This playbook is aimed at healthcare and public health providers and staff in the United States Central Command (USCENTCOM) Area of Responsibility (AOR). The USCENTCOM AOR is a medically austere operational environment where Role 3 (R3) is the highest level of medical capability. All planning assumptions proceed from there. This playbook is a concise source of key information, references, and materials for providers and healthcare leaders to easily review. The playbook is comprehensive but not all inclusive and does not negate the need for communication and information sharing with local, Joint Task Force (JTF), Service Component and USCENTCOM Headquarters (HQ) Command and Surgeon Cells.
Key Assumptions in an Austere Environment: Management of COVID-19 in Austere Operational Environments, Joint Trauma System (JTS) Clinical Practice Guideline (CPG), Special Edition V1.0, 14 Apr 2020, p. 3.
This document provides key information in text and graphic images for rapid review. The Table of Contents will link users to the topic they want to review, which will contain those key facts and figures and also link users to other resources that can provide greater detail. Users are encouraged to use this playbook as a tool to connect to best practice resources that will augment existing clinical and military expertise and local, JTF, Service Component, and USCENTCOM guidance.
AE - Aeromedical Evacuation
AFMES - Air Force Medical Examiner System
AOR - Area of responsibility
C2 - Command and Control
CJTF - Combined Joint Task Force
CCIR - Commander’s Critical Information Reporting
CCOP - Central Command Operating Procedures
CCSG - Command Surgeon
CONOPS - Concept of Operations
CONPLAN - Concept of Operations Pan
CSOC - Crisis Standards of Care
DHA - Defense Health Agency
EXORD - Executive Order
FFR - Filtering Facepiece Respirators
HIPAA - Health Insurance Portability and Accountability Act
HPCON - Health Protection Conditions
ICW - Intermediate Care Ward
KSA - Knowledge, Skills and Abilities
MS - Medication Safety
MSAT - Medical Situational Awareness in the Theater
MWR - Morale Welfare and Recreation
PHEO - Public Health Emergency Officer
PHEM - Public Health Emergency Management
PFA - Psychological First Aid
PMG - Patient Management Guide
PPE - Personal Protective Equipment
PS - Patient Safety
PUI - Person Under Investigation
QS - Quality and Safety
SIPRNet - Secret Internet Protocol Router Network
SME - Subject matter expert
TPMRC-E - Theater Patient Movement Requirements Center East
USCENTCOM – United States Central Command
USTRANSCOM - U.S. Transportation Command
VITAL-T - Virtual Inspection and LINKUP in Theater
VH - Virtual Health
USCENTCOM CONPLAN 1251-15, Regional Concept Plan for Preparation and Response for Pandemic Influenza and Infectious Disease (PI&ID) delineates the policies, actions, and requirements for the employment of military resources within the USCENTCOM AOR for PI&ID preparation and response. This plan is available for download on the USCENTCOM SIPRnet website. You can also reach the SIPRnet website through https://ccsg.nonrel.centcom.smil.mil/Private/SitePages/Home.aspx and click on the COVID 19 link. There will be links to EXORDS and instructions. Refer to G3 for assistance if copies of instructions are needed.
Specific Health Service Guidance is delineated in the Annex Q to the USCENTCOM EXORD Novel Coronavirus Outbreak Response Operations in the above SIPRnet website.
USCENTCOM SIPRnet website: https://ccsg.rel.centcom.smil.mil/sites/CCSG/THEATER%20MEDICAL%20POLICIES/Forms/AllItems.aspx
Coordination is essential between Command Staff, medical teams, and public health/preventive medicine assets. Given the highly complex nature of the COVID-19 disease and need for subject matter expertise (SME), Commanders are encouraged to designate a COVID-19 response and planning team consisting of medical and public health/preventive medicine SMEs along with operational planners.Task Force Med Leaders are encouraged to coordinate with respective Surgeon teams and Force Health Protection assets to translate and communicate all guidance and policy down to the most forward units with attention to operational security and patient privacy laws. In order to facilitate a coherent Joint effort, the response should follow established DoD procedures as outlined in DODI 6200.03 Public Health Emergency Management (PHEM) Within the DoD, 28 Mar 2019 and DODI 6055.17 DoD Emergency Management (EM) Program, Change 3 effective 12 Jun 2019.
