On March 1, 1991, PFC David A. Fisher was exposed to a chemical agent while exploring enemy bunker complexes. PFC Fisher developed blister symptoms roughly eight hours following exposure. Medical evaluation and treatment diagnosed the exposure as liquid mustard chemical warfare agent. Fox reconnaissance vehicle readings of the bunker and PFC Fishers clothing alarmed for mustard agents, and the testing of a urine sample gave positive results for a mustard breakdown product. Although later analysis of physical evidence did not confirm the exposure, experts concluded that PFC Fishers skin injuries were most likely caused by exposure to mustard agent. PFC Fisher received a Purple Heart for his injuries. The assessment for this incident is that chemical warfare agent exposure is "Likely." No other reports of similar blisters were made by PFC Fishers unit or other units in the area. Likewise, no other symptoms of exposure to liquid mustard chemical warfare agent were reported.
A single incident of exposure to mustard liquid occurred on March 1, 1991, in southeastern Iraq near the Iraq-Kuwait border. The location of the bunker was reported to be in the vicinity of geographical coordinates 29� 56 N 47� 6 E as well as Universal Transverse Mercator (UTM) coordinates QU053072, or 29� 49 N 47� 4 indicated in Figure 2.
Figure 2. Kuwait Theater of Operations: Mustard Exposure
This incident was documented at the time of its occurrence by COL M. A. Dunn, an expert in chemical warfare agents who testified before the Presidential Advisory Committee (PAC). PFC Fisher later corroborated the facts in telephone interviews. Further confirmation of the events was provided by correspondence with a member of the Fox reconnaissance vehicle crew that examined PFC Fishers clothing. This incident has also been reported by veterans to the Gulf War Illnesses Incident Reporting Line, and is cited in numerous documents on GulfLINK and elsewhere. No other reports of similar blister agents were made by PFC Fishers unit or other units in the area. Likewise, no other symptoms of exposure to liquid mustard chemical warfare were reported. A CIA information report documenting this incident in March 1991 states: "There has been only one instance in which a soldier may have been, and by indication was, exposed to chemical agents."
The following is from COL Dunns information paper:
PFC David Allen Fisher... is assigned to Scout Platoon, HTT, 4/8 Cavalry, 2nd Bde, 3d Armored Division, as a cavalry scout, MOS 19D. His exposure to mustard liquid occurred on 1 March 1991 on the objective of 4/8 Cav in northwestern Kuwait ... PFC Fishers mission on 1 March included exploring enemy bunker complexes for intelligence materiel and personnel, and demolition of enemy fighting vehicles. On that day he wore Nomex tanker coveralls and a ballistic protective vest. While exploring numerous bunkers, he remembers coming into contact with many surfaces in tight passages, resulting in the soiling of his clothing and equipment. He participated in demolition of ZSU-23 antiaircraft systems, BRDM vehicles, and T55 tanks only. He specifically states that he was not in contact with tube or rocket field artillery systems.
Inside one bunker, which he entered by squeezing through the doorway and passage, PFC Fisher saw crates and many loose artillery projectiles. These appeared in disarray, possibly due to an earlier bombing. He noted a "skull and crossbones" on at least one of the crates, took this as a danger sign, and immediately left the bunker. Exiting, he again brushed up against the wall and doorway.
COL Dunns information paper continues:
PFC Fisher completed his mission at about 1700 on 1 March, returned to his platoon area, and experienced no symptoms for 8 hours until he started radio watch at 0100 on 2 March. At that time he felt stinging pain on the skin of his left upper arm, saw that the skin had a red sunburned appearance without blisters, and thought that it felt like a spider bite. He slept from 0300 to 0400, woke for stand-to, and felt more stinging pain on his arm. At this time there were blisters on the upper arm and more reddened skin on the lower arm. At 0800 his company medic checked him, thought he might have a heater burn, and had him return at 1600, when more blisters had formed on the lower arm. At that time he was seen by CW2 Ahmed and CW3 Wildhelm at the 4/8 Cavalry aid station. They suspected he might be a blister agent casualty, decontaminated him with 0.5% chlorine solution, applied a local dressing and evacuated him to C Co., 45th Support Bn.
