A hospital ethics committee at war: the hospital ship Mercy experience during Operation Desert Shield and Operation Desert Storm.
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Bioethical Issues↗
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Health service support in Operations Desert Shield and Desert Storm.
Operations Desert Shield and Desert Storm have brought into focus a number of difficulties with the medical support of U.S. Army tactical forces. These difficulties include inadequate preparation of Medical Corps officers for command, inadequate medical training of field medical unit personnel, and problems utilizing available equipment to support Operation Desert Storm tactical operations. This paper will discuss these difficulties, potential solutions for these difficulties, and some unresolved issues created by or despite these potential solutions.
Leadership↗
Serum antibody to lipopolysaccharide antigens of Shigella species among U.S. military personnel deployed to Saudi Arabia and Kuwait during Operations Desert Shield and Desert Storm.
During Operations Desert Shield and Desert Storm, U.S. troops were at high risk of diarrheal disease due to Shigella spp., particularly Shigella sonnei. In order to better understand the serologic response to Shigella infection, 830 male U.S. combat troops were evaluated before and after the deployment to Saudi Arabia and Kuwait for immunoglobulin A (IgA) and IgG anti-Shigella lipopolysaccharide (LPS) (antibody to S. sonnei form I and Shigella flexneri serotypes 1a, 2a, and 3a) in serum. Just before deployment, 10.3% of the subjects were seropositive for IgA and 18.3% were positive for IgG anti-Shigella LPS. IgA and IgG anti-LPS antibody levels in serum prior to deployment were significantly associated with nonwhite race and ethnicity, birth outside the United States, and antibody to hepatitis A virus and Helicobacter pylori. During the deployment, which lasted for a mean of 131 days, 60% of the subjects reported at least one episode of diarrhea and 15% reported an episode of diarrhea with feverishness; also, 5.5% of the subjects exhibited IgA seroconversion to Shigella LPS and 14.0% exhibited IgG seroconversion. A significant association between the development of diarrheal symptoms and either positive predeployment anti-LPS antibody or seroconversion was not found. These data indicate that in this population of U.S. Desert Storm troops who were at high risk of Shigella infection, there was no apparent relation between IgA or IgG anti-Shigella LPS in serum and diarrheal disease.
Adolescent↗
A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield.
Reports suggest that deployed soldiers during Operations Desert Shield and Desert Storm remained healthy, but primary care data are limited. We reviewed the outpatient visit surveillance data from the 3d Armored Cavalry Regiment to obtain information regarding soldiers' health in the field. Nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits, followed by unintended injuries, gastrointestinal, respiratory, and dermatologic conditions. Visits for heat injuries, sexually transmitted diseases, unexplained fever, and psychiatric problems were low, probably due to preventive measures. These results suggest that increased prevention to decrease orthopedic problems and unintended injuries may substantially reduce outpatient visits during future deployments. Medical surveillance during future deployments can be improved by taking advantage of current advances in technology to facilitate patient data retrieval and provide timely information to first- and second-echelon medical personnel.
Ambulatory Care↗
Diarrheal disease during Operation Desert Shield.
BACKGROUND: Under combat conditions infectious disease can become a major threat to military forces. During Operation Desert Shield, there were numerous outbreaks of diarrhea among the U.S. forces. To evaluate the causes of and risk factors for diarrheal disease, we collected clinical and epidemiologic data from U.S. troops stationed in northeastern Saudi Arabia. METHODS: Between September and December 1990, stool cultures for enteric pathogens were obtained from 432 military personnel who presented with diarrhea, cramps, vomiting, or hematochezia. In addition, a questionnaire was administered to 2022 soldiers in U.S. military units located in various regions of Saudi Arabia. RESULTS: A bacterial enteric pathogen was identified in 49.5 percent of the troops with gastroenteritis. Enterotoxigenic Escherichia coli and Shigella sonnei were the most common bacterial pathogens. Of 125 E. coli infections, 39 percent were resistant to trimethoprim-sulfamethoxazole, 63 percent to tetracycline, and 48 percent to ampicillin. Of 113 shigella infections, 85 percent were resistant to trimethoprim-sulfamethoxazole, 68 percent to tetracycline, and 21 percent to ampicillin. All bacterial isolates were sensitive to norfloxacin and ciprofloxacin. After an average of two months in Saudi Arabia, 57 percent of the surveyed troops had at least one episode of diarrhea, and 20 percent reported that they were temporarily unable to carry out their duties because of diarrheal symptoms. Vomiting was infrequently reported as a primary symptom, but of 11 military personnel in whom vomiting was a major symptom, 9 (82 percent) had serologic evidence of infection with the Norwalk virus. CONCLUSIONS: Gastroenteritis caused by enterotoxigenic E. coli and shigella resistant to a number of drugs was a major problem that frequently interfered with the duties of U.S. troops during Operation Desert Shield.
