FIRST AID. Field Manual (2002)

•

Convulsions.

•

Unconsciousness.

•

Respiratory failure.

•

Bradycardia.

7-8.

First Aid for Nerve Agent Poisoning

First aid for nerve agent poisoning consists of administering the MARK I or

ATNAA and CANA.

Injection Site. The injection site for administering the antidotes

is normally in the outer thigh muscle. The thigh injection site is the area

about a hand’s width above the knee to a hand’s width below the hip joint

(Figure 7-3). It is important that the injection be given into a large muscle

area. If the individual is thinly built, then the injections should be admin-

istered into the upper outer quarter (quadrant) of the buttock (Figure 7-4).

Injecting in the buttocks of a thinly built individual avoids injury to the

thighbone.

Self-Administer MARK I. If you experience any or all of the

nerve agent MILD symptoms (paragraph 7-7a), you must IMMEDIATELY

put on your protective mask and self-administer one MARK I (Figure 7-2A).

Follow the procedure given in Table 7-1. The MARK I is carried in your

protective mask carrier, pocket of the MOPP overgarment, or other location

as specified in your unit tactical standing operating procedure (TSOP).

(In

cold weather, the MARK I should be stored in an inside pocket of your

clothing to protect the antidote from freezing. A frozen MARK I cannot be

immediately used to provide you with antidote, when needed.

(However, the

MARK I can still be used after complete thawing.)

Table 7-1. Self Aid for Nerve Agent Poisoning

MARK I*

ATNAA*

STEP 1. OBTAIN ONE MARK I.**

STEP 1. OBTAIN ONE ATNAA.**

STEP 2. CHECK INJECTION SITE.

STEP 3. HOLD MARK I AT EYE LEVEL

STEP 3. HOLD ATNAA WITH

WITH NONDOMINANT HAND WITH THE

DOMINANT HAND (FIGURE 7-12A).

LARGE INJECTOR ON TOP (FIGURE

7-5A).

7-8

Table 7-1. Self Aid for Nerve Agent Poisoning (Continued)

MARK I*

ATNAA*

STEP 4. GRASP SMALL INJECTOR

STEP 4. GRASP SAFETY CAP WITH

(ATROPINE) (FIGURE 7-5B) AND

NONDOMINANT HAND AND REMOVE

REMOVE FROM CLIP (FIGURE 7-5C).

FROM INJECTOR (FIGURE 7-12B).

STEP 5. CLEAR HARD OBJECTS FROM

STEP 5. CLEAR HARD OBJECTS

INJECTION SITE.

FROM INJECTION SITE.

STEP 6. INJECT ATROPINE AT

STEP 6. INJECT ATNAA AT INJECTION

INJECTION SITE APPLYING EVEN

SITE APPLYING EVEN PRESSURE TO

PRESSURE TO THE INJECTOR

THE INJECTOR (FIGURE 7-14 OR 7-15).

(FIGURE 7-6 OR 7-7). HOLD IN PLACE

HOLD IN PLACE FOR 10 SECONDS.

FOR 10 SECONDS.

STEP 7. HOLD USED INJECTOR WITH

STEP 7. BEND NEEDLE OF USED

NONDOMINANT HAND.

INJECTOR BY PRESSING ON A HARD

SURFACE TO FORM A HOOK.

STEP 8. GRASP THE LARGE (2 PAM Cl)

STEP 8. ATTACH USED INJECTOR TO

INJECTOR (FIGURE 7-8B) AND PULL IT

BLOUSE POCKET FLAP OF BDO/JSLIST

FROM CLIP (FIGURE 7-8C). DROP CLIP

(FIGURE 7-16).

TO GROUND.

STEP 9. INJECT 2 PAM Cl AT

STEP 9. MASSAGE INJECTION SITE,

INJECTION SITE APPLYING EVEN

MISSION PERMITTING.

PRESSURE TO THE INJECTOR (FIGURE

7-6 OR 7-7). HOLD IN PLACE FOR 10

SECONDS.

STEP 10. BEND THE NEEDLES OF ALL

USED INJECTORS BY PRESSING ON A

HARD SURFACE TO FORM A HOOK.

STEP 11. ATTACH ALL USED

INJECTORS TO BLOUSE POCKET FLAP

OF BDO/JSLIST (FIGURE 7-9).

STEP 12. MASSAGE INJECTION SITE,

MISSION PERMITTING.

* USE STEPS LISTED FOR TYPE OF ANTIDOTE DEVICE ISSUED.

** ONLY ADMINISTER ONE MARK I OR ATNAA AS SELF-AID. DO NOT SELF-

ADMINISTER CANA.

7-9

Figure 7-5. Removing the atropine autoinjector from the MARK I clip.

CAUTION

DO NOT cover or hold the needle end with your hand,

thumb, or fingers—you might accidentally inject yourself. An

accidental injection into the hand WILL NOT deliver an

effective dose of the antidote, especially if the needle goes

through the hand.

Figure 7-6. Thigh injection site for self-aid.

NOTE

If you are thinly built, inject yourself into the upper outer

quadrant of the buttock (Figure 7-7). There is a nerve that

crosses the buttocks; hitting this nerve can cause paralysis.

Therefore, you must only inject into the upper outer quadrant

of the buttock.

7-10

Figure 7-7. Buttocks injection site for self-aid.

Figure 7-8. Removing the 2 PAM Cl autoinjector from the MARK I clip.

Figure 7-9. One set of used MARK I autoinjectors attached to pocket flap.

NOTES

1. DO NOT give yourself another set of injections. If you are

able to walk without assistance, know who you are, and where

you are, you WILL NOT need the second set of injections.

(If

not needed, giving yourself a second set of MARK I injections

or ATNAA may create a nerve agent antidote overdose, which

could cause incapacitation

[inability to perform mission or

defend yourself].)

2. If you continue to have symptoms of nerve agent poisoning,

seek someone else (a buddy) to check your symptoms and

administer the additional sets of injections, if required.

7-11

Buddy Evaluation and Buddy Aid. Service members may seek

assistance after self-aid (self-administering one MARK I or ATNAA) or may

become incapacitated after self-aid. A buddy must evaluate the individual to

determine if additional antidotes are required to counter the effects of the

nerve agent. Also, service members may experience SEVERE symptoms of

nerve agent poisoning (paragraph 7-7b); they will not be able to treat

themselves. In either case, other service members must perform buddy aid

as quickly as possible. Before initiating buddy aid, determine if one set of

MARK I autoinjectors has already been used so that no more than three sets

of the antidote are administered. Buddy aid also includes administering the

CANA with the third MARK I or ATNAA to prevent convulsions. Follow

the procedures indicated in Table 7-2.