Several veterans have also reported this incident to the Incident Reporting Line. One such report was given by a chemical officer who was involved in the identification of the exposure:
I was working at the tactical operation center of the cavalry. We had a soldier reporting he was biten [sic] by a spider. I personally saw the soldier, I looked at the wound and he had blisters on it. I am a chemical officer, so I asked to see his clothing, he had on a tankers jacket, on his jacket he had a wet spot. I took the jacket to the [Fox reconnaissance] vehicle... I did a reading and it came positive for blister agent. I did a second reading and it became positive again. After that I basically notified the commander and division HQ [Headquarters]... I used chemical warning to report the incident. He was referred for medical treatment as a chemical casualty... After a week or two he was given a purple heart and sent back to the U.S."
COL Dunn documented PFC Fishers medical treatment in his information paper:
At C Co, 45th Support Bn, PFC Fisher was treated by MAJ DeClew, who confirmed the clinical diagnosis of blister agent exposure, photographed the blisters, applied a topical antibiotic and gauze dressing, and returned him to duty with follow-up at his unit. PFC Fisher remains in full duty status. I examined him and interviewed CW2 Ahmed and CW3 Wildhelm on 3 March at 1100. PFC Fisher had 2 blisters, about 2 cm diameter each, on the left upper arm, and another 2 blisters, 1 to 2 cm diameter, on the lateral left forearm, each surrounded by a narrow margin of erythema, or reddening. The roof of one upper arm blister had broken and the other three remained fluid-filled. PFC Fisher felt fine except for mild local pain that did not interfere with his duty performance. The skin area was photographed and a urine sample was saved in preservative for later analysis for thiodiglycol, a mustard breakdown product.... 
The blisters described by COL Dunn are consistent with known effects of mustard agent. In addition to the injuries documented by COL Dunn, PFC Fisher noted during a March 1996 interview that he has "scars" on one of his legs from the blisters. These scars are not mentioned in any of the medical reports.
Physical Evidence Collected
Physical evidence collected in this case consists of:
- the photographs of the blisters,
- a urine sample,
- samples of PFC Fishers clothing, and
- Fox reconnaissance vehicle readings of the clothing and bunker believed to be the location of the exposure.
During PFC Fishers evacuation, the medics were assisted by NBC (Nuclear, Biological, Chemical) personnel, who monitored PFC Fishers clothing and equipment with the spectrometer of a Fox reconnaissance vehicle. Initial readings of the clothings soiled areas showed weak positive spectra suggesting possible lewisite or phosgene oxime contamination. (Lewisite and phosgene oxime are both blister agents.) A later reading of a soiled area on the ballistic vest left upper shoulder pad alarmed for HQ, sesqui mustard. A subsequent Fox survey of the bunker was positive for distilled mustard, HD, but no chemical munitions were found in the bunker.
