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Real time military exercise prepares military nurses for deployment around the world. (Military Nursing).

Each year, military medical units throughout the United States are selected to participate in simulated war exercises at the Joint Readiness Training Center (JRTC), Fort Polk, Louisiana. The purpose of the JRTC is to provide a simulated environment in which units assess their ability to deploy and conduct military operations. Military operations include peace-keeping and humanitarian missions as well as preparation for war. Military medical units deploy to evaluate their ability to conduct medical, nursing, dental, veterinary, preventive medicine, and combat stress care in an austere environment under stressful conditions (see Figures 1 & 2). Versatility, adaptability, and teamwork are critical to mission success.


Military medical-surgical nurses are integral members of the health care team who must possess a keen understanding of the military and medical mission. The JRTC environment places medical-surgical nurses under the duress of military threats to ascertain their ability to adapt and overcome barriers to patient care, and complete the medical mission. Chemical/biological, air, and ground attacks on the hospital are examples of reality-based scenarios to which nurses must react using their knowledge of triage and the medical rules of engagement (MROE), while simultaneously responding to patient care needs.

Putting Training into Practice

During a chemical/biological attack, the medical-surgical nurse must put training into practice by assuming a level of Mission Oriented Protective Posture (MOPP). The MOPP level is determined by the degree of exposure to chemical and biological hazards, and dictates the wear of the Chemical Protective Over-Garment (CPOG) and protective mask/gas mask. The components of the CPOG include vinyl boots, gloves (with inserts), and a carbon-lined camouflaged jacket and trousers. Table 1 illustrates the levels of MOPP medical-surgical nurses must intrinsically know to avoid becoming chemical/biological casualties and continue patient care.

Providing care during a chemical/biological attack or exposure extends beyond the bedside. Military medical-surgical nurses often are members of chemical/biological decontamination teams. Decontamination teams are tasked to travel to the site of a chemical/biological attack and set up a decontamination station. Contaminated patients are brought to the station, cleaned, stabilized, triaged, and then evacuated. Team members wear full protective equipment throughout the decontamination process (MOPP 4). Military medical-surgical nurses are prepared for their role on the decontamination team by attending The Field Medical Chemical and Biological Course (FMCBC). The FMCBC teaches decontamination procedures and provides information on chemical and biological agents, methods of delivery, and treatment regimens. In addition to the FMCBC, medical-surgical nurses are required to attend mandatory refresher courses on interaction with the media, MROE, and triage.

Knowledge of the triage process is critical to correctly prioritizing the sick and wounded, and may be the deciding factor between life and death. Triage is the process of sorting casualties based on their individual needs and the availability of time, personnel, and supplies, and founded on the principal, "The greatest good for the greatest number." A physician is usually responsible for triage; however, experienced medical-surgical nurses may be assigned to triage when a physician is unavailable. Advanced cardiac and trauma life-support courses and familiarization with the MROE are invaluable in the triage decision-making process. Table 2 lists triage categories and the criteria used to sort casualties.

Overcoming Barriers

The MROE are applied during triage and also guide the level of treatment provided to the sick and wounded of other countries. Enemy prisoners of war (EPW), local national citizens, and NATO soldiers are examples of patient categories that fall under the MROE. The MROE direct that EPW are triaged and receive medical and nursing care equivalent to that provided to an American soldier. The Geneva Convention specifies the human rights of EPW, and the United States is held to these provisions as a member of the world community. Medical-surgical nursing care of an EPW varies only slightly from the norm. The EPW is kept under armed guard at all times until stabilized and transported to a holding facility. Awareness of the EPW's exposure to diseases such as tuberculosis is important in minimizing the spread of pathogens to other patients on the medical-surgical unit. Medical-surgical nurses who care for EPW must remain objective and professional in their interactions despite potential subjective feelings of animosity that may prevail during war.

Care of the chemical/biological casualty, triage, and knowledge of the MROE are a portion of the requirements that military medical-surgical nurses must know to safely and effectively provide nursing care. The real-time training environment provides an opportunity for nurses and other health care professionals to identify strengths and overcome barriers to patient care prior to worldwide deployment.
Table 1.
MOPP Levels and the CPOG Worn

Equipment        MOPP 0      MOPP 1      MOPP 2    MOPP 3    MOPP 4

Overgarment      Available   Worn        Worn      Worn      Worn
Vinyl overboot   Available   Available   Worn      Worn      Worn
Mask and hood    Carried     Carried     Carried   Worn      Worn
Gloves           Available   Carried     Carried   Carried   Worn

More information on chemical/biological agents, MOPP, and CPOG is
available at

Table 2.
Triage Categories


I--Immediate   All patients who have a correctable compromise in
               airway, breathing, and circulation (ABCs) fall into
               this category. Treatment must begin at once.

D--Delayed     Most patients will fall into this category. ABCs are
               maintained; however, there is usually a significant
               mechanism of injury. Treatment must be started within
               4 hours.

M--Minimal     These patients are termed "walking wounded" and have
               no compromise in ABCs. Treatment should be started
               within 6 to 12 hours.

E--Expectant   Mortally wounded patients. Expectant patients are
               frequently retriaged and may be moved to a higher
               triage category.

More information on triage is available at

Note: The views and opinions expressed in this article are solely those of the author and do not necessarily reflect those of the U.S. Army, Department of Defense, or the U.S. Goverment.

Edward E. Yackel, MSN, RN, CNP, is a Major, United States Army, currently serving with the 28th Combat Support Hospital, Fort Bragg, NC.
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Author:Yackel, Edward E.
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Aug 1, 2003
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