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Bridging the chemical and medical gaps for mass casualty decontamination.

The threat of chemical, biological, radiological, nuclear, and explosives (CBRNE) incidents perpetrated by rogue states or terrorist organizations presents a clear and present danger to the security of the United States and allied nations around the world. CBRNE materials are inherently hazardous, and they have the potential to produce significant injuries and a large number of casualties in a short timeframe. This operational environment can stretch standard rescue and health care providers beyond their capacity to provide effective care and treatment. A mass casualty scenario often requires the assistance of Army consequence mitigation response units to surge military personnel and supplies to the incident area. However, due to the inherent nature and complexity of these scenarios, friction points may develop. This can slow down the response, generate confusion among response assets, and reduce the overall effect of the response strategy.

To ensure the effectiveness and efficiency of CBRNE consequence management response strategies, innovative Army leaders design realistic and challenging training plans that ensure unit proficiency in CBRNE consequence management techniques and procedures. One unit engaged in such efforts is the 71st Chemical Company, 8th Military Police Brigade, 8th Theater Sustainment Command, Schofield Barracks, Hawaii. The 71st Chemical Company forward-deployed to Camp Arifjan, Kuwait, and conducted a joint mass casualty decontamination (MCD) exercise with the 581st Area Support Medical Company, 61st Multifunctional Medical Battalion, 1st Medical Brigade, 13th Sustainment Command, Fort Hood, Texas. Chemical units often cross-train with military police and explosive ordnance disposal units to execute an all-hazards approach to consequence management operations. However, medical units are not normally included in training partnerships beyond basic medical support.

Both companies dedicated a week to exchanging information and conducting demonstrations of tactics, techniques, and procedures for responding to an MCD event. During the first 3 days of execution, the companies conducted chemical- and medical-specific training, the 71st Chemical Company demonstrated CBRNE decontamination procedures, and the 581st Medical Company demonstrated medical triage and evaluation procedures. Teams from both companies executed tasks at their respective stations to further improve their training methods. The week-long event culminated in a situational training scenario derived from recent reports of chemical agents employed in the Middle East. The units were challenged with 75 simulated ambulatory and nonambulatory casualties who presented with a variety of medical issues and symptoms induced by exposure to a simulated, unknown, persistent, CBRNE agent during a 3-hour timeframe. The MCD exercise was executed with 145 Soldiers contributing to mission accomplishment from the joint company effort. The 71st Chemical Company leadership briefed Area Support Group-Kuwait and U.S. Army Central Command senior leaders, including Brigadier General Timothy M. McKeithen, to provide a comprehensive overview of U.S. Army Central Command MCD capabilities. The exercise was fast-paced and specifically designed to challenge the units to determine the limits of their respective and synergistic capabilities. The commander's intent for the training exercise was met, and the units incorporated lessons learned into a comprehensive standard operating procedure to enhance the U.S. Army Central Command theater all-hazards consequence response plan.

A mass casualty incident is defined as any incident that exceeds the emergency disaster response capabilities of an area. Due to the abrupt, immediate nature of a CBRNE incident, initial responders are commonly composed of local emergency responders (police, fire department officials). Effective mass casualty response is founded on the principle of triage--the system of sorting and prioritizing casualties based on the tactical situation, mission, and available resources. The goal is to provide the highest level of assistance to the greatest number of casualties within the limitations of time, distance, and capability. Contaminated casualty management is complicated; casualties must be evaluated and possibly treated and evacuated while contaminated with a deadly CBRNE agent. Decontamination must be conducted quickly to save lives. Chemical, biological, radiological, and nuclear (CBRN) units should use resources that are immediately available to facilitate a rapid response.

Following triage operations, the rapid physical removal of the CBRNE agent from the victim is the most important action associated with effective decontamination. Physical removal includes wiping or blotting visible agents from the victim's skin, disrobing the victim, using adsorbents to soak up the agent, and showering or flushing with large quantities of water. After a CBRNE agent attack, vapor or aerosol hazards may still be present--especially if the agent was disseminated within an enclosed structure. After casualties are moved through the wash and rinse stations of the decontamination line, they are monitored with detection equipment, which varies based on the type of CBRNE agent present. This ensures thorough decontamination by reducing contamination to levels as low as reasonably achievable. The casualties then proceed to medical personnel for thorough diagnosis and treatment of medical issues and injuries.

A successful mass casualty response heavily depends on many factors, including--

* The size of the incident in terms of the physical area and the number of casualties.

* The level of care provided by the first responders.

* The type of CBRNE agent employed.

* The proximity of the response assets to the incident area.

* The number of personnel available for the response.

Unit leaders specifically designed the training event to determine which of these operational factors were integral to the successful execution of a consequence management response strategy. In addition, they investigated whether the time required to move a response unit into position, set up, and become fully capable of executing a specific mission would allow achievement of the overall desired response.

