. Dip scissors in HTH solution.
14. Cut from center of forehead over the top of the head.
15. Fold left and right sides of the hood to the side of the patient's head, laying sides on the litter.

C. The Quick Doff Hood is loosened and removed.

3. Decontaminate protective mask/face.

1. Use M258A1, M291, or 0.5% hypochlorite solution.
2. Cover both inlet valve covers with gauze or hands.
3. Wipe external parts of mask.
4. Uncover inlet valve covers.
5. Wipe exposed areas of patient's face.

1. Chin
2. Neck
3. Back of ears

4. Remove Field Medical Card (FMC).

1. Cut the FMC tie wire.
2. Allow the FMC to fall into a plastic bag.
3. Seal plastic bag and wash with 0.5% hypochlorite solution.
4. Place plastic bag under back of mask head straps.

5. Remove all gross contamination from the patient's overgarment.

1. Wipe all evident contamination spots with M258A1 Decon Kit, M291, or 5% hypochlorite solution.
2. Wipe external parts of mask with M258A1 Decon Kit or M291.
3. Use wipe 1, then wipe 2, to clean exterior of mask; use wipe 2, then wipe 1 to clean interior.

6. Cut and remove overgarment. Cut clothing around tourniquets, bandages, and splints. Two people will be cutting clothing at the same time. Dip scissors in 5% hypochlorite solution before doing each complete cut to avoid contaminating inner clothing.

1. Unzip protective overgarment.
2. Cut from wrist area of sleeves, up to armpits, and then to neck area.
3. Roll chest sections to respective sides with inner surface outward.
4. Tuck clothing between arm and chest.
5. Repeat procedure for other side of jacket.

1. Cut from cuff along inseam to waist on left leg.
2. On right overgarment leg, cut from cuff to just below zipper and then go sideways into the first cut.
3. Allow trouser halves to drop to litter with contamination away from patient.
4. Tuck trouser halves to sides of body and roll the camouflage sides under between the legs.

7. Remove outer gloves. This procedure can be done with one aidman on each side of the patient working simultaneously. Do not remove inner gloves.

1. Lift the patient's arms by grasping his gloves.
2. Fold the glove away from the patient over the sides of the litter.
3. Grasp the fingers of the glove.
4. Roll the cuff over the finger, turning the glove inside out.
5. Carefully lower the arm(s) across the chest when the glove(s) is removed. (Do not allow the arms to contact the exterior (camouflage side) of the overgarment.)
6. Dispose of contaminated gloves.

1. Place in plastic bag.
2. Deposit in contaminated dump.

8. Remove overboots.

1. Cut laces.
2. Fold lacing eyelets flat outward.
3. Hold heels with one hand.
4. Pull overboots downwards over the heels with other hand.
5. Pull towards you until removed.
6. Place overboots in contaminated disposal bag.

9. Remove personal articles from pockets.

1. Place in plastic bags.
2. Seal bags.
3. Place in contaminated holding area.

10. Remove combat boots without touching body surfaces.

1. Cut boot laces along the tongue.
2. Pull boots downward and toward you until removed.
3. Place boots in contaminated dump.

11. Remove inner clothing.

1. Unbuckle belt.
2. Cut battle dress uniform (BDU) pants following same procedures as for overgarment trousers.
3. Cut fatigue jacket following the same procedures as for overgarment jacket.

12. Remove undergarments following same procedure as for fatigues. If patient is wearing a brassiere, it is cut between cups. Both shoulder straps are cut where they attach to the cups and laid back off the shoulders.

13. Clothing removal to skin decontamination. Transfer the patient to a decontamination litter. After the patient's clothing has been cut away, he is transferred to a decontamination litter or a canvas litter with a plastic sheeting cover. Three decontamination team members decontaminate their gloves and apron with the 5% hypochlorite solution. One member places his hands under the small of the patient's legs and thigh, a second member places his arms under the patient's back and buttocks, and the third member places his arms under the patient's shoulders and supports the head and neck. They carefully lift the patient using their knees, not their backs, to minimize back strain. While the patient is elevated, another decontamination team member removes the litter from the litter stands and another member replaces it with a decontamination (clean) litter. The patient is carefully lowered onto the clean litter. Two decontamination members carry the litter to the skin decontamination station. The contaminated clothing and overgarment are placed in bags and moved to the decontaminated waste dump. The dirty litter is rinsed with the 5% decontamination solution and placed in a litter storage area. Decontaminated litters are returned by ambulance to the maneuver units.