WARNING

Squat, DO NOT kneel, when masking the casualty or

administering the nerve agent antidote to the casualty.

Kneeling may force the chemical agent into or through

your protective clothing.

CAUTION

DO NOT use your own MARK I, ATNAA, or CANA on a

casualty. If you use your own, you may not have any

antidote if needed for self-aid.

WARNING

DO NOT inject into areas close to the hip, knee, or thigh-

bone.

Table 7-2. Buddy Aid/Combat Lifesaver Aid for Nerve Agent Casualty.

MARK I*

ATNAA*

CANA**

STEP 1. MASK THE CA-

STEP 1. OBTAIN BUDDY’S

SUALTY AND POSITION

CANA.

HIM ON HIS SIDE

(SWIMMER’S POSITION).

STEP 2. POSITION YOUR- STEP 2. POSITION YOUR-

STEP 2. CHECK INJEC-

SELF NEAR THE CASU-

TION SITE.

ALTY’S THIGH.

7-12

Table 7-2. Buddy Aid/Combat Lifesaver Aid for

Nerve Agent Casualty (Continued).

MARK I*

ATNAA*

CANA**

STEP 3. OBTAIN BUDDY’S

STEP 3. HOLD CANA IN A

THREE OR REMAINING

CLOSED FIST WITH

MARK Is.

ATNAAs.

DOMINANT HAND (FIGURE

7-12A).

STEP 4. CHECK INJEC-

STEP 4. GRASP SAFETY

TION SITE.

CAP WITH NONDOMINANT

HAND AND REMOVE FROM

INJECTOR (FIGURE 7-12B).

STEP 5. HOLD MARK I

STEP 5. HOLD ATNAA IN

STEP 5. CLEAR HARD

WITH NONDOMINANT

A CLOSED FIST WITH

OBJECTS FROM

HAND (FIGURE 7-5A).

DOMINANT HAND

INJECTION SITE.

(FIGURE 7-12A).

STEP 6. GRASP SMALL

STEP 6. GRASP SAFETY

STEP 6. INJECT CANA AT

INJECTOR (ATROPINE)

CAP WITH NONDOMINANT

INJECTION SITE BY

AND REMOVE FROM CLIP

HAND AND REMOVE

APPLYING EVEN

(FIGURE 7-5B).

FROM INJECTOR

PRESSURE TO THE

(FIGURE 7-12B).

INJECTOR, NOT A

JABBING MOTION (FIGURE

7-14 OR 7-15). HOLD IN

PLACE FOR 10 SECONDS.

STEP 7. CLEAR HARD

STEP 7. BEND NEEDLE OF

OBJECTS FROM INJEC-

INJECTOR BY PRESSING

TION SITE.

ON A HARD SURFACE TO

FORM A HOOK.

STEP 8. INJECT ATRO-

STEP 8. INJECT ATNAA

STEP 8. ATTACH USED

PINE AT INJECTION SITE

AT INJECTION SITE BY

INJECTOR TO BLOUSE

BY APPLYING EVEN

APPLYING EVEN PRES-

POCKET FLAP OF BDO/

PRESSURE TO THE IN-

SURE TO THE INJECTOR,

JSLIST (FIGURE 7-16).

JECTOR, NOT A JABBING

NOT A JABBING MOTION

MOTION (FIGURE 7-10 OR

(FIGURE 7-14 OR 7-15).

7-11). HOLD IN PLACE

HOLD IN PLACE FOR 10

FOR 10 SECONDS.

SECONDS.

STEP 9. HOLD USED

STEP 9. BEND NEEDLE

STEP 9. MASSAGE

INJECTOR BETWEEN

OF INJECTOR BY

INJECTION SITE, MISSION

LITTLE FINGER AND RING

PRESSING ON A HARD

PERMITTING.

FINGER OF NONDOM-

SURFACE TO FORM A

INANT HAND (FIGURE

HOOK.

7-5A).

STEP 10. PULL LARGE

STEP 10. ATTACH ALL

INJECTOR (2 PAM Cl)

USED INJECTORS TO

FROM CLIP (FIGURE 7-5C).

BLOUSE POCKET FLAP

DROP CLIP TO GROUND.

OF BDO/JSLIST (FIGURE

7-16).

7-13

Table 7-2. Buddy Aid/Combat Lifesaver Aid for

Nerve Agent Casualty (Continued).

MARK I*

ATNAA*

CANA**

STEP 11. INJECT 2 PAM

STEP 11. MASSAGE

Cl AT INJECTION SITE

INJECTION SITE,

BY APPLYING EVEN

MISSION PERMITTING.

PRESSURE TO THE

INJECTOR, NOT A JAB-

BING MOTION (FIGURE

7-10 OR 7-11). HOLD IN

PLACE FOR 10

SECONDS.

STEP 12. REPEAT

STEPS ABOVE FOR

REMAINING MARK Is.

STEP 13. BEND THE

NEEDLES OF ALL USED

INJECTORS BY

PRESSING ON A HARD

SURFACE TO FORM A

HOOK.

STEP 14. ATTACH ALL

USED INJECTORS TO

BLOUSE POCKET FLAP

OF BDO/JSLIST (FIGURE

7-13).

STEP 15. MASSAGE

INJECTION SITE,

MISSION PERMITTING.

USE STEPS LISTED FOR TYPE OF ANTIDOTE DEVICE ISSUED.

CANA IS USED IN BUDDY AID/CLS AID ONLY. DO NOT USE IN SELF-AID.

NOTE

If the casualty is thinly built, inject the antidote into the buttock.

Only inject the antidote into the upper outer portion of the

casualty’s buttock (Figure 7-11). This avoids hitting the nerve

that crosses the buttocks (Figure 7-4). Hitting this nerve can

cause paralysis.

7-14

Figure 7-13. Three sets of used MARK I autoinjectors and one CANA

autoinjector attached to pocket flap.

Self-Administer Antidote Treatment Nerve Agent Autoinjector.

If you experience any or all of the nerve agent MILD symptoms (paragraph

7-7b), you must IMMEDIATELY self-administer one ATNAA following

the procedure given Table 7-1.

