Chapter XXI: 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).