14. Skin decontamination. The areas of potential contamination should be spot decontaminated using the M258A1 kit, the M291 kit, or 0.5% hypochlorite solution. These areas include the neck, wrists, lower face, and skin under tears or holes in the protective ensemble. After the patient is decontaminated, his dressings and tourniquet are changed. Superficial (not body cavities, eyes, or nervous tissue) wounds are flushed with the 0.5% CL solution and new dressings are applied as needed. Cover massive wounds with plastic or plastic bags. New tourniquets are placed 0.5 to 1 inch proximal to the original tourniquet, and then the old tourniquets are removed. Splints are not removed but saturated to the skin with 0.5% CL solution. If the splint cannot be saturated (air splint or canvas splint), it must be removed sufficiently so that everything below the splint can be saturated with the 0.5% CL solution. The patient, his wounds, and the decontaminable stretcher have now been completely decontaminated.

15. Final monitoring and movement to treatment area. The patient is monitored for contamination using the Chemical Agent Monitor (CAM), M8 paper, or M9 paper. The contents of the M258A1 kit (pad 1 and pad 2 when used separately or together) and hypochlorite solution on the skin do not affect the CAM. However, pad 1 of the M258A1 kit causes M8 paper to turn dark green (V agent), pad 2 causes no color change, and the pads used together cause M8 paper to turn yellow (G agent). Each pad causes the M9 paper to react (turn red). Once the casualty is confirmed clean of chemical agent, he is transferred via a shuffle pit over the hot line. The shuffle pit is composed of two parts Super Tropical Bleach (STB) and three parts earth or sand. The shuffle pit should be deep enough to cover the bottom of the protective overboots. The buddy system wash of the TAP apron and gloves in 5.0% hypochlorite solution precedes the transfer of the patient to a new, clean canvas litter if the decontaminable stretchers are in limited supply. A three-person patient lift is again used as the litter is switched. If the litter as well as the patient was checked, both patient and the same litter can be placed over the hot line.

Casualties who are decontaminated in an ambulatory area are those who (1) require treatment that can be supplied in the emergency treatment area, or (2) require resupply of their protective overgarment in the clean area before return to duty. Those who require clothing removal use the litter decontamination procedure, as removal of clothing is not done in this area.

Personnel from the decontamination station might assist the casualty, or the casualties might assist each other during this process under close supervision.

Decontamination of ambulatory patients follows the same principles as for litter patients. The major difference is the sequence of clothing removal, listed below, to lessen the chance of the patient contaminating himself and others.

The first five steps are the same as in litter patient decontamination and are not described in detail.

1. Remove load-bearing equipment.

2. Decontaminate mask and hood and remove hood.

3. Decontaminate skin around mask.

4. Remove Field Medical Card and put it into a plastic bag.

5. Remove gross contamination from the outergarment; remove and bag personal effects from overgarment.

6. Overgarment Jacket Removal

1. Clench his fist.
2. Stand with arms held straight down.
3. Extend arms backward at about a 30-degree angle.
4. Place feet shoulder width apart.

1. Untie drawstring.
2. Unsnap jacket front flap.
3. Unzip jacket front.

1. Grasp jacket collar at sides of the neck.
2. Peel jacket off shoulders at a 30-degree angle down and away from the patient.
3. Smoothly pull the inside of sleeves over the patient's wrists and hands.

7. Removal of Butyl Rubber Gloves

1. Patient's arms are still extended backward at a 30-degree angle.

1. Dip your gloved hands in 5% hypochlorite solution.
2. Use thumbs and forefingers of both hands.
3. Grasp the heel of patient's glove at top and bottom of forearm.
4. Peel gloves off with a smooth downward motion. This procedure can easily be done with one person or with one person on each side of the patient working simultaneously.
5. Place gloves in contaminated disposal bag.
6. Tell the patient to reposition his arms, but not to touch his trousers.

8. Remove patient's overboots.

1. Cut overboot laces with scissors dipped in 5% hypochlorite solution.
2. Fold lacing eyelets flat on ground.
3. Step on the toe and heel eyelet to hold eyelets on the ground.
4. Instruct patient to step out of the overboot onto clean area. If in good condition, the overboot can be decontaminated and reissued.

9. Remove overgarment trousers.

1. Unfasten or cut all ties, buttons, or zippers.
2. Grasp trousers at waist.
3. Peel trousers down over the patient's boots.
4. Cut trousers to aid removal if necessary.

1. Cut around all bandages and tourniquets.
2. Cut from inside pant leg ankle to groin.
3. Cut up both sides of the zipper to the waist.
4. Allow the narrow strip with zipper to drop between the legs.
5. Peel or allow trouser halves to drop to the ground.
6. Tell patient to step out of trouser legs one at a time.
7. Place trousers into contaminated disposal bag.

10. Remove glove inner liners. Patient should remove the liners since this will reduce the possibility of spreading contamination. Tell patient to remove white glove liners.

1. Grasp heel of glove without touching exposed skin.
2. Peel liner downward and off.
3. Drop in contaminated disposal.
4. Remove the remaining liner in the same manner.
5. Place liners in contaminated disposal bag.