NOTE

If you are thinly-built, inject yourself into the upper outer

quarter (quadrant) of the buttock (Figure 7-15). There is a

nerve that crosses the buttocks; hitting this nerve can cause

paralysis. Therefore, you must only inject into the upper outer

quarter (quadrant) of the buttocks.

Figure 7-14. Self-administration of ATNAA (thigh).

Figure 7-15. Self-administration of ATNAA (buttock).

7-16

NOTE

If you continue to have symptoms of nerve agent poisoning,

seek someone else (a buddy) to check your symptoms and

administer your remaining sets of injections, if required.

Figure 7-16. Used ATNAA attached to clothing.

Buddy Assistance. Service members may seek assistance after

self-aid (self-administering one ATNAA) or may become incapacitated after

self-aid. A buddy must evaluate the individual to determine if additional

antidotes are required to counter the effects of the nerve agent. Also, service

members may experience SEVERE symptoms of nerve agent poisoning

(paragraph 7-7b); they will not be able to treat themselves. In either case,

other service members must perform buddy aid as quickly as possible. Before

initiating buddy aid, determine if one ATNAA has already been used so that

no more than three ATNAA are administered. Buddy aid also includes

administering the CANA with the third ATNAA to prevent convulsions.

Follow the procedures indicated in Table 7-2.

WARNING

Squat, DO NOT kneel, when masking the casualty or

administering the nerve agent antidotes to the casualty.

Kneeling may force any chemical agent on your

overgarment into or through your protective clothing.

Figure 7-17. Buddy injecting casualty’s outer thigh (ATNAA or CANA).

7-17

NOTE

If the casualty is thinly built, inject the antidote into the buttocks

(Figure 7-18). Only inject the antidote into the upper outer

portion of the casualty’s buttocks. This avoids hitting the nerve

that crosses the buttocks (Figure 7-4). Hitting this nerve can

cause paralysis.

WARNING

DO NOT inject into areas close to the hip, knee, or

thighbone.

Figure 7-18. Buddy injecting casualty’s buttocks (ATNAA or CANA).

Figure 7-19. Three used ATNAAs and one CANA autoinjector

attached to clothing.

Combat Lifesaver.

(1)

The combat lifesaver must check to verify if the

individual has received three sets of MARK I or ATNAAs. If not, the

combat lifesaver performs first aid as described for buddy aid above. If the

7-18

individual has received the initial three sets of MARK I, then the combat

lifesaver may administer additional atropine injections at approximately 15

minute intervals until atropinization is achieved (that is a heart rate above 90

beats per minute, reduced bronchial secretions, and reduced salivations).

Administer additional atropine at intervals of

30 minutes to 4 hours to

maintain atropinization or until the casualty is placed under the care of medical

personnel. Check the heart rate by lifting the casualty’s mask hood and

feeling for a pulse at the carotid artery. Request medical assistance as soon

as the tactical situation permits.

(2)

The CLS should administer additional CANA to

casualties suffering convulsions. Administer a second, and if needed, a third

CANA at 5 to 10 minute intervals for a maximum of three injections (30

milligrams diazepam). Follow the steps and procedures described in buddy

aid for administering the CANA. DO NOT give more than two additional

injections for a total of three (one self-aid plus two by the CLS).

7-9.

Blister Agents

Blister agents (vesicants) include mustard (H and HD), nitrogen mustards

(HN), lewisite (L), and other arsenicals, mixtures of mustards and arsenicals,

and phosgene oxime (CX). Blister agents may act on the eyes, mucous

membranes, lungs, and skin. They burn and blister the skin or any other

body parts they contact. Even relatively low doses may cause serious injury.

Blister agents damage the respiratory tract (nose, sinuses, and windpipe)

when inhaled and cause vomiting and diarrhea when absorbed. Lewisite and

CX cause immediate pain on contact. However, mustard agents are deceptive

as there is little or no pain at the time of exposure. Thus, in some cases,

signs of injury may not appear for several hours after exposure.

Protective Measures. Your protective mask with hood and

protective overgarment provide protection against blister agents. If it is

known or suspected that blister agents are being used, STOP BREATHING,

put on your mask and your protective overgarment.

CAUTION

Large drops of liquid vesicants on the protective over-

garment ensemble may penetrate it if allowed to stand for

an extended period. Remove large drops as soon as

possible.

7-19

Signs and Symptoms of Blister Agent Poisoning.

(1)

Immediate and intense pain upon contact with L, LH

(lewisite and mustard) mixture, and CX. No initial pain upon contact with

mustard.

(2)

Inflammation and blisters

(burns) resulting in tissue

destruction. The severity of a chemical burn is directly related to the

concentration of the agent and the duration of contact with the skin. The longer

the agent is in contact with the tissue, the more serious the injury will be.

(3)

Vomiting and diarrhea. Exposure to high concentrations

of vesicants may cause vomiting or diarrhea.

(4)

Death. The blister agent vapors absorbed during

ordinary field exposure will probably not cause enough internal body

(systemic) damage to result in death. However, death may occur from

prolonged exposure to high concentrations of vapor or from extensive liquid

contamination over wide areas of the skin, particularly when decontamination

is neglected or delayed.

First Aid Measures.

(1)

Use your M291 Skin Decontaminating Kit to

decontaminate your skin and use water to flush contaminated eyes.

Decontamination of vesicants must be done immediately (within 1 minute is

best).

(2)

If blisters form, cover them loosely with a field dressing

and secure the dressing.

CAUTION

Blisters are actually burns. DO NOT attempt to decon-

taminate the skin where blisters have formed, as the agent

has already been absorbed.

(3)

If you receive blisters over a wide area of the body, you

are considered seriously burned. Seek medical assistance immediately.

(4)

If vomiting occurs, the mask should be lifted

momentarily and drained—while the eyes are closed and the breath is held—

and replaced, cleared, and sealed.

7-20

(5)

Remember, if vomiting or diarrhea occurs after having

been exposed to blister agents, seek medical assistance immediately.

7-10. Choking Agents (Lung-Damaging Agents)

Chemical agents that attack lung tissue, primarily causing fluid buildup

(pulmonary edema), are classified as choking agents (lung-damaging agents).

This group includes phosgene (CG), diphosgene (DP), chlorine (Cl), and

chloropicrin (PS). Of these four agents, CG is the most dangerous and is

more likely to be employed by the enemy in future conflict.