All leaders should operate under a number of considerations/assumptions including (but not limited to):
Refer to Headquarters, CJTF, and Component guidance for specific information and requirements with regards to operational planning guidance.
The U.S. Department of Health and Human Services provides, Critical Care Planning-COVID-19 Quick Notes, a two-page document which describes operationalization of the concept in three major categories: space, staff, supplies, and provision of critical care.
The Planning and Preparation section of the DoD COVID-19 Practice Management Guide (PMG), 14 April 2020, Version 2.0, pp3-5 and pp47-48.
All USCENTCOM bases and facilities should establish a local and regional PACE (Primary-Alternate- Contingency-Emergency) plan for both operational and clinical communication incorporating social distancing and division of labor during the pandemic response period.
The USCENTCOM Component and CJTF teams may have prospectively published local and regional PACE plans for both operational and clinical consultation and communication. Forward-stationed medical teams/medics should identify and test these options PRIOR to needing urgent consultation.
Division of labor and social distancing could strain all routine secure and unsecure DoD communication and collaboration platforms (i.e. teleconferencing video conferencing networks, remote access email), resulting in the incorporation of non-DoD unsecure platforms (e.g., Zoom, Skype, WhatsApp). Operational security and patient privacy must be a primary consideration when selecting communication platforms, especially when using non-DoD platforms.
UPDATE 2.0: In answer to this challenge the DoD has established the Commercial Virtual Remote (CVR) environment that utilizes the approved Microsoft Teams platform to improve personnel connection and information sharing. This platform is approved for controlled unclassified information sharing and is noted HIPAA compliant. It connects with individuals? regular NIPR email accounts for ease of communications and scheduling. For more information on how to get connected visit https://www.cloud.mil/CVR/.
Refer to the Planning and Preparation section (p. 4) in the DoD COVID-19 Practice Management Guide, 14 April 2020, Version 2.0.
Documentation of patient care and movement should continue via the usual platforms (i.e. paper or electronic charts) as previously established at the local treatment facility. The appropriate ICD-10 codes, and symptoms (e.g. fever, cough and shortness of breath), should be entered as detailed as possible in order to capture these patients in Theater Medical Data Store (TMDS) and Medical Situational Awareness in the Theater (MSAT) and future databases and overall future performance improvement opportunities.
JTS has published the ICD-9 and ICD-10 Codes to accompany the new COVID-19 registry under development. The codes can be found on the JTS website. https://jts.amedd.army.mil/assets/docs/education/COVID-19_ICD-9_ICD-10_Codes.pdf
Please ensure that outpatient encounters are closed at the end of the patient encounter (i.e. when the patient departs medical facility).
All patients, staff, and support personnel with symptoms (fever, cough, shortness of breath) should be tested for COVID-19 using the available confirmatory diagnostic test.
All persons who test positive need to be moved into isolation and prepared for evacuation to OCONUS or CONUS locations as designated for the evacuation plan per that region.
Command and medical teams are responsible for establishing a plan for patient tracking and re-unification (for family notification of patient status) locally. In accordance with USCENTCOM regulations, local Commanders will including COVID-19 patient tracking as part of their Commander's Critical Information Reporting (CCIR). Patient tracking for the USCENTCOM AOR will be accomplished using MSAT.
The Joint Trauma System (JTS) is partnering with the Uniformed Services University of Health Sciences (USU) to develop a registry for COVID-19 patient data acquisition. Detailed documentation is essential to assist key term triggers for audits. If using hard copy/paper charting, all documentation should be uploaded as soon as possible.
The registry will ease tracking and monitoring the progress of this disease process, while evaluating the quality and possibility for improvement of delivery of care. In the meantime, units should designate a person responsible for tracking and monitoring the COVID-19 patient care and patient movement.
JTS and USU host biweekly e-conferences focused on COVID-19 PI. These conferences are a forum to discuss issues affecting care of these patients. For information email: DHA.JBSA.j-3.List.JTS-PIP@mail.mil (JTS PI team).