11. Final monitoring and decontamination.

1. Monitor/test with M8 Detection Paper or CAM.
2. Check all areas of patient's clothing.
3. Give particular attention to:

1. Discolored areas
2. Damp spots
3. Tears in clothing
4. Neck
5. Wrist
6. Around dressings
4. Decontaminate all contamination on clothing or skin by cutting away areas of clothing or using 5% hypochlorite solution, the M291, or the M258A1 for clothing or 0.5% hypochlorite solution and the M291, or the M258A1 for skin.

12. The medical corpsman should remove bandages and tourniquets and decontaminate splints using the procedures described in the decontamination of a litter patient during overgarment removal.

13. The patient is decontaminated and ready to be moved inside the hot line. Instruct patient to shuffle his feet to dust his boots thoroughly as he walks through the shuffle pit.

14. In the clean treatment area the patient can now be retriaged, treated, evacuated, etc. In a hot climate the patient will probably be significantly dehydrated, and the rehydration process should start.

The clean area is the resupply point for the patient decontamination site. Water is needed for rehydration of persons working in the decontamination area. The resupply section should have an adequate stock of canteens with the chemical cap.

A location is needed in each decontamination area (75 meters from the working decontamination site) to allow workers, after they have decontaminated their TAP aprons, to remove their masks and rehydrate. There are generally not enough battle dress overgarments (BDOs) available to allow workers to remove them during the rest cycle and don new gear before going back to work. If these clean/shaded rest areas are not provided, the workers must remain in MOPP IV even during rest periods, and water must be drunk through the mask via the drinking port. If all water consumption is by mask, there must be a canteen refill area adjacent to the vapor/clean line in which empty canteens can be decontaminated and placed for refill and clean full canteens are present for rehydration.

(The above procedures were adapted from FM 8-10-4 and FM 8-10-7.)

The diagram (not yet available) shows a set-up for casualty reception in a contaminated environment. The chapter on casualty management describes the stations.

The actual set-up of this area may vary depending on the assets and circumstances.

The following foldout (not yet available) is a diagram of the Personnel Decontamination Station. This is a decontamination procedure for noncasualty personnel. It is not a medical specific procedure, but a procedure that all units in the military, including medical units, employ.

Using this procedure, contaminated, noncasualty personnel can move from the contaminated (dirty) area across the hot line to the non-contaminated (clean) area. In a medical unit, this procedure would be followed by those working in the dirty area (such as the triage officer, the decontamination team) moving to the clean area.

A related procedure (not shown) is the MOPP exchange station. In this station, personnel who have been wearing contaminated MOPP gear longer than the recommended time can exchange their dirty protective garments for clean garments.

(Taken from FM 3-5.)

The following tables provide estimated human toxicity data on the agents discussed in this Handbook.

PHYSICOCHEMICAL DATA

The following tables provide physicochemical data on the agents discussed in this Handbook.

MEDICAL EQUIPMENT SET

CHEMICAL AGENT PATIENT DECONTAMINATION

FOLD-OUT CHART (not yet available)

The enclosed chart is intended to serve as a reminder of the agents, their effects, first-aid measures, detection, and skin decontamination

It is in no way complete, nor is it intended to be complete. Consult the appropriate chapter for further details.

ACAA: Automatic Chemical Agent Alarm

AMEDD: Army Medical Department

BDO: Battle Dress Overgarment

BDU: Battle Dress Uniform

CAM: Chemical Agent Monitor

CANA: Convulsive Antidote, Nerve Agent

CARC: Chemical Agent Resistant Coating

C/B: Chemical/Biological

CDC: Chemical Decontamination Center

CBPS: Chemical and Biological Protective Shelter

CPS: Chemical Protective Shelter

DAAMS: Depot Area Air Monitoring System

DBDO: Desert Battle Dress Overgarment

DTD: Detailed Troop Decontamination

ECP: Entry Control Point

FMC: Field Medical Card

GREGG: Graves Registration

HTH: High Test Hypochlorite

KPH: Kilometer Per Hour

ICAD: Individual Chemical Agent Monitor

LBE: Load Bearing Equipment

LCL: Liquid Control Line

MES: Medical Equipment Set

MOPP: Mission Oriented Protective Posture

MTF: Medical Treatment Facility

MTO&E: Modified Table of Organization and Equipment

NAAK: Nerve Agent Antidote Kit

NATO: North Atlantic Treaty Organization

NBC: Nuclear/Biological/Chemical

NCO: Noncommissioned Officer

NCOIC: Noncommissioned Officer-in-Charge

OIC: Officer-in-Charge

SDK: Skin Decontamination Kit

TAP: Toxicological Agent Protective, e.g., TAP apron

TC: Training Circular

VCL: Vapor Control Line