Protective Measures. Your protective mask gives adequate

protection against choking agents.

Signs and Symptoms. During and immediately after exposure

to choking agents (depending on agent concentration and length of exposure),

you may experience some or all of the following signs and symptoms:

•

Tears (lacrimation).

•

Coughing.

•

Choking.

•

Tightness of chest.

•

Nausea and vomiting.

•

Headaches.

Self-Aid.

(1)

The protective mask should be put on immediately when

any of the conditions described in b above exist. Another indication of a CG

attack is an odor like newly mown hay; however, DO NOT rely upon odor

as indication of a chemical attack.

(2)

If some CG is inhaled, normal combat duties should be

continued unless there is difficulty in breathing, nausea, vomiting, or more

than the usual shortness of breath during exertion. If any of the above

symptoms occur and the mission permits, remain at quiet rest until medical

evacuation is accomplished.

Death. With ordinary field exposure to choking agents, death

will probably not occur. However, prolonged exposure to high concentrations

of the vapor and neglect or delay in masking can be fatal.

7-21

7-11. Cyanogen (Blood) Agents

Cyanogen agents interfere with proper oxygen utilization in the body.

Hydrogen cyanide (AC) and cyanogen chloride (CK) are the primary agents

in this group.

Protective Measures. Your protective mask with a fresh filter

gives adequate protection against field concentrations of cyanogen agent

vapor. The protective overgarments, as well as the mask, are needed when

exposed to liquid AC.

Signs and Symptoms. During and immediately after exposure

to cyanogen agents

(depending on agent concentration and length of

exposure), you may experience some or all of the following signs and

symptoms:

•

Tearing (lacrimation).

•

Eye, nose, and throat irritation.

•

Sudden stimulation of breathing (unable to hold breath).

•

Nausea.

•

Coughing.

•

Tightness of chest.

•

Headache.

•

Light-headedness (dizziness).

•

Unconsciousness.

First Aid.

(1)

Hydrogen cyanide. During any chemical attack, if you

get a sudden stimulation of breath or detect an odor like bitter almonds, PUT

ON YOUR MASK IMMEDIATELY. Speed is absolutely essential since

this agent acts so rapidly that within a few seconds its effects will make it

impossible for service members to put on their mask by themselves. Stop

breathing until the mask is on, if at all possible. This may be very difficult

since the agent strongly stimulates respiration.

(2)

Cyanogen chloride. Put your mask on immediately if

you experience any irritation of the eyes, nose, or throat. Service members

7-22

who are unable to mask should be masked by the nearest service member

(buddy).

Medical Assistance. If you suspect that you have been exposed

to blood agents, seek medical assistance immediately.

7-12. Incapacitating Agents

An incapacitating agent is a chemical agent which produces temporary,

disabling conditions which persist for hours to days after exposure. Unlike

riot control agents, which usually are momentary or fleeting in action,

incapacitating agents have a persistent effect. It is likely that smoke-producing

munitions or aerosols will disseminate such agents, thus making breathing

their means of entry into the body. The protective mask is, therefore,

essential.

There are no specific first aid measures to relieve the symptoms

of incapacitating agents. Supportive first aid and physical restraint may be

indicated. If the casualty is stuporous or comatose, be sure that respiration is

unobstructed; then turn him on his side in case vomiting should occur.

Complete cleansing of the skin with soap and water should be done as soon as

possible; or, the M291 Skin Decontaminating Kit can be used if washing is

impossible. Remove weapons and other potentially harmful items from

service members who are suspected of having these symptoms. Harmful

items include cigarettes, matches, medications, and small items that might be

swallowed accidentally. Delirious (confused) persons have been known to

attempt to eat items bearing only a superficial resemblance to food.

Incapacitating agents

(anticholinergic drugs BZ type) may

produce alarming dryness and coating of the lips and tongue; however, there

is usually no danger of immediate dehydration. Fluids should be given

sparingly, if at all, because of the danger of vomiting and because of the

likelihood of temporary urinary retention due to paralysis of bladder muscles.

If the body temperature is elevated and mucous membranes

are dry, immediate and vigorous cooling (as for heatstroke) is indicated.

Methods that can be used to cool the skin are spraying with cool water and air

circulation (fanning); applying alcohol soaked cloths and air circulation; and

providing maximum exposure to air in a shaded area, along with maximum

air circulation. Such cases are usually a result of anticholinergic poisoning.

Rapid evacuation should be accomplished since medical treatment with the

appropriate medication may be lifesaving.

7-23

CAUTION

DO NOT use ice for cooling the skin.

Reassurance and a firm, but friendly, attitude by individuals

providing first aid will be beneficial if the casualty appears to comprehend

what is being said. Conversation is a waste of time if the service member is

incoherent or cannot understand what is being said. In such cases, the less

said, the better it is—these casualties will benefit more from prompt and

vigorous restraint and evacuation to an MTF.

7-13. Incendiaries

Incendiaries can be grouped as WP, thickened gasoline, metal, and oil and

metal. You must learn to protect yourself against these incendiaries.

White phosphorus is used primarily as a smoke producer but

can be used for its incendiary effect to ignite field expedients and combustible

materials. The burns from WP are usually multiple, deep, and variable in

size. When particles of WP get on the skin or clothing, they continue to burn

until deprived of air. They also have a tendency to stick to a surface and

must be brushed off or picked out.

(1)

If burning particles of WP strike and stick to your

clothing, quickly take off the contaminated clothing before the WP burns

through to the skin.

(2)

If burning WP strikes your skin, smother the flame with

water, a wet cloth, or mud.

NOTE

Since WP is soluble in oil, DO NOT use grease, oily ointments,

or eye ointments to smother the flame.

(3)

Keep the WP particles covered with a wet material to

exclude air until you can remove them or have them removed from your skin.

(4)

Remove the WP particles from the skin by brushing

them with a wet cloth and by picking them out with a knife, bayonet, stick, or

other available object.

7-24

(5)

Seek medical assistance when the mission permits.

Thickened fuel mixtures (napalm) have a tendency to cling to

clothing and body surfaces, thereby producing prolonged exposure and severe

burns. The first aid for these burns is the same as for other heat burns. The

heat and irritating gases given off by these combustible mixtures may cause

lung damage, which must be treated by medical personnel.