Intermediate and after action reviews for provide an important source for sharing best practices and innovative ideas to enhance performance improvement:
Transport guidance has changed frequently and is ever changing with current environment. Check with local G3 to ensure most current guidance is followed. As of the date of this publication:
The U.S. Transportation Command (USTRANSCOM) Instruction 41-02, 11 July 2019 outlines Patient Movement of Contagious and potentially exposed casualties. (Instruction 41-02 is attached.) This playbook is a summary that pertains specifically to COVID-19. Early and close coordination of these movement requests with the appropriate Theater Patient Movement Requirements Center Europe (TPMRC-E) is crucial.
To ensure correct resource allocation and transport prioritization, units should refrain from using locally-derived patient categorization. Patient classification should remain IAQ AFI 48-307, En Route Care and Aeromedical Evacuation Medical Procedures, 9 January 2017.
Movement of multiple COVID-19 patients will be performed using a DoD certified and approved contagious patient movement system.Planning considerations must take into account downtime for decontamination of aircraft following COVID-19 patient evacuation. Upon consultation and appropriate approvals, capabilities developed outside of the DoD for moving patients exposed to or infected with COVID-19 may be used for approved missions via commercial aircraft. The sending MTF must coordinate movement with TPMRC-E for both intra and inter-theater PM.
Refer to local, CJTF, Component, and USCENTCOM guidance for specific knowledge on Operational Planning assumptions, considerations and guidance located on the USCENTCOM Surgeon (CCSG) SharePoint at: https://ccsg.nonrel.centcom.smil.mil/Private/SitePages/Home.aspx
There is a need for a standardization of language for documenting and communicating patient condition. The table below presents the best recommendation for that standard language to ensure correct considerations for patient safety in movement.
Categorization Tool for Patient Assessment Documentation
COVID-19 is a respiratory virus that requires up to advanced droplet (droplet/airborne) precautions depending on the risk of activity (below). All re-use and extension of PPE MUST be done in accordance with CDC, JTS, and USCENTCOM best practices and guidance.
USCENTCOM Infection Prevention and Control Policy in a Deployed Setting (June 2019) pp. 19-23 or service component site such as: https://portal.arcent.swa.army.mil/covid19opt/SitePages/Home.aspx
USCENTCOM policies align with CDC guidance. Capabilities are limited in the AOR by the types of equipment available. Follow CDC link for updated guidance:
Employed cleaning protocols should ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, as well as all workspaces and quarters. All non-dedicated, non-disposable patient care medical equipment should be cleaned and disinfected according to manufacturer?s instructions and facility policies.
Doorway Management: Strategic opening and closing of doorways can prevent viral transmission. Opening high-flow doorways in hallways can reduce the number of high-touch surfaces in a facility, while closing the doors of individual office spaces can reduce cross-contamination of virus across office spaces. Doorway management approaches MUST consider operational security, facility security, safety, and privacy guidelines.
Isolation areas will need to be established in accordance with best practice and other applicable guidance. Because known sick and infected patients will be localized in this location, placement and establishment of these areas MUST take into consideration the following issues:
Units will investigate and proactively plan inpatient and outpatient surge capabilities within their existing resources. Special consideration should be given to preventing cross-infection of the patient population. A sample checklist to assist with surge capability planning at the role 1, 2, 3 level is at Appendix A.
CSOC are guidelines that are applied when a pervasive or catastrophic disaster makes it impossible to achieve the usual standards of care.
The National Academies Press released an article from the National Academies of Sciences, Engineering and Medicine entitled, Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic. This expert guide assists the provider in establishing a rationale for the implementation of crisis standards of care. This PDF can be located at the following link: https://www.nap.edu/catalog/25765/rapid-expert-consultation-on-crisis-standards-of-care-for-the-covid-19-pandemic-march-28-2020
Additional assistance in developing and implementing this crisis standards of care can be accessed in the milBook under: https://www.milsuite.mil/book/groups/covid-19-clinical-operations-group
There are limited resources for both the treatment and the diagnosis of COVID-19. Within the framework of responding to a global crisis, there must be evaluation and conservation of critical resources in terms of personnel, supplies and equipment. This section offers the resources for establishing a protocol for resource management with the focus on conservation. This is a broad approach and should be tailored to the resources of the facility for which the provider is managing.