Several important discoveries were made through this joint training exercise. It was determined that the time needed to execute a CBRNE mass casualty response may be too great to be effective against most CBRNE agents. When the lethality rate of certain chemical warfare agents (G and V series nerve agents, chlorine gas) is taken into account, the life-saving benefit from an MCD response may be extremely low. Due to significant time and logistics requirements for moving response assets into position, setting up decontamination and medical stations, and achieving a ready status to begin treating casualties, many of the casualties requiring decontamination may be deceased. The MCD capability may be more useful when agents with a slower mechanism of action (persistent blister agents) are employed. To achieve the desired level of theater response capability, senior leaders must assess the likelihood of a particular event and position CBRNE assets accordingly.

The results of this exercise called the effects of the CBRNE MCD response into question in terms of execution time. The perception of, and expectation for, an MCD operation involves a large number of ambulatory casualties with low to moderate degrees of injury, and many MCD training exercises are developed for this scenario. For nonambulatory casualties, a litter must be processed through the decontamination line. This requires more time, personnel, and space. The decontamination of nonambulatory casualties is labor-intensive, and it requires significant numbers of augmentation personnel and additional equipment. Nonambulatory casualty decontamination slows the process of casualty evaluation and treatment, and it is physically demanding for response personnel. These factors must be taken into account when determining the number of Soldiers assigned to support an MCD operation.

Asymmetric warfare may further complicate the mass casualty event if combatant, noncombatant, or third-world country nationals are included among the injured. A CBRNE incident demands a rapid transition from routine to contingency operations, triggered by the earliest recognition of this threat within a unit area of responsibility. This transition can be made more efficiently and effectively by a thoroughly developed MCD response plan that is routinely rehearsed, assessed, and validated.

Decontamination by removing clothing and/or showering or flushing with water is the most expedient and practical method for MCD. Showering is recommended when liquid transfer from clothing to skin is suspected. Disrobing should occur before showering for CBRNE agents; however, the decision to disrobe should be made by the incident commander based on the situation. When large numbers of potential casualties are involved and queued for decontamination or when a limited volume of water is available, it may be necessary to significantly reduce shower times. Water alone is an excellent means of decontamination; showering or flushing with water physically removes the CBRNE agent from skin by dilution. By adding soap, a marginal improvement can be achieved by ionic degradation of the chemical agent. Soap aids in dissolving oily substances such as mustard or other blister agents. The most important reason for decontaminating exposed victims is to remove the agent from the victim's skin and clothing, reducing further possible agent exposure and further effects among victims. Protecting emergency responders and medical personnel from secondary transfer exposures is also a concern.

Several opportunities currently exist for CBRN leaders to improve their unit level of readiness for performing a successful MCD operation. The U.S. Army Chemical, Biological, Radiological, and Nuclear School, Fort Leonard Wood, Missouri, offers the CBRN Mass Casualty Decontamination Course. The course focuses on providing the skills and knowledge required to prepare for, and respond to, a CBRNE incident as part of the state and federal emergency management response system. The course is specifically designed to provide CBRN Soldiers with comprehensive training in CBRNE decontamination operations techniques and procedures through a combination of academic curricula and hands-on practical exercises.

Commanders at all levels should consider the lessons learned from joint training exercises when determining which CBRNE incidents would benefit from an MCD response. It is critical for leaders to understand the limits of the MCD capability so that CBRN units can be used most effectively. The partnership between medical and CBRN assets is critical for effectively and efficiently treating large numbers of CBRNE incident casualties. Opportunities that exercise interoperability between these skill sets serve not only to greatly enhance the Chemical and Medical Corps, but also the Army's posture to successfully engage in an all-hazards consequence management operational environment.


Steven A. Bland, "Chemical, Biological, Radiological and Nuclear (CBRN) Casualty Management Principles", Conflict and Catastrophe Medicine, 2014, pp. 747-770.

Field Manual 8-55, Planning for Health Services Support, 9 September 1994.

William Lake et al., Guidelines for Mass Casualty Decontamination During a HAZMAT/Weapon of Mass Destruction Incident: Volumes 1 and 2, Edgewood Chemical Biological Center, August 2013, < /for-the-fire-service/mass-casualty-decontamination>, accessed on 19 August 2015.

First Lieutenant Piasecki is the platoon leader for a dismounted reconnaissance platoon with the 71st Chemical Company. He holds bachelor's degrees in physiology and psychology from Michigan State University, East Lansing, Michigan. He is currently pursuing a master's degree in emergency disaster management from the American Military University.
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Author:Piasecki, Christopher C.
Publication:CML Army Chemical Review
Date:Dec 22, 2015
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