The crew member contacted by the IAD through electronic mail gave an account of the Fox readings:
Day 1 - A scout from 2nd Brigade 3rd Armored Division (PFC Fischer) [sic] complains of a severe rash and burning after a day of reconning Iraq bunkers. I do not know the exact location, but it was approximately 15-20 kilometers inside Iraq, 150-200 kilometers north of Saudi border. The 3AD was straddling the Iraq-Kuwait border at that time. Fischer [sic] developed a large blister on his arm and the Brigade Chemical Officer stated that it appeared to be a blister agent burn. At that time the soldier was taken to the two Fox reconnaissance vehicles which were attached to the 2nd Brigade. [My platoon sergeant] and [my second squad leader] were in charge of the two Fox vehicles located with that brigade. [My platoon sergeant] directed his MM1 mobile mass spectrometer operator... to attempt to get a contamination reading from PFC Fischer's Nomex jump suit. After close to an hour of testing, [his MM1 mobile mass spectrometer operator] got readings and was able to print a mass spectrum for an unusual blister agent (HQ). The test took so long because of the high concentration of sweat, oil and other petroleum based products in the suit. [His mobile mass spectrometer operator] had to attempt various temperature ranges in the capillary column before he was able to obtain good separation between the agent and the oil products (which registered as FAT, OIL, WAX on the MM1.) Division Chemical was notified of the results of the testing. A Medical Service Corps Colonel who was one of the military's top experts on chemical agent casualties was flown in to examine PFC Fischer. His preliminary findings after examining the soldier were that the burns had the appearance of a blister agent. He also took blood and urine samples for analysis elsewhere. I never saw the lab reports from these tests, but I was later informed by Division Chemical personnel that the blood test had confirmed the presence of HQ mustard. 
Day 2 or 3. I received an order from Division Chemical to use another Fox to confirm the MM1 readings from [the first Fox] vehicle. PFC Fischer's Nomex jumpsuit was no longer available since it had been buried as contaminated waste,) [sic] but we still had his Kevlar flak vest. I took my Fox and [the first] Fox to an open area in the desert approximately 5 kilometers inside of Iraq. (These two vehicles had been attached to 3rd Brigade 3AD, but had been released after the cessation of ground combat back to 22nd Chemical Company, which was attached to 3AD DISCOM and was located in the Kuwaiti portion of the division sector.) I used my MM1 operator... on my vehicle and temporarily replaced [the first Fox's] MM1 operator... with... my most experienced and skilled MM1 operator. We used both MM1's to analyze the flak vest. Both MM1's "alarmed" (i.e. registered) high readings of HQ mustard as well as faint readings of Lewisite (which I was later told is a component of HQ.) We were unable to obtain a spectrum of HQ because the concentration of FAT, OIL, WAX was always higher than the concentration of HQ. The MM1 will only take the mass spectrum of the highest concentration present. [The operator in the first Fox vehicle] filmed this procedure, including the MM1 screen, with his video camera. Protective masks were NOT worn durning [sic] the sampling because I had been informed that HQ remains a soil [sic] until approx. 90 degrees F, and does not vaporize until almost 180 degrees F. I did wear a MOPP protective suit and protective gloves. I was the only member of my platoon to handle the vest. After testing, we placed the vest, my protective gear, and a set of sample wheels from the Fox (which we had unsuccessfully used trying to extract agent from the vest,) into plastic trash bags and triple bagged the samples. I then passed the samples along with the original mass spectrum for HQ and the "alarm" readings from the other two MM1's to Division Chemical.
Day 4 +. It was further discussed that we should attempt to locate the bunker in which PFC Fischer contacted the agent. Testing was done around the exteriors of all bunkers using [my second squad leader's] Fox, but no chemical was detected. Through a process of elimination (which I no longer remember) it was determined that one bunker in particular was most likely the source of contamination. [My second squad leader] took his Fox back to the suspected bunker, rammed a hole into the side of the bunker with the armored bow of his Fox, then lowered his MM1 probe into the hole. His crew was unable to get a reading for chemical agent, which is not surprising since there should not be a vapor hazard at that temperature. I coordinated with Division Chemical to go back out to the bunker the following day. I would get into complete MOPP4 protective gear, enter the bunker, and remove all boxes, supports, and removable equipment. I also intended to scrape samples off of walls and surfaces that PFC Fischer might have brushed up against. We would then attempt to get an MM1 reading by direct contact with the items and samples I removed. Approximately 20 minutes prior to beginning this operation, I received a call from Division Chemical stating the... Commanding General, 3d AD... had personally canceled the mission. I was told that he did not want to risk the personal safety of any of his soldiers since we had already confirmed the presence and nature of the contamination. Since the bunker was in Iraq, it was not militarily essential that we confirm the exact site of contamination.