The below table published by New England Journal of Medicine is a community standard consensus opinion of values.
During a local, regional, national and global crisis, many decisions may require ethical considerations. These decisions are best managed in a multidisciplinary/multi-level command structure setting employing a good, better, best approach. Additional resources are listed below.
Ethics of Clinical Research during a Pandemic, DoD COVID-19 Practice Management Guideline, 14 April 2020:
Crisis Standards of Care: A Toolkit for indicators and Triggers; Board on Health Sciences Policy; Institute of Medicine
Medical triage is a familiar concept for all military medical personnel. The primary goal of saving as many lives as possible remains the same for pandemic disease triage. However, the operational concepts shift to two main ideas:
DoD COVID-19 PMG, Clinical Management of COVID-19, 14 Apr 2020, pp. 4-5, pp. 9-10
COVID-19 Austere Practice Management Guide, 14 April 2020, pp.4-5, 23-24
The trauma and COVID-19 screening and treatment locations were separated to minimize exposure. A speaker phone was placed outside the hospital entrance for direct access to the Patient Administration Department (PAD) line. Patients answered a series of questions to dictate their course. If COVID-19 was suspected and the patient was stable, they would wait to be assessed in the COVID-19 screening trailer located 50 meters from the hospital entrance. For patients deemed unstable, the evaluation would be conducted within the COVID-19 ICU (C-ICU). Pending the results of the provider’s assessment, the patient would either go into quarantine in the respective base location or get admitted to the COVID-19 portion of the medical footprint. Those that were able to be quarantined were evaluated at various intervals and provided meals by the hospital staff until release criteria was met.
Standard hospital infection prevention and control procedures will be implemented immediately in accordance with practice guidelines and best practice principles. Isolation (aka Transmission-Based Precautions) and Quarantine protocols are ?step above? infection prevention and control measures employed in an epidemic/pandemic situation.
Quarantine and Isolation Procedures: Management of COVID-19 in Austere Operational Environments, 14 April 2020, pp. 5-10
Outside of medical setting personnel must practice basic public health and infection prevention guidelines that focus on:
Non-Medical Infection Control, USCENTCOM Infection Prevention and Control Policy, pp. 17-18. CAC required
Social Distancing is the practice of maintaining a minimum amount of separation between individuals and all other persons outside of their routine close contacts. Routine close contacts are those groups that routinely experience a close contact environment. Examples include roommates in barracks/quarters, family members in the same household, and teams that routinely experience unavoidable close contact in execution of daily duties (e.g., medical staff). For social distancing consider the following:
Shelter-in-Place Restrictions require that all personnel limit their activity to quarters and their designated duty location (ONLY during their scheduled work period). This mandates NO social gathering or non-essential activities outside of personal areas AND closure of non-essential facilities (e.g., MWR, shoppettes). Essential activities/facilities include dining facilities (See Food Safety and Food Service section for more information **INSERT LINK**),duty activities (as scheduled), medical care, and personal laundry.
Hygiene and General Protection Measures. All personnel should maintain an elevated awareness of personal hygiene and routine cleaning practices that will prevent the spread of the virus including hand hygiene, routine wear of face coverings outside of personal areas, daily personal hygiene and grooming, cleaning/disinfection of high touch surfaces and common areas.
Outbreak response requires advanced staffing approaches to ensure safety and well-being of staff and patients, while limiting the spread of infectious disease. Facility managers should identify and assign essential personnel as per operational planning. Plans should identify tiered strategy planning and minimal risk approach. The tiered staffing strategy for pandemic (below) will be applied and tailored according to local resources and manning. Exact staffing plans and staffing ratios will depend on personnel, resources, and mission requirements. Additional considerations include:
Case Example: Staffing Approach used by TF MED 14
A tiered approach assisted strategic staff management. Pandemic staffing ratios were used as a guideline, but modified based on tactical patient care/workload. Permitting unit skill sets, nursing personnel were categorized into COVID19 and Trauma teams. A minimum of two staff members were required on shift regardless of census and a critical care nurse for Rapid Response.