Metal incendiaries pose special problems. Thermite particles

on the skin should be immediately cooled with water and then removed. The

first aid for these burns is the same as for other heat burns. Particles of

magnesium on the skin burn quickly and deeply. Like other metal

incendiaries, they must be removed. Ordinarily, medical personnel should

do the complete removal of these particles as soon as possible. Immediate

medical treatment is required.

Oil and metal incendiaries have much the same effect on

contact with the skin and clothing as those discussed (b and c above). First

aid measures for burns are discussed in Chapter 3.

7-14. Biological Agents and First Aid

Biological attacks can result in combat ineffectiveness by

introducing disease-causing organisms into a troop population.

Once a disease is identified, first aid or medical treatment is

initiated, depending on the seriousness of the disease. First aid measures are

concerned with observable symptoms of the disease such as diarrhea or

vomiting.

7-15. Toxins

Toxins are alleged to have been used in past conflicts. Witnesses and victims

have described the agent as toxic rain (or yellow rain) because it was reported

to have been released from aircraft as a yellow powder or liquid that covered

ground, structures, vegetation, and people.

Signs and Symptoms. The occurrence of the symptoms from

toxins may appear in a period of a few minutes to several hours depending on

the particular toxin, the service member’s susceptibility, and the amount of

toxin inhaled, ingested, or deposited on the skin. Symptoms from toxins

usually involve the central nervous system but are often preceded by less

prominent symptoms, such as nausea, vomiting, diarrhea, cramps, or stomach

7-25

irritation and burning sensation. Typical neurological symptoms often

develop rapidly in severe cases; for example, visual disturbances, inability to

swallow, speech difficulty, lack of muscle coordination, and sensory

abnormalities (numbness of mouth, throat, or extremities). Yellow rain

(mycotoxins) also may have hemorrhagic symptoms, which could include

any or all of the following:

•

Dizziness.

•

Severe itching or tingling of the skin.

•

Formation of multiple, small, hard blisters.

•

Coughing up blood.

•

Shock (which could result in death).

Self-Aid. Upon recognition of an attack employing toxins, you

must immediately take the following actions:

(1)

Stop breathing, put on your protective mask with hood,

and then resume breathing. Next, put on your protective clothing.

(2)

Should severe itching of the face become unbearable,

quickly—

•

Loosen the cap on your canteen.

•

Take and hold a deep breath and lift your mask.

•

While holding your breath, close your eyes and

flush your face with generous amounts of water.

CAUTION

DO NOT rub or scratch your eyes. Try not to let the water

run onto your clothing or protective overgarment.

•

Put your protective mask back on, seat it properly,

clear it, and check it for a seal; then resume breathing.

•

Decontaminate your skin by bathing with soap and

water as soon as the mission permits.

7-26

•

Change clothing and decontaminate your protective

mask using soap and water. Replace the filters if directed.

(3)

If vomiting occurs, the mask should be lifted

momentarily and drained—while the eyes are closed and the breath is held—

and replaced, cleared, and sealed.

Medical Assistance. If you suspect that you have been exposed

to toxins, you should seek medical assistance immediately.

7-16. Nuclear Detonation

Three types of injuries may result from a nuclear detonation.

These are thermal, blast, and radiation injuries. Many times the casualty will

have a combination of these types of injuries. First aid for thermal and blast

injuries is provided based on observable injuries, such as burns, hemorrhage,

or fractures.

The signs and symptoms of radiation illness in the initial phase

include the rapid onset of nausea, vomiting, and malaise (tiredness). The

only first aid procedure for radiological casualties is decontamination.

7-27

CHAPTER 8

FIRST AID FOR

PSYCHOLOGICAL REACTIONS

8-1.

General

Psychological first aid is as natural and reasonable as physical first aid and is

just as familiar. When you were hurt as a child, the understanding attitude of

your parents did as much as the psychological effect of a bandage. Later,

your disappointment or grief was eased by supportive words from a friend.

Certainly, taking a walk and talking things out with a friend are familiar ways

of dealing with an emotional crisis. The same natural feelings that make us

want to help a person who is injured make us want to give a helping hand to a

buddy who is upset. Psychological first aid really means nothing more

complicated than assisting people with emotional distress whether it results

from physical injury, disease, or excessive stress. Emotional distress is not

always as visible as a wound or a broken bone. However, overexcitement,

severe fear, excessive worry, deep depression, misdirected irritability, and

anger are signs that stress has reached the point of interfering with effective

coping. The more noticeable the symptoms become, the more urgent the

need for you to be of help and the more important it is for you to know how

to help.

8-2.

Importance of Psychological First Aid

You must know how to give psychological first aid to be able to help yourself,

your buddies, and your unit in order to keep performing the mission.

Psychological first aid measures are simple and easy to understand. Your

decision of what to do depends upon your ability to observe the service

member and understand his needs. Making the best use of resources requires

ingenuity on your part. A stress reaction resulting in poor judgment can

cause injury or even death to yourself or others on the battlefield. It can be

even more dangerous if other persons are affected by the judgment of an

emotionally upset service member. If it is detected early enough, the affected

service member stands a good chance of remaining in his unit as an effective

member. If it is not detected early and if the service member becomes more

emotionally upset, he may become a threat to himself and to others.

8-3.

Situations Requiring Psychological First Aid

•

Psychological first aid (buddy aid) is most needed at the first

sign that a service member cannot perform the mission because of emotional

8-1

distress. Stress is inevitable in combat, in hostage and terrorist situations,

and in civilian disasters such as floods, hurricanes, or industrial accidents.

Most emotional reactions to such situations are temporary, and the service

member can still carry on with encouragement. Painful or disruptive

symptoms may last for minutes, hours, or days. However, if the stress

symptoms are seriously disabling, they may be psychologically contagious

and endanger not only the emotionally upset service member but also the

entire unit.

•

Sometimes people continue to function well during a disastrous

event, but suffer from emotional scars which impair their job performance or

quality of life at a later time. Painful memories and dreams may recur for

months and years and still be considered a normal reaction. However, if the

memories are so painful that the person must avoid all situations which

arouse them, becomes socially withdrawn, or shows symptoms of anxiety,

depression, or substance abuse, he needs treatment. Experience with police,

firemen, emergency medical technicians, and others who deal with disasters

has proved that the routine application of psychological first aid to all the

participants, including those who have functioned well, greatly reduces the

likelihood of future serious post-traumatic stress disorders (PTSDs).