That is the full synopsis of events involving the PFC Fischer case as I remember them.
Analysis of Physical Evidence
Although copies of the photographs showing the blisters have been examined in this investigation, they are of extremely poor quality and no analysis of the blisters could be made based on these photographs.
Army Central Command (ARCENT) Chemical analyzed the urine sample on March 3, 1991, and "the specimen was tested positive." However, later testing of the urine sample--within a month of the samples collection--was negative. In testimony to the Presidential Advisory Committee, COL Dunn reported: "The urine sample I obtained showed no evidence of the mustard breakdown product, thiodiglycol, on analysis at my Institutes laboratory [the US Army Medical Research Institute of Chemical Defense]. We expected this analysis to be negative as well, based on the low level of exposure."
Fox spectra printouts and samples of the coverall sleeve and ballistic vest were retained by Nuclear, Biological, Chemical (NBC) personnel for analysis and were transported back to the US. The package was received on March 7, 1991 by the US Army Chemical Research, Development and Engineering Center, and then forwarded to the Analytical Research Division, Research Directorate for analysis on March 11, 1991. A videotape of a Fox spectrum reading of the clothing was also analyzed. (This reading was taken by a different Fox than the one that printed the tape. Both readings involving the printout and the videotape are discussed in the account given by the Fox crew member above.) "No evidence of any known CW [chemical warfare] agent or agent degradation product was found" during analysis of the clothing. A subject matter expert at the US Army Chemical and Biological Defense Command (CBDCOM) examined the Fox spectra printouts and the videotape. The subject matter expert determined them to be inconclusive evidence for the detection of mustard (although the subject matter expert was able to draw a conclusion based on additional information, as discussed below).
At the time of the incident, COL Dunn, who is an expert in chemical warfare agents, concluded:
PFC Fishers skin injury was caused by exposure to liquid mustard chemical warfare agent. The complete sequence of events is consistent with this conclusion. In particular, the latent period of 8 hours between exposure and first symptoms is characteristic of mustard exposure. No other corrosive or skin-toxic chemical compound that could reasonably be expected to have been present on the battlefield shows this latent period. The confirmatory Fox alarms are also consistent. It seems more likely that PFC Fishers exposure occurred during bunker exploration rather than during vehicle demolition because of the positive Fox result in the bunker complex and the lack of established chemical capability of the vehicle types he encountered.
Later, the CBDCOM expert also concluded that the incident was an exposure to mustard agent:
I reviewed a copy of [the printer tape] and belve [sic] it was a real mustard detection for these reasons: physical evidence (burn, medically diagnosed); plausible scenario of mustard in a bunker; detections at fairly high response levels (3.5 to 4.9 initially, then dropping off over several minutes); crews seemed well versed in MM-1 operation and applied correct procedures. Even though the spectra taken did not verify the agent alarms (they were reported as Fats Oils, waxes or "Unknown"), the high amount of oil/grease on the clothing could have caused this. I have just seen the videotape... it shows the MM-1 taking a spectrum, and verifying the detected material as HD. The questions I have though, are due to the reported detections of HQ, a mixture of HD and Q. If HQ was detected, both HD and Q should have been detected, with the HD being more likely to be detected since it is more volatile than the Q component. This may have been the case in [the] videotape, we cant really tell... but that was NOT the case in the MM-1 printer tape which came back with the clothing samples for analysis.
Finally, in his testimony to the Presidential Advisory Committee, COL Dunn stated:
I conclude that the soldier may well have been exposed to a low level of mustard during his exploration of the bunker complex. The exposure clearly did not appear to me to represent intentional use of a chemical warfare agent by Iraq, which in my own experience with Iran-Iraq Gulf War casualties, as well as the experience of others, would have produced far more exposed persons and more severe effects, as it did on every occasion when it was used by Iraq in that conflict. Without solid chemical evidence to prove that the exposure was in fact to mustard, the strongest indication to support mustard as the cause was the 8 hour delay between the time of exposure and first symptoms. A later exposure, that the soldier might not have noticed, to one of many other rapidly corrosive or skin-injuring compounds remains as an alternative possibility in the absence of chemical confirmation.