Staff, COVID-19 Practice Management Guidelines V2.0, 14 April 2020 pp. 5-8
TF MED 14 COVID-19 Nursing Document (LINK)
All healthcare personnel should be up-trained and practice at the top of their licensure. All healthcare personnel should familiarize or review how to conduct certain critical activities (in case of personnel shortages):
The following are recommended critical care topics for providers to review and drill improve response and success in managing COVID-19 critical patients:
Units should conduct practice drills: PPE donning/doffing, patient procedures, transfers, proning, Code Blue, etc.
Leadership should consider cross-training non-medical personnel to assist clinical staff as appropriate and allowable. Non-medical personnel must perform Just-in-Time Training: DHA US-001 HIPAA and Privacy Act Training. CAC required.
Skill Building/Training, DoD COVID-19 Practice Management Guidelines, 14 April 2020. pp. 5-8
The Elsevier, COVID-19 Health Care Hub provides clinical toolkits, podcasts, expert opinions and many other tools for providers and staff in the COVID-19 response.
Society of Critical Care Medicine provides free COVID-19 Resources for Non-ICU Clinicians. Topics include:
There are also resources for care of older adults and children. The web-based resources are free but require initial completion of a basic online form. https://www.sccm.org/COVID19
Individual risk assessment and fitness for duty should be determined with the support of serology testing results, if available and updated staff medical records.
Additional Training, Resources, and Tools are listed at Appendix B
All testing recommendations prioritize testing for persons with consistent with COVID-19. There are no DOD or CDC recommendations on screening the general population for asymptomatic infection with COVID-19. Until this becomes available, facilities should follow the guidance of USCENTCOM HQ and local Command and Surgeon teams.
At this time the focus of diagnostic testing for COVID-19 are patients who demonstrate symptoms, (fever, cough, shortness of breath) and those who are at high risk for infection or potential complications (healthcare workers, elderly, or patients with known medical comorbidities, and who are immunocompromised). Please refer to the laboratory section of this document for guidance on performing testing.
There is no cure or vaccination for COVID-19. The treatment available now remains supportive care, which includes antipyretics, supplemental oxygen, and potentially mechanical ventilation. All medications currently used in the treatment of COVID-19 are off-label or are a part of research study protocols.
COVID-19 has manifested primarily as a significant respiratory infection that can rapidly deteriorate into a severe pneumonitis, requiring supplemental oxygen and potentially mechanical ventilation. The severity seems to primarily affect the elderly population, and those with underlying medical comorbidities. However, this virus has also affected otherwise young healthy individuals. Providers must be aware and monitor all patients for potential rapid deterioration and intervene as soon as possible.
The DoD developed the DoD COVID-19 Practice Management Guidelines to assist providers throughout the DoD with comprehensive care for treatment and management of COVID-19.
With the decreased availability of staff and resources in the austere setting, a supplement to the DoD PMG for COVID-19 contains a section for considerations in the austere environment, under the same link immediately above.
Due to the global nature of this pandemic, as well as the infectivity of COVID-19, there are many special considerations when planning to evacuate patients from downrange. It is recognized that the DOD?s usual protocols and ability to evacuate patients has been severely limited. Patients may require treatment over a prolonged time (possibly several days) prior to evacuation to a higher echelon of care. It is a priority for the downrange provider to plan for longer than expected care. The DoD PMG for COVID-19 and the CPG for austere locations referenced previously, are useful tools. Additionally, the JTS prolonged field care guidelines, while not specific to COVID-19, are useful for prolonged field care and can be found here:
Discharging a patient from Transmission-Based Precautions (AKA Isolation) has been based on either testing strategies or time based. Patients can move through the various levels of care (mild outpatient self care, moderate ward level care and severe ICU level care) but must remain in isolation and follow transmission-based precautions (TBP) during this entire time. A patient can be discharged from TBP once their symptoms improve AND their fever resolves AND they have two negative PCR tests which are 24hrs apart (test based strategy). Alternatively, a time based strategy may be used which requires patients to have recovered (fever free off antipyretics AND improvement in symptoms) for 72 hours and at least 10 days have elapsed since symptoms first started. Below is a diagram of several time based scenarios.