8-4.

Interrelationship of Psychological and Physical First Aid

Psychological first aid should go hand in hand with physical first aid. The

discovery of a physical injury or cause for an inability to function does not

rule out the possibility of a psychological injury (or vice versa). The person

suffering from pain, shock, fear of serious injury, or fear of death does not

respond well to joking, indifference, or fearful-tearful attention. Fear and

anxiety may take as high a toll of the service member’s strength as does the

loss of blood.

8-5.

Goals of Psychological First Aid

The goals of psychological first aid are to—

•

Be supportive; assist the service member in dealing with his

stress reaction.

•

Prevent, and if necessary control, behavior harmful to himself

and to others.

•

Return the service member to duty as soon as possible after

dealing with the stress reaction.

8-2

8-6.

Respect for Others’ Feelings

Accept the service member you are trying to help without

censorship or ridicule. Respect his right to his own feelings. Even though

your feelings, beliefs, and behavior are different, DO NOT blame or make

light of him for the way he feels or acts. Your purpose is to help him in this

tough situation, not to be his critic. A person DOES NOT WANT to be upset

and worried. When he seeks help, he needs and expects consideration of his

fears, not abrupt dismissal or ridicule.

Realize that people are the products of a wide variety of

factors. All people DO NOT react the same way to the same situations.

Each individual has complex needs and motivations, both conscious and

unconscious, that are uniquely his own. Often the one thing that finally

causes the person to become overloaded by a stressful situation is not the

stressor itself, but some other problem.

8-7.

Emotional and Physical Disability

Accept emotional disability as being just as real as physical

disability. If a service member’s ankle is seriously sprained in a fall, no one

expects him to run right away. A service member’s emotions may be

temporarily strained by the overwhelming stress of battle or other traumatic

incident. DO NOT demand that he pull himself together immediately and

carry on without a break. Some individuals can pull themselves together

immediately, but others cannot. The service member whose emotional

stability has been disrupted has a disability just as real as the service member

who has sprained his ankle. There is an unfortunate tendency in many people

to regard as real only what they can see, such as a wound or bleeding. Some

people tend to assume that damage involving a person’s mind and emotions is

just imagined, that he is not really sick or injured, and that he could overcome

his trouble by using his will power.

The terms it’s all in your head, snap out of it, and get control

of yourself are often used by people who believe they are being helpful.

Actually, these terms are expressions of hostility because they show lack of

understanding. They only emphasize weakness and inadequacy. Such terms

are of no use in psychological first aid.

Every physically injured person has some emotional reaction

to the fact that he is injured.

(1)

It is normal for an injured person to feel upset. The

more severe the injury, the more insecure and fearful he becomes, especially

8-3

if the injury is to a body part which is highly valued. For example, an injury

to the eyes or the genitals, even though relatively minor, is likely to be

extremely upsetting. An injury to some other part of the body may be

especially disturbing to an individual for his own particular reason. For

example, an injury of the hand may be a terrifying blow to a surgeon or an

injury to the eye of a pilot.

(2)

An injured service member always feels less secure,

more anxious, and more afraid not only because of what has happened to him

but because of what he imagines may happen as a result of his injury. This

fear and insecurity may cause him to be irritable, uncooperative, or

unreasonable. As you help him, always keep in mind that such behavior has

little or nothing to do with you personally. He needs your patience,

reassurance, encouragement, and support.

8-8.

Combat and Other Operational Stress Reactions

Stress reaction is a temporary emotional disorder or inability to function,

experienced by a previously normal service member as a reaction to the

overwhelming or cumulative stress of combat. Stress reaction gets better

with reassurance, rest, physical replenishment, and activities that restore

confidence. All service members are likely to feel stress reaction under

conditions of intense and/or prolonged stress. They may even become stress

reaction casualties, unable to perform their mission for hours or days. Other

combat and operational stress reactions (COSRs) may result in negative

behavior, but are not termed stress reaction, as they need more intensive

treatment. These negative COSRs may result in misconduct stress behaviors

such as drug and alcohol abuse, criminal acts, looting, desertion, and self-

inflicted wounds. These harmful COSRs can often be prevented by good

psychological first aid. Service members who commit misconduct stress

behaviors may require disciplinary action rather than medical treatment.

8-9.

Reactions to Stress

Most service members react to stressful incidents after the situation has

passed. All service members feel some fear. This fear may be greater than

they have experienced at any other time, or they may be more aware of their

fear. In such a situation, they should not be surprised if they feel shaky or

become sweaty, nauseated, or confused. These reactions are normal and are not

a cause for concern. However, some reactions, either short- or long-term,

will cause problems if left unchecked. See paragraph 8-13 for more information.

Emotional Reactions.

8-4

(1)

The most obvious combat stress reaction

(CSR) is

inefficient performance. This can be demonstrated by—

•

Slow thinking (or reaction time).

•

Difficulty recognizing priorities and seeing what

needs to be done.

•

Difficulty getting started.

•

Indecisiveness and having trouble focusing

attention.

•

Tendency to do familiar tasks and be preoccupied

with familiar details.

(This can reach the point where the person is very

passive, such as just sitting or wandering about not knowing what to do.)

(2)

A less common reaction may be uncontrolled emotional

outbursts; this can be demonstrated by crying, screaming, or laughing. Some

service members will react in the opposite way. They will be very withdrawn

and silent and try to isolate themselves from everyone. These service

members should be encouraged to remain with their assigned unit.

Uncontrolled reactions may appear by themselves or in any combination (the

person may be crying uncontrollably one minute and then laughing the next).

In this state, the person is restless and cannot keep still. He may run about,

apparently without purpose. Inside, he feels a great rage or fear and his

physical acts may show this. In his anger he may indiscriminately strike out

at others.

Loss of Adaptability.

(1)

In a desperate attempt to get away from the danger,

which has overwhelmed him, a service member may panic and become

confused. His mental ability may be so impaired he cannot think clearly or

even follow simple commands. His judgment may be faulty and he may not

be aware of his actions, such as standing up in his fighting position during an

attack.

(2)

In other cases, overwhelming stress may produce

symptoms that are often associated with head injuries. For example, the

service member may appear dazed or be found wandering around aimlessly.