Adolescent↗
Use of inpatient psychiatric services on a U.S. Army combat support post during Operations Desert Shield and Desert Storm: the stress of non-deployment.
We studied the utilization of inpatient psychiatric services during Operations Desert Shield and Desert Storm (the Persian Gulf War of 1990-1991) on a U.S. Army combat support post. Inpatient psychiatric admissions and dispositions for the post's catchment area were tallied before, during, and after Operations Desert Shield and Desert Storm. Subjects included active duty soldiers (deployed soldiers were not studied while they were away from the post), their families, and retirees. Overall, there was no increase in psychiatric hospitalizations for active duty soldiers, their family members, or retirees. However, coincident with the return of soldiers from Operations Desert Shield and Desert Storm, the psychiatric proportion of all hospitalizations increased in the subpopulation of soldiers not deployed who had served less than 1 year. These soldiers in training may be more susceptible to increased stress levels associated with the return of soldiers from war because of their inadequate group bonding.
Combat Disorders↗
Arthroscopic surgery of the knee on the U.S. Naval Hospital Ships during Operation Desert Shield.
Between September 1990 and January 1991, while deployed to the Persian Gulf for Operation Desert Shield, 118 patients underwent arthroscopic surgery of the knee on the U.S. Naval Hospital Ships USNS Mercy and USNS Comfort. There were 113 men and 5 women, with an average age of 28 years (range, 19-59 years). The most common findings at the time of arthroscopy were meniscus tears (53%), anterior cruciate ligament tears (29%), and normal arthroscopic examinations (9%). There were three complications, two hemarthroses and one superficial portal site infection. Seventy patients (59%) were able to be returned to duty at an average of 6 days post-operatively, obviating the need to evacuate these patients out of the Middle East theater to Europe or the United States, thus avoiding additional delay, expense, and loss of the service member to his military unit.
Adult↗
Respiratory disease among military personnel in Saudi Arabia during Operation Desert Shield.
OBJECTIVES: The purpose of this study was to determine whether respiratory disease due to crowded living conditions and high levels of suspended and blowing sand had a major adverse impact on US military personnel during Operation Desert Shield. METHODS: A questionnaire survey was administered to 2598 combat troops stationed in Northeast Saudi Arabia for a mean of 102 days. Samples of surface sand from seven different locations were analyzed by scanning electron microscopy and x-ray diffraction. RESULTS: Among surveyed troops, 34.4% reported a sore throat, 43.1% complained of a cough, 15.4% complained of chronic rhinorrhea, and 1.8% were unable to perform their routine duties because of upper respiratory symptoms. Evaluation of sleeping accommodations indicated that complaints of a sore throat and cough were most closely associated with sleeping in air-conditioned buildings; in contrast, complaints of rhinorrhea were associated with exposure to the outdoor environment while living in tents. Sand samples consisted mostly of quartz, with just 0.21% by weight of respirable size (< 10 microns in diameter). CONCLUSIONS: These findings indicate that upper respiratory complaints were frequent among Operation Desert Shield troops and were related both to the troops' housing and to their exposure to the outside environment.
Adolescent↗
Diarrheal and respiratory disease aboard the hospital ship, USNS-Mercy T-AH 19, during Operation Desert Shield.