The assessment for this incident is that chemical warfare agent exposure is "Likely." This assessment is based on the following facts:
Two doctors trained to identify chemical warfare agent effects examined PFC Fisher and diagnosed his injuries to be caused by exposure to mustard. One of these doctors--COL Dunn--was a medical expert in chemical warfare agents. Although COL Dunn later qualified his initial diagnosis, he consistently maintains that PFC Fisher "may well have been exposed" to mustard agent.
Various soldiers involved in the incident consistently reported the same exposure scenario. Accounts of this incident--provided by PFC Fisher, the chemical officer, the Fox crew member, as well as COL Dunn--report that PFC Fisher developed blister symptoms after a day of exploring Iraqi bunkers.
Physical evidence from inside the bunker, which could have confirmed the presence of chemical agents, was not collected. (Recall the Fox crew member's statement that his mission to return to the bunker for further testing was canceled because the Commanding General, 3d AD "did not want to risk the personal safety of any of his soldiers since we had already confirmed the presence and nature of the contamination. Since the bunker was in Iraq, it was not militarily essential that we confirm the exact site of contamination.") Although the Army Central Command (ARCENT) Message cites that a Fox reconnaissance vehicle did alarm for mustard agents in one bunker, the alarm was not confirmed by a spectrum analysis. As indicated in the Fox Reconnaissance Vehicle Information Paper, the Fox's design results in many false positive alarms and requires a full spectrum analysis to confirm a detection.
The fact that PFC Fisher was the only casualty is consistent with the overall scenario because his exposure was due to reconnaissance in Iraqi bunkers, which he entered alone, and not related to intentional use of chemical weapons against US and coalition troops.
As stated in COL Dunn's information paper and testimony, the latent period of eight hours between exposure during bunker exploration and development of symptoms is consistent with effects of exposure to mustard agent.
The in-theater analysis of PFC Fisher's clothing by Fox reconnaissance vehicles gave positive spectra for the presence of mustard agent, not just alarms. While the subsequent analysis of the clothing samples performed by the US Army Chemical Research, Development and Engineering Center (CRDEC) did not find evidence of chemical warfare agent contamination, it is possible that the sections of the clothing selected for testing were not contaminated sections. (The portions tested are listed on the first page of Memorandum for Record, Subject: Analysis/Evaluation of Clothing and Gauze Samples, US Army Chemical Research, Development and Engineering Center, March 1991.)
The urinalysis performed by ARCENT Chemical "tested positive." Because the later urinalysis performed in the US is negative, the validity of the ARCENT Chemical result is called into question. However, COL Dunn reported that he did not expect a positive result based on the low level of exposure. Therefore, the lack of a positive urinalysis does not necessarily indicate negative confirmation of exposure.
The injured soldier was awarded a Purple Heart after contemporaneous investigation.
To summarize, PFC Fisher probably acquired his injuries in the bunker complex in southeastern Iraq even though only one Fox alarmed to chemical warfare agents there and this could not be corroborated by a second Fox. Collection of additional materials for testing within the bunkers did not occur so as not to put troops at risk. Positive detections of mustard agent were made in-theater from analysis of Fisher's clothing and urine. Though these results were not replicated in US laboratories later, the medical assessment of trained and expert doctors was that PFC Fisher may "well have been exposed" to mustard agent.
Taking all these points into consideration within their total context, the assessment of this incident is that chemical warfare agent exposure is "Likely."
This case is still being investigated. As additional information becomes available, it will be incorporated. If you have records, photographs, recollections, or find errors in the details reported, please contact the DOD Persian Gulf Task Force Hot Line at 1-800-472-6719.