He may appear confused and disoriented and may seem to have a complete or

partial loss of memory. In such cases, especially when no eyewitnesses can

provide evidence that the service member has NOT suffered a head injury, it

is necessary for him to be rapidly medically evacuated. DO NOT allow the

8-5

service member to expose himself to further personal danger until the cause

of the problem has been determined.

Sleep Disturbance and Repetition of Dreams. A person who

has been overwhelmed by stress often has difficulty sleeping. The service

member may experience nightmares related to the stressors. Remember that

nightmares, in themselves, are not considered abnormal when they occur

soon after a period of intensive stress. As time passes, the nightmares

usually become less frequent and less intense. In extreme cases, a service

member, even when awake, may think repeatedly of the incident, feel as

though it is happening again, and act out parts of his stress over and over

again. For some persons, this repetitious reexperiencing of the stressful

event may be necessary for eventual recovery; therefore, it should not be

discouraged or viewed as abnormal. For the person reexperiencing the

event, such reaction may be disruptive. The service member needs to be

encouraged to ventilate about the incident. Ventilation is a technique where

the service member is given the opportunity to talk extensively, often

repetitiously about the experience.

8-10. Severe Stress or Stress Reaction

You do not need specialized training to recognize severe stress or stress

reaction that will cause problems for the service member, the unit, or the

mission. Reactions that are less severe, however, are more difficult to

detect. To determine whether a person needs help, you must observe him

to see whether he is doing something meaningful, performing his duties,

taking care of himself, behaving in an unusual fashion, or acting out of

character.

8-11. Application of Psychological First Aid

The emotionally disturbed service member has built a barrier against fear.

He does this for his own protection, although he is probably not aware that he

is doing it. If he finds that he does not have to be afraid and that there are

normal, understandable things about him, he will feel safer in dropping this

barrier. Persistent efforts to make him realize that you want to understand

him will be reassuring, especially if you remain calm. Nothing can cause an

emotionally disturbed person to become even more fearful than feeling that

others are afraid of him. Try to remain calm. Familiar things, such as a cup

of coffee, the use of his name, attention to a minor wound, being given a

simple job to do, or the sight of familiar people and activities, will add to his

ability to overcome his fear. He may not respond well if you get excited,

angry, or abrupt.

8-6

Ventilation. After the service member becomes calmer, he is

likely to have dreams about the stressful event. He also may think about it

when he is awake or even repeat his personal reaction to the event. One

benefit of this natural pattern is that it helps him master the stress by going

over it just as one masters the initial fear of parachuting from an aircraft by

doing it over and over again. Eventually, it is difficult to remember how

frightening the event was initially. In giving first aid to the emotionally

disturbed service member, you should let him follow this natural pattern.

Encourage him to talk. Be a good listener. Let him tell, in his own words,

what actually happened. If home front problems or worries have contributed

to the stress, it will help him to talk about them. Your patient listening will

prove to him that you are interested in him, and by describing his personal

problem, he can work at mastering his fear. If he becomes overwhelmed in

the telling, suggest a cup of coffee or a break. Whatever you do, assure him

that you will listen again as soon as he is ready. Do try to help put the

service member’s perception of what happened back into realistic perspective;

but DO NOT argue about it.

Activity.

(1)

A person who is emotionally disturbed as the result of a

combat action is a casualty of anxiety and fear. He is disabled because he has

become temporarily overwhelmed by his anxiety. A good way to control

fear is through activity. Almost all service members, for example, experience

a considerable sense of anxiety and fear while they are poised, awaiting the

opening of a big offensive; but this is normally relieved, and they actually

feel better once they begin to move into action. They take pride in effective

performance and pleasure in knowing that they are good service members,

perhaps being completely unaware that overcoming their initial fear was their

first major accomplishment.

(2)

Useful activity is very beneficial to the emotionally

disturbed service member who is not physically incapacitated. After you

help a service member get over his initial fear, help him to regain some self-

confidence. Make him realize his job is continuing by finding him something

useful to do. Encourage him to be active. Get him to help load trucks, clean

up debris, or dig fighting positions. If possible, get him back to his usual

duty. Seek out his strong points and help him apply them. Avoid having him

just sit around. You may have to provide direction by telling him what to do

and where to do it. The instructions should be clear and simple and should

be repeated. A person who has panicked is likely to argue. Respect his

feelings, but point out more immediate, obtainable, and demanding needs.

Channel his excessive energy and, above all, DO NOT argue. If you cannot

get him interested in doing more profitable work, it may be necessary to

enlist aid in controlling his overactivity before it spreads to the group and

8-7

results in more panic. Prevent the spread of such infectious feelings by

restraining and segregating if necessary.

(3)

Involvement in activity helps a service member in three

ways; he—

•

Forgets himself.

•

Has an outlet for his excessive tensions.

•

Proves to himself he can do something useful.

Rest. There are times, particularly in combat, when physical

exhaustion is a principal cause for emotional reactions. A unit sleep plan

should be established and implemented. When possible, service members

should be given a safe and relatively comfortable area in which to sleep.

Examples would be an area away from heavy traffic, noise, and congestion

or a place that is clean and dry and protected from environmental conditions.

The more uninterrupted sleep a service member gets the better he will be able

to function in the tactical environment.

Hygiene. Field hygiene is an important ingredient in a service

member’s morale. A service member who is dirty and unkempt will not

function as well as a service member who has had the opportunity to bathe

and put on clean, dry clothing. During combat, unit leaders should stress the

importance of personal hygiene. Good personal hygiene not only improves

morale, it also is a preventive measure against disease and nonbattle injury

(DNBI).

Group Activity. You have probably already noticed that a

person works, faces danger, and handles serious problems better if he is a

member of a closely-knit group. Each service member in the team supports

the other team members. Esprit de corps is built because the service members

have the same interests, goals, and mission, and as a result they are more

productive; furthermore, they are less worried because everyone is involved.

It is this spirit that takes a strategic hill in battle. It is so powerful that it is

one of the most effective tools you have in your psychological first aid bag.

Getting the service member back into the team or squad activities will

reestablish his sense of belonging and security and will go far toward making

him a useful member of the unit.

8-12. Reactions and Limitations

Up to this point the discussion has been primarily about the feelings of the

emotionally distressed service member. What about your feelings toward

8-8

him? Whatever the situation, you will have emotional reactions (conscious

or unconscious) toward this service member. Your reactions can either help

or hinder your ability to help him. When you are tired or worried, you may

very easily become impatient with him if he is unusually slow or exaggerates.