Listed below are emergency telehealth resources which forward-stationed medical teams/medics can use for assistance or clarification on any topics or concerns:
Virtual Inspection and LINKUP in Theater (VITAL-T) provide ?real time? virtual access to Quality and Safety (QS) expertise through Virtual Health (VH) capabilities for Infection Prevention and Control (IPC), Patient Safety (PS), and Medication Safety (MS).
Submit a Vital-T Consult in 2 Easy Steps
During the COVID-19 crisis, consult services could be conducted using any of the following approved means (the optimal means for connection will be individualized):
Additionally, many Virtual Critical Care Consultation (VC3) service providers have deployed to austere settings before and can help work through the unique problems faced in austere settings
DHA Infection Prevention and Control Tiger Team
The DHA Tiger Team is an alternative source for infection prevention and control reach-back, which is overwhelmed in the current situation. The team will review received questions on a daily basis and work to develop a response within 1-2 business days. firstname.lastname@example.org
379 EMDG SGH: DSN 318-455-5042 or cell 011-974-5080-3442
379 EMDG Help Line (answered 24/7): DSN 318-455-1000
455 EMDG: DSN 318-481-4664
KAF: DSN 318-421-6339, Intensivist: CDR Carl Riddick via WhatsApp at 503-539-7167
CRNA: CDR Diane Howell via WhatsApp at 631-402-3060
Kabul: DSN 318-449-9259
BDSC: DSN 318-239-2033, Intensivist: LTC Sally Delvecchio
USCENTCOM Preventive Medicine Physicians: Col(s) Vinh Tran, DSN 312-529-0348; MAJ(P) Fred Hauser, DSN 312-529-0361
USCENTCOM Pharmacist: MAJ Franklin Small, DSN: 318-480-5094/SVOIP: 308-430-6834
PHEO: MAJ Brandon Aden, DSN is 318-480-6087; SOVIP is 308-430-8507
**Note: MEDCENS may be intensively involved in COVID-19 response locally. Personnel should exhaust all local, regional, and USCENTCOM reach back and all dedicated Telehealth resources PRIOR to calling MEDCENs.
Landstuhl Regional Medical Center, Germany. DSN: 314-590-7141 Intensive Care Unit
Walter Reed National Military Medical Center, MD. (301) 295-4611, option 4 Command Duty (301) 295-4810 Emergency Room
Madigan Army Medical Center, Fort Lewis, WA (DSN 782) (253) 968-1110 Information Desk
Brooke Army Medical Center, Fort Sam Houston, TX (DSN 429) (210) 916-0808 Emergency Room
Naval Medical Center Portsmouth, NS Norfolk, VA (DSN 377) (757) 592-5473 Critical Care (757) 953-1365 Emergency Room
Eisenhower Army Medical Center, Fort Gordon, GA (DSN 773) (706) 787-6938/6019 AOD (706) 787-6039 Emergency Room
David Grant Medical Center, Travis Air Force Base, CA (DSN 799) (707) 423-3040 ICU or (707) 423-3825 Emergency Room
Tripler Army Medical Center, HI (DSN 433) (808) 433-6661 Information Desk (808) 433-4032 ICU or (808) 433-3707 Emergency Room
William Beaumont Army Medical Center, Fort Bliss, TX (915)892-6880 House Supervisor or (915) 742-2139 ICU
Keesler Medical Center, Keesler AFB, MS (DSN 591) (228) 376-0500 Emergency Room
Leaders must consider the behavioral health and mental/physical resiliency of health providers and staff responding to an outbreak, as well as that of COVID-19 patients and the general population, who are experiencing major life-style changes and isolation. A number of tools and resources have been provided for leaders to respond to behavioral health concerns and improve resiliency. Forward stationed medics/medical teams are encouraged to reach back locally to Role 2/Role 3 facilities, where behavioral health resources may be stationed, utilize chaplain services, and telehealth resources to connect persons in need with help.
Special considerations for behavioral health during the COVID-19 pandemic include:
Mental Health and Wellness in COVID-19 Clinical Management (patients, providers) - COVID-19 Practice Management Guide 14 Apr 2020- pp. 49-50
Leadership checklist to mitigate team stress is located at Appendix C.