Diarrhea and respiratory disease were common problems among ground troops deployed to the Middle East during Operation Desert Shield. In order to determine the prevalence and impact of diarrheal and upper respiratory disease among shipboard personnel during this period, an epidemiologic survey was conducted on the hospital ship, USNS Mercy T-AH 19. An episode of acute diarrhea was reported by 46% of the surveyed population, and 79% reported upper respiratory symptoms. Six percent of personnel were temporarily unable to perform scheduled duties due to gastrointestinal symptoms and 7% due to respiratory symptoms. Officers were at increased risk of experiencing an episode of diarrhea, and female crew members more often reported respiratory complaints. Improved strategies to prevent diarrhea and respiratory disease among shipboard personnel are needed.
Adolescent↗
Laparoscopic cholecystectomy: use and preparation for Operation Desert Shield.
While stationed at Winn army hospital, Fort Stewart, Georgia as backfill surgeons during the initial stages of Operation Desert Shield, we performed eight laparoscopic cholecystectomies (LC) over a 2 1/2 week period. Our patients included four active duty soldiers, three dependents, and one retiree. There were no complications. The average hospital stay was 2 days, and the average time to return to duty was 10 days for LC compared to 5 and 30 days, respectively, with standard cholecystectomy (SC). Performing LC whenever possible can return soldiers back to duty in one-third the time and greatly reduce health care costs by reducing the hospital stay.
Cholecystectomy↗
Operation Desert Shield and Storm: impact on undergraduate and graduate internal medicine education.
We evaluated the impact of mobilization during Operation Desert Shield and Storm on undergraduate and graduate internal medicine education. Surveys were sent to the 425 residency program directors and 128 chairs of departments of medicine of U.S. medical schools in February 1991. Among graduate programs (46% response), 1.6% of full-time faculty, 0.2% of voluntary faculty, and 0.1% of residents were mobilized. No full-time faculty, voluntary faculty, and residents were mobilized at 77%, 90%, and 93% of programs, respectively. Negative impact ranged from none (68%) to significant (2%). For undergraduate education (51% response), 1.2% of full-time faculty, 0.1% of voluntary faculty, and 0.3% of residents were activated. Sixty-three percent reported no full-time faculty, 97% no voluntary faculty, and 86% no residents activated. Negative impact ranged from none (53%) to significant (4%). The effect of mobilization was small, and program directors and chairs should feel comfortable supporting participation in reserve activities.
Education, Medical, Undergraduate↗
Ocular and ocular adnexal injuries treated by United States military ophthalmologists during Operations Desert Shield and Desert Storm.
BACKGROUND: Ocular and ocular adnexal injuries, both combat-related and accidental, are common during wartime. In a combat setting, the eye is particularly vulnerable to serious injury from tiny flying particles that might minimally affect other parts of the body. The purpose of this study is to examine the incidence of serious ocular and ocular adnexal injuries that occurred during Operations Desert Shield and Desert Storm. METHODS: The authors retrospectively reviewed serious ocular and ocular adnexal injuries treated by United States Army and Navy ophthalmologists that occurred during Operations Desert Shield and Desert Storm. Only those injuries that resulted in, or would have resulted in, hospital admission because of the ocular or ocular adnexal injury alone are presented. RESULTS: During Desert Shield, 20 patients (23 eyes) suffered serious ocular or ocular adnexal injuries compared with 160 patients (198 eyes) in Desert Storm. During Desert Storm, 78% of all serious injuries were caused by blast fragmentation from munitions. More than one third of the 98 globe lacerations reported in this article were 10 mm or less in size. Of 35 enucleations performed during Desert Storm, 94% were the result of munitions fragments. CONCLUSIONS: During Operation Desert Storm, fragmentation wounds from munitions were the most common cause of ocular and ocular adnexal morbidity. The authors' findings indicate that polycarbonate ballistic protective eyewear could have prevented many of the ocular injuries that they report.
Adolescent↗
Orthopedic casualties in an activated National Guard Mechanized Infantry Brigade during Operation Desert Shield.