You may even feel resentful toward him. At times when many physically

wounded lie about you, it will be especially natural for you to resent

disabilities that you cannot see. Physical wounds can be seen and easily

accepted. Emotional reactions are more difficult to accept as injuries. On

the other hand, will you tend to be overly sympathetic? Excessive sympathy

for an incapacitated person can be as harmful as negative feelings in your

relationship with him. He needs strong help, but not your sorrow. To

overwhelm him with pity will make him feel even more inadequate. You

must expect your buddy to recover, to be able to return to duty, and to

become a useful service member again. This expectation should be displayed

in your behavior and attitude as well as in what you say. If he can see your

calmness, confidence, and competence, he will be reassured and will feel a

sense of greater security.

8-13. Stress Reactions

See Tables 8-1, 8-2, and 8-3 for more information.

Table 8-1. Mild Stress Reaction

PHYSICAL SIGNS*

EMOTIONAL SIGNS*

TREMBLING, TEARFUL

1. ANXIETY, INDECISIVENESS

JUMPINESS, NERVOUSNESS

2. IRRITABLE, COMPLAINING

COLD SWEAT, DRY MOUTH

3. FORGETFUL, UNABLE TO

POUNDING HEART, DIZZINESS

CONCENTRATE

INSOMNIA, NIGHTMARES

4. EASILY STARTLED BY NOISE,

NAUSEA, VOMITING, DIARRHEA

MOVEMENT

FATIGUE

5. GRIEF, TEARFUL

THOUSAND-YARD STARE

6. ANGER, BEGINNING TO LOSE

DIFFICULTY THINKING, SPEAKING,

CONFIDENCE IN SELF AND UNIT

AND COMMUNICATING

SELF- AND BUDDY AID

CONTINUE MISSION PERFORMANCE, FOCUS ON IMMEDIATE MISSION.

EXPECT SERVICE MEMBER TO PERFORM ASSIGNED DUTIES.

REMAIN CALM AT ALL TIMES; BE DIRECTIVE AND IN CONTROL.

LET SERVICE MEMBER KNOW HIS REACTION IS NORMAL, AND THAT

THERE IS NOTHING SERIOUSLY WRONG WITH HIM.

KEEP SERVICE MEMBER INFORMED OF THE SITUATION, OBJECTIVES,

EXPECTATIONS, AND SUPPORT. CONTROL RUMORS.

BUILD SERVICE MEMBER’S CONFIDENCE, TALK ABOUT SUCCEEDING.

KEEP SERVICE MEMBER PRODUCTIVE (WHEN NOT RESTING) THROUGH

RECREATIONAL ACTIVITIES, EQUIPMENT MAINTENANCE.

8-9

8. ENSURE SERVICE MEMBER MAINTAINS GOOD PERSONAL HYGIENE.

9. ENSURE SERVICE MEMBER EATS, DRINKS, AND SLEEPS AS SOON AS

POSSIBLE.

10. LET SERVICE MEMBER TALK ABOUT HIS FEELINGS. DO NOT “PUT DOWN”

HIS FEELINGS OF GRIEF OR WORRY. GIVE PRACTICAL ADVICE AND PUT

EMOTIONS INTO PERSPECTIVE.

* MOST OR ALL OF THESE SIGNS ARE PRESENT IN MILD STRESS

REACTION. THEY CAN BE PRESENT IN ANY NORMAL SERVICE MEMBER IN

COMBAT YET HE CAN STILL DO HIS JOB.

Table 8-2. More Serious Stress Reaction

PHYSICAL SIGNS*

EMOTIONAL SIGNS*

CONSTANTLY MOVES AROUND

1. RAPID AND/OR INAPPROPRIATE

FLINCHING OR DUCKING AT

TALKING

SUDDEN SOUNDS

2. ARGUMENTATIVE, RECKLESS

SHAKING, TREMBLING (WHOLE

MOVEMENTS/ACTIONS

BODY OR ARMS)

3. INATTENTIVE TO PERSONAL

CANNOT USE PART OF BODY,

HYGIENE

NO PHYSICAL REASON (HAND,

4. INDIFFERENT TO DANGER

ARM, LEGS)

5. MEMORY LOSS

CANNOT SEE, HEAR, OR

6. SEVERE STUTTERING, MUMBLING,

FEEL (PARTIAL OR

OR CANNOT SPEAK AT ALL

COMPLETE LOSS)

7. INSOMNIA, NIGHTMARES

PHYSICAL EXHAUSTION,

8. SEEING OR HEARING

CRYING

THINGS THAT DO NOT EXIST

FREEZING UNDER FIRE, OR

9. RAPID EMOTIONAL SHIFTS

TOTAL IMMOBILITY

10. SOCIAL WITHDRAWAL

VACANT STARES, STAGGERS,

11. APATHETIC

SWAYS WHEN STANDS

12. HYSTERICAL OUTBURSTS

PANIC RUNNING UNDER FIRE

13. FRANTIC OR STRANGE BEHAVIOR

TREATMENT PROCEDURES**

IF A SERVICE MEMBER’S BEHAVIOR ENDANGERS THE MISSION, SELF, OR

OTHERS, DO WHATEVER IS NECESSARY TO CONTROL HIM.

IF THE SERVICE MEMBER IS UPSET, CALMLY TALK HIM INTO

COOPERATING.

IF CONCERNED ABOUT THE SERVICE MEMBER’S RELIABILITY:

• UNLOAD HIS WEAPON.

• TAKE WEAPON IF SERIOUSLY CONCERNED.

• PHYSICALLY RESTRAIN HIM ONLY WHEN NECESSARY FOR SAFETY OR

TRANSPORTATION.

REASSURE EVERYONE THAT THE SIGNS ARE PROBABLY JUST STRESS

REACTION AND WILL QUICKLY IMPROVE.

IF STRESS REACTION SIGNS CONTINUE:

• GET THE SERVICE MEMBER TO A SAFER PLACE.

• DO NOT LEAVE THE SERVICE MEMBER ALONE, KEEP SOMEONE HE

KNOWS WITH HIM.

• NOTIFY SENIOR NONCOMMISSIONED OFFICER (NCO) OR OFFICER.

• HAVE THE SERVICE MEMBER EXAMINED BY MEDICAL PERSONNEL.

8-10

FIRST AID. Field Manual (2002) - page 6