Leadership checklist to promote team sleep is at Appendix D.
Navy Leader?s Guide for Managing Sailors in Distress ?The purpose is to help Leaders recognize distress related behaviors, provide support to Sailors within the unit, and collaborate with Navy helping agencies to meet the needs of distressed individuals.
The DoD and VA offer the below mobile apps for mental health guidance.
Provider Resilience: Through psychoeducation and self-assessments, Provider Resilience gives frontline providers tools to keep themselves productive and emotionally healthy as they help our nation?s service members, veterans, and their families. Apple version. Android version.
Psychological First Aid (PFA): PFA Mobile was designed to assist responders who provide psychological first aid (PFA) to adults, families, and children. Apple version. Android version.
Other apps can be viewed by downloading the below brochure at https://health.mil/Reference-Center/Publications/2019/08/28/DoD-and-VA-Mobile-App-Clinicians-Guide. Brochure does not provide links to the apps.
All U.S Military Service Members and U.S. Civilian personnel who die in an Operational Environment are under the medico-legal jurisdiction of Armed Forces Medical Examiner System (AFMES) in accordance with Title 10 U.S. Code 1471. If a death occurs, immediately notify AFMES at (202) 409-6811. All medical intervention should remain in place. Contact mortuary affairs for further guidance on the handling of the decedent. Secure clothing, personal protective gear, and medical/treatment records. These should accompany the decedent to mortuary affairs.
Ancillary service personnel will practice previously described infection prevention and COVID-19 medical management control measures.
Goals are to reduce the impact of exposure risks and preserve access to medications. Pharmacists will support ongoing clinical evaluation studies and treatment protocols for emerging therapeutics.
DHA COVID-19 Response CONOPS. See CONOPS attachment.
Once providers deem a diagnostic study necessary, take measures to minimize risk of cross contamination of equipment and environment. Equipment (including wheels) and X-ray cassettes shall be wiped down prior to entering and exiting patient care areas. Use disposable X-ray cassette protective sleeves or other type of similar barrier material for portable chest X-ray capability and equipment. Portable machines should be positioned so as to prevent contact with the patient whenever possible.
Frequently Asked Questions about Biosafety and COVID-19Appropriate PPE and infection control/prevention procedures to prevent blood borne pathogen and aerosol exposure will be employed. Patient screening may include nasopharyngeal swab specimens (most common) or tracheal aspirates from intubated patients.
Testing capability may include: I-STAT ABG or VBG, Rapid Flu test, Rapid Dengue test, respiratory pathogen film array (BioFire), and COVID-19 polymerase chain reaction (PCR) test.
Management of COVID-19 in Austere Operational Environments, 14 Apr 2020, pages 6, 7
Employed cleaning protocols should ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, as well as all workspaces and quarters. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer?s instructions and facility policies.
Force Health Protection
Force Health Protection (FHP) assets ? including public health, preventive medicine, and veterinary services ? are important stakeholders and subject matter experts on issues of infectious disease control (including zoonotic disease), sanitation, food protection and safety, and water systems protection & safety. Veterinary Services (VS) are additionally important subject matter experts in animal medicine and husbandry, human-animal bond, and agricultural systems. Where available, FHP personnel should be consulted regarding these issues but there are several forums and toolkits available for FHP- and VS-related issues. This information in this section is provided to supplement (but does not supersede) the USCENTCOM/ARCENT and TRANSCOM policy and guidance. Any operational issues or challenges regarding FHP or the movement and care of authorized animals and animal-care personnel should be resolved through local, ARCENT, and USCENTCOM Command leadership.
DOD Veterinary Services COVID-19 Resource Page (https://www.milsuite.mil/book/community/spaces/armyveterinaryservices/one-health/emergent-health-events) ? Provides white papers, external links, situation reports (SITREPS) and other operational guidance related to food safety and protection, Force Health Protection (FHP), and animal medicine/animal health during the COVID-19 pandemic.