From November 1990 to April 1991, the 48th Infantry Brigade (Mechanized), an Army National Guard unit, was activated under Operation Desert Shield and deployed to the National Training Center, Fort Irwin, California, for training in desert warfare. All casualties requiring care beyond the battalion aid stations were evacuated to the medical company organic to the 48th Brigade. Each of 727 orthopedic patient visits were grouped into one of eight etiologies: trauma, degenerative, overuse, infectious, neoplastic, congenital/pediatric, miscellaneous, and psychiatric. Each case was also classified according to anatomic region, severity, and disposition as well as need for a minor procedure, operation, or referral. Orthopedic casualties in a reserve mechanized infantry brigade undergoing intensive field training primarily arose from four common etiologic/regional presentations: wrist/hand trauma, knee/leg trauma, spine/pelvis degenerative, and ankle/foot overuse. Many of these injuries are predictable consequences of a particular soldier's military occupational specialty and unit mission.
Cumulative Trauma Disorders↗
Ophthalmomyiasis during Operation Desert Shield.
A case of fly larva infestation of the eye (ophthalmomyiasis) is reported in an American soldier serving in Operation Desert Shield. Background information, prognosis, and treatment are discussed.
Adult↗
Operational medical support of an aviation brigade deployed during Operation Desert Shield.
This is a brief report on the medical support provided to an aviation brigade from September 1, 1990 to November 1, 1990, deployed during Operation Desert Shield. The aviation brigade consisted of 1,400 personnel including attachments. Medical support was provided by 3 physicians, a physician's assistant, and 24 enlisted personnel. Daily patient load was 2.5% of the unit strength.
Humans↗
U.S. Army Reserve optometry mobilization in support of Operations Desert Shield and Desert Storm.
Reserve participation contributed significantly to the successful optometric support of the U.S. Army in Operations Desert Shield and Desert Storm. This survey profiles the experiences of reserve optometry officers during these operations. Many doctors suffered personal and financial hardship, the latter being particularly common for those in private practice settings. Readiness may be impaired as many responses indicated that a considerable number plan to separate from the reserve in order to avoid future activation.
Humans↗
A retrospective review of orthopedic patients returning from Operations Desert Shield and Desert Storm to an Army Medical Center.
A retrospective review of all casualties received related to Operations Desert Shield and Desert Storm was conducted at Madigan Army Medical Center. Of the 180 patients determined to have returned from the Persian Gulf theater of operations, 93 (52%) had at least one orthopedic diagnosis and 84 (45%) were transported with a primary orthopedic diagnosis. The evacuation diagnosis was not substantiated by medical center evaluation in 37 (40%), and 42 (45%) were returned to duty without further treatment. Thirty-five patients (38%) were evacuated for a condition for which they had previously been profiled at least once. Peacetime duty limitations must be accurate and appropriate with respect to potential wartime demands.
Hospitals, Military↗
Incidence and methods of diagnosis of musculoskeletal injuries incurred in Operations Desert Shield and Desert Storm.
RATIONALE AND OBJECTIVES: The authors studied the incidence and distribution of orthopedic injuries sustained in Operation Desert Shield and Desert Storm by evaluating whether existing diagnostic imaging modalities were sufficient to diagnose the types of musculoskeletal injuries incurred. The authors also sought to determine if a dedicated extremity MR scanner would provide monetary benefits and enhance military readiness. METHODS: The authors retrospectively reviewed data on all musculoskeletal injuries incurred in Desert Shield/Desert Storm to determine the total number of injuries, proportion of orthopedic injuries, number of soft-tissue orthopedic injuries, and the country where the diagnosis was established. The authors also determined the number of patients, duration, and economic impact of the evacuation process. RESULTS: There were 1011 fractures and 1177 soft-tissue injuries; 408 soft-tissue injuries were diagnosed in the Persian Gulf countries, and 769 diagnosed in the United States and Germany. The average time to evacuate these 769 patients was 21 days with an estimated replacement cost of $836,885. CONCLUSIONS: Musculoskeletal soft-tissue injuries comprised 34% of the overall injuries in the Persian Gulf War, and twice as many patients required evacuation for diagnosis as were diagnosed locally using existing imaging modalities. A dedicated extremity magnetic resonance scanner in the battlefield would obviate many evacuations and hence be of both monetary and military readiness benefit.
Fractures, Bone↗