The en-route care approach to the combined CBRN/trauma casualty should not differ from POI through MEDEVAC. The (MARCHE)2 mnemonic provides a helpful methodology for assessing and applying critical interventions during transport. The medical provider should perform regular reassessments, recheck all (MARCHE)2 interventions, and intercede where necessary. Challenges of the physical exam during transport are amplified in the CBRN environment when the medical provider and crew are wearing PPE. Training while in Mission Oriented Protective Posture (MOPP) IV and practicing patient care maneuvers that may be hindered by this protective posture is paramount to successful care of the CBRN casualty. Incorporating evacuation planning considerations into training exercises will allow optimal casualty management and provider safety.

MEDICAL REGULATING

Military Treatment Facility (MTF)

- Decontamination (DECON)/Treatment Coordination: Ensure MTF is prepared to receive exposed casualties.
- Ensure MTF is prepared to conduct decontamination of exposed casualties as needed.
- Treatment Capabilities (Toxicology, Critical Care, Trauma Surgery): Determine whether the MTF has capability to care for and sustain the CBRN casualty on site and/or establish telemedicine support.
- Capacity: The CBRN casualty is far more resource intensive than a typical trauma or critically ill casualty. Assess the MTF’s capacity to treat CBRN casualties and identify potential alternate locations.

LANDING ZONE/CASUALTY EXCHANGE POINTS

Each scenario will be unique based on the mission, location, available assets, etc. General considerations include:

1. Route coordination: consider alternate routes, primary routes may be jammed or unavailable.
2. Environmental Considerations
   - Wind
   - Terrain/Slope
   - Drainage
   - Water sources

EVACUATION PLATFORMS

Clean and Dirty: It is necessary to plan for both clean and dirty platforms for evacuation.

1. Refuel: When planning evacuations, consider the time it takes for refueling in a MASCAL situation, the distance from the objective to the DECON site and MTF, and any platform decontamination necessary before arrival at the refueling site.
2. Aircraft/Vehicle DECON (Focused, Wash Down, Detailed): Based on the available assets, determine the time it will take to conduct each type of decontamination. Note that vehicle decontamination may not be viable in the field setting and some vehicles may need to be designated “dirty transport.”
3. Preparation time: Factor the time it takes to prepare the platform for a hasty or deliberate CBRN mission.
4. Protective Measures

- Barrier (disposable; plan for additional on-hand quantities)
  - Preventive maintenance checks need to occur on a regular basis
  - Consider time required for deliberate vs. hasty set-up
  - 6mm tarp and chemical/100-mph tape for improvised barrier
- PPE (Pilots/Drivers/Crew)

CASUALTY CARE

Class VIII (medical supplies) and critical care support equipment:

1. Antidote and countermeasure resupply and additional stock (Service/CCMD specific stocks and Joint Deployment Formulary)
2. Airway support/ventilation: Anticipate need for advanced airway management and ventilators
3. Casualty Monitoring

- Close clinical monitoring to include vital signs and ETCO2 monitoring
- Hypothermia: Special emphasis must be placed on maintaining body temperature, as casualty decontamination procedures will create greater exposure to environmental factors. Additionally, chemical agent exposure by itself (especially nerve agent) is likely to create or exacerbate hypothermia.