American Veterinary Medical Association (AVMA) COVID-19 webpage (https://www.avma.org/resources-tools/animal-health-and-welfare/covid-19)
Field Sanitation and Isolation. In many cases, isolation facilities will need to be rapidly established that may require alternative waste and hygiene approaches to protect the uninfected general population (e.g. alternative showering facilities, pit latrines, bed cans). FHP assets should be consulted to ensure best possible practices are being implemented and that all safety and handling precautions are implemented.
Food Safety and Food Service during the COVID-19 pandemic. There is still no evidence for concern that food and food packaging serves any role in transmission of COVID-19. Protection in dining facilities will focus on protection against direct human to human transmission and should include the following considerations.
More information can be found on the DoD Veterinary Services COVID-19 Resource Page & .
Regarding the potential of COVID-19 to transmit between animals and humans (zoonotic potential). The COVID-19 virus is known to have zoonotic origins; believed to originate at a live animal and wet market in Wuhan, China. It appears that in rare situations, persons who are ill will the COVID-19 virus can spread the virus to their animal companions. The virus has been detected in felids (wild and domestic cats), canids (domestic dogs), and mustelids (ferrets and similar). It is unlikely that this virus will cause disease in healthy domestic animals and there is NO EVIDENCE to suggest that domestic animals serve any significant role in transmission of the virus to humans. Human-human transmission remains the primary source of transmission. However, given the possibility for zoonotic transmission of the COVID-19 virus, the following recommendations should be implemented:
CDC Evaluation for SARS CoV-2 Testing in Animals https://www.cdc.gov/coronavirus/2019-ncov/php/animal-testing.html
DOD Veterinary Services COVID-19 Resource Page (https://www.milsuite.mil/book/community/spaces/armyveterinaryservices/one-health/emergent-health-events)
Continuation of Veterinary Care. GOAs and authorized POAs should continue to receive veterinary medical care IAW DoD and contract specific guidelines at local VS locations (veterinary treatment facility or similar). Any currently understood possibility of zoonotic transmission DOES NOT exceed the harm caused by not ensuring care for these animals. Elective procedures and veterinary medical care activities should be cancelled for the duration, but standards of care for public health and readiness should be maintained IAW applicable policy, health certificate, and best practice guidelines (e.g. vaccination, emergency care, etc.).
Considerations for animal care personnel. VS personnel should routinely implement and train local non-VS animal care personnel in the principles and standards of infection control outlined in the NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings and applicable infection control policy and best practices. Elective veterinary visits and procedures should be cancelled through the pandemic. Animal care personnel should remain aware of current shortages and high demand of PPE for their human medical counterparts and practice prudent PPE implementation when treating animals, conducting laboratory procedures, and routine husbandry practices during the COVID-19 pandemic. The CDC makes recommendation on their website for PPE use when caring for animals . Working dog handlers that require isolation or quarantine should NOT conduct daily care for their dog. The Kennel Master, trainer, or other handlers should provide routine care for that dog until the assigned handler can return to duty.
NASPHV Compendium of Measures to Prevent Disease Associated with Animals in Public Settings http://www.nasphv.org/Documents/AnimalContactCompendium2017.pdf
Interim Infection Prevention and Control Guidance for Veterinary Clinics Treating Companion Animals During the COVID-19 Response https://www.cdc.gov/coronavirus/2019-ncov/community/veterinarians.html
CDC Interim Guidance for Public Health Professionals Managing People With COVID-19 in Home Care and Isolation Who Have Pets or Other Animals https://www.cdc.gov/coronavirus/2019-ncov/php/interim-guidance-managing-people-in-home-care-and-isolation-who-have-pets.html
AVMA Interim recommendations for intake of companion animals from households where humans with COVID-19 are present https://www.avma.org/resources-tools/animal-health-and-welfare/covid-19/interim-recommendations-intake-companion-animals-households-humans-COVID-19-are-present
All disposable and non-durable medical supplies (including PPE) stock will be distributed and stocked IAW with pre-planning and role/location specific guidance.
Employ cleaning protocols to ensure adequate sanitization in all environments, including quarantine/isolation/patient care areas, workspaces and quarters. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to existing location and USCENTCOCM specific infection control policies, manufacturer guidelines, and best practice solutions.
The following resources are available for rapid access and review in preparing for or responding to COVID-19 patients locally: