III. NARRATIVE 
On March 15, 1991, at Al Jubayl, Saudi Arabia, a US Marine corporal sought treatment for skin irritation and blisters on his right forearm. In 1996, the Persian Gulf Illnesses Investigation Team, predecessor to the Office of the Special Assistant for Gulf War Illnesses, identified the corporal as a potential victim of a chemical warfare agent. Marines interviewed for other cases under investigation also identified the corporal as a person they believed was injured by an exposure to a chemical warfare agent.[4,5] In testimony given in 1997 before the Presidential Advisory Committee on Gulf War Veterans Illnesses, one Marine referred to this incident as a possible instance of a chemical warfare agent injury during the Gulf War.
This narrative draws heavily on interviews conducted years after the corporal's injury and, since memories are fragile, there are inconsistencies among his recollections. In an effort to supplement the corporals recollections and with his permission, we reviewed portions of the corporals personnel and medical records. We could not, however, find any other physical evidence, such as operational or administrative records or reports to corroborate the interview statements. The narrative concludes with some insights on possible lessons learned.
On February 4, 1991, the corporal arrived in Saudi Arabia following completion of new equipment training in Germany. This new equipment training included learning to operate and maintain the XM93 Fox Nuclear, Biological, and Chemical Reconnaissance (Fox) Vehicle and its MM-1 Mobile Mass Spectrometer (MM-1). The Fox vehicle is a six-wheeled, light-armored vehicle designed primarily to detect, identify, and mark areas of persistent ground contamination (e.g., puddled chemical agents). See Tab D for more information about the Fox vehicle and its capabilities.
The corporals Fox vehicle and crew were assigned to support the I Marine Expeditionary Force (I MEF) at Al Jubayl to help familiarize Marines with the appearance and capabilities of the vehicle. Approximately three weeks after the crews arrival, the corporal and the rest of the Fox vehicle crew relocated to Kibrit, located about 57 kilometers west of Al Mishab, Saudi Arabia (Figure 2). The compound was known as Kibrit because of the tiny Bedouin settlement of Abraq al Kibrit, which was about 20 kilometers further west.
Figure 2. Map of Saudi Arabia showing area from Al Jubayl to Al Kanjar
Kibrit encompassed approximately 40 square kilometers and contained a 470-bed hospital, 1.8 million gallons of fuel storage, a graves registration area, 15,800 tons of ammunition, and an enemy prisoner of war (EPW) holding area. A drawing of the corporal's description of the compound appears at Figure 3. An interview with another veteran placed the EPW holding area outside the compound.[14,15]
Figure 3. The Kibrit compound as recalled by the corporal
The daily routine of the Fox crew did not vary much following the ground war. Each day, the operations center assigned the Fox crew locations around Kibrit to sample the air for possible chemical warfare agent vapor. The Fox vehicle commander then took the vehicle and crewmembers to locations around the Kibrit compound to familiarize Marines with the Fox vehicle. Then, every evening, the Fox vehicle crew would drive the perimeter of this compound and randomly test the air for possible chemical warfare agent vapor using the MM-1. The MM-1, however, is not optimized for alerting to vapor hazards. To improve the Fox vehicles vapor detection capability, Fox vehicles had the M43 chemical vapor detector, designed to detect nerve agent vapor, added during Desert Storm. The corporal did not enable the M43 chemical vapor detector on the Fox vehicle the day of the possible exposure.
C. The Injury
Twelve days after the Gulf War cease-fire, the corporal and the Fox vehicle commander arrived at the EPW holding area in their Fox vehicle at approximately 11:00 AM on March 12, 1991. According to the corporal, a Marine staff sergeant approached them and asked for assistance. The staff sergeant had been using a chemical agent monitor (CAM) to test items from three large crates (five feet on a side and five feet deep) of enemy prisoner of war personal field equipment. The crates contained field equipment such as gas masks and their carriers, field belts and suspenders, and ammunition magazine pouches. The CAM had indicated the presence of a possible chemical warfare agent and the staff sergeant wanted another means to confirm the CAM readings. Because we have been unable to locate the staff sergeant, the number of positive CAM readings he received and what chemical warfare agent was possibly identified are unknown. The corporal agreed to assist the staff sergeant while the Fox vehicle commander went to observe the prisoners who were in the immediate area, but away from the testing. The corporal backed the Fox vehicle to the crates containing the equipment and prepared the mass spectrometer to analyze the equipment. According to the corporal, he operated the Fox vehicles MM-1 as he had been trained. This training included looking for any possible source of interferents that might cause the MM-1 to misidentify a sample as a chemical warfare agent. Sources of interferents included vehicle exhaust and several occupational chemicals such as Decontaminating Solution Number 2, a decontamination agent, and lindane, a delousing agent. Such substances could initially cause an alarm, but subsequently would be identified through a spectrum analysis.
According to the corporal's account some years later, at the time of this incident, the staff sergeant was wearing camouflage work pants, a tee shirt, and latex gloves to protect his hands while working with the field equipment. He was not wearing any nuclear, biological, and chemical (NBC) protective clothing. The corporal was wearing British NBC protective pants and overgarment. He also wore latex gloves (covering up to his wrists) to assist the staff sergeant.
Knowing that inaccurate or false readings were possible, the corporal collected a baseline spectrum to confirm the MM-1s settings before he began sampling. The corporal then got out of the vehicle and assisted the staff sergeant in holding the Iraqi equipment up to the Foxs sampling probe. The staff sergeant took the lid off of the crate that contained the equipment he said had previously caused the CAM alarm to sound. He removed the items from the crate, handing them one by one to the corporal. When the corporal held up the third or fourth piece of equipment, an ammunition pouch or a portable weather data gathering station, which had traces of reddish dust on it, to the probe, the corporal heard an alarm from the mass spectrometer. The corporal then asked the staff sergeant to continue to hold the piece of equipment to the probe while the corporal went inside the Fox to look at the mass spectrometer readings. The corporal changed the method of operation of the mass spectrometer from Air/High to Surface/Low and, again, received a low-level reading, possibly for lewisite. Changing to Surface/Low method lowers the probe temperature, increases the separation of ions in the sample for the mass spectrometer, and thus increases the reliability of the reading from a sample. The corporal noted that the mass spectrometer indicated a low level reading for the chemical warfare agent lewisite. In his initial June 1997 interview, the corporal reported that he had positive MM-1 readings for both mustard and lewisite. In April 1999, the corporal indicated he only had readings for lewisite and not mustard. However, he could not be certain of the intensity of these readings.
Table 1. Chemical warfare agent effects
|Burning Sensation in the Eyes||X||X|
|Immediate Stinging to Skin||X|
|Inflammation of Soft Tissue||X|
(fluid build-up in the lungs)
After hearing the alarm, the corporal ran a spectrum analysis and printed a tape, which he said also indicated the presence of lewisite. The corporal experienced no chemical warfare agent exposure symptoms and took no additional chemical protective measures. See Table 1 for chemical warfare agent exposure symptoms of a few known military chemical warfare blister agents that we suspected, before the war, were in the Iraqi inventory during preparations for DESERT SHIELD/STORM. After getting low level readings (for lewisite) on two additional pieces of equipment, which also had traces of the red dust, he continued testing equipment for several hours with the staff sergeant but received no other alerts for chemical warfare agents from the rest of the equipment. Since none of the enemy prisoners of war or Marines in the area were exhibiting symptoms consistent with exposure to a chemical warfare agent, the corporal and the staff sergeant did not send an NBC report, which his procedures called for if he believed he had a valid detection for a chemical warfare agent.
Lewisite is a liquid chemical warfare agent. We have not found any evidence that lewisite exists in a dusty form, and not in the form of a red dust. Additionally, the United Nations Special Commission in Iraq reported that their inspectors found no lewisite in their inspections of Iraqs production and storage facilities. Mustard chemical warfare agents exist in a dusty form, but we have no evidence that they exist as a red dust. More importantly, we have no evidence that Iraq deployed dusty mustard for use against Coalition forces during DESERT SHIELD/STORM.
Although lewisite causes immediate pain on contact, the corporal reported that he did not experience any such pain while working with the EPW equipment. A senior medical staff officer in the Kibrit area, who would have known about and directed the treatment of any chemical warfare agent injuries, recalled no incidents of treatment for chemical warfare agent injuries.
The corporal stated that he performed a spectrum analysis and printed a tape of that analysis. The Fox vehicle commander recalled giving the tape to the I MEF NBC officer, but could not find the copy he had kept for his personal records. However, the I MEF NBC officer did not remember receiving such a tape. Although we have conducted an extensive search, no tapes containing the spectrum analyses have been found.
After the corporal finished testing all of the equipment, he removed his latex gloves and buried them. He wanted to rinse his hands of the accumulated dirt from handling the captured field equipment, but had no water or personal hygiene supplies in the Fox vehicle. The corporal has been unclear on what happened next.
In his April 1999 account, he remembered that while the staff sergeant went to get some water and cleaning materials, he used one of the chemically-treated decontamination wipes from his M258 decontamination kit (Tab E) to clean his right forearm and then washed his hands and arms in a bleach-and-water solution. In a June 1999 interview, he indicated that he used both treatment packages and again wiped only his right arm "because it felt grimy," prior to washing with the bleach-and-water solution. After his January 2000 review of the narrative, the corporal recalled that he only washed his hands and arms in the bleach solution and that he did not use the decontamination kit until the next morning.
After the staff sergeant returned with a bucket of water and another bucket with a bleach and water mixture, the corporal used the bleach and water mixture to wash his hands and arms up to the elbow. The Fox vehicle commander and the corporal then left the EPW holding area about 3:00 PM and returned to their quarters. During the evening of March 12, 1991, the corporal began to feel an intense itching and burning sensation on his right forearm. The inside of his right forearm, from the crook of the elbow to two inches up from his palm, was red and irritated. In an attempt to relieve the discomfort, he scratched so intensely that he broke the skin on his right forearm. He stated that the itching and burning was irritating enough to prevent him from falling asleep until approximately 1:00 AM.
On the morning of March 13, 1999, the corporals right forearm was still red and a quarter-sized blister had formed. According to his January 2000 recollection, this is when he used the decontamination kit, and allowed the decontamination solutions to remain on his skin for several hours before taking a shower.
The chemically treated wipes, contained in the M258 personal decontamination kit, are caustic and can cause skin eruptions and irritation. Likewise, using bleach and water on the skin might cause a slight burn or white spot, depending on the strength of the bleach solution. Combining the M258 kit use and the bleach and water washing, as stated in the earlier testimony, could have been sufficient to cause blistering. However, if the bleach-and-water washing and the M258 kit use happened on different days, as indicated in the corporals January 2000 review, interaction between the two is not likely to have caused the corporals blister because he had already experienced the itching, redness and a blister before using the M258 kit. A biochemist on our staff also has assessed the bleach and water washing on March 12th as a potential cause of the redness, itching, and the first blister the Marine experienced.
D. Medical Treatment History
On the morning of March 13, 1991, the corporal showed the blister on his forearm to his Fox vehicle driver who had not been present at the EPW holding area the previous day. The driver suggested that the corporal might have been exposed to something while handling the EPW equipment. After showing the blister to the Fox vehicle commander, the corporal went to the battalion aid station at the Kibrit compound.
The corporal stated that he and the Navy corpsman who treated him at the battalion aid station at Kibrit were unsure of the cause of the blister. According to the corporal, the corpsman treated the blister with cortisone cream, Neosporin� ointment, and a saline-soaked gauze pad. However, at the time, the treatment was not recorded on a medical treatment form (Standard Form 600) for later inclusion in the corporals medical record. It wasnt until a later visit to the medical facility at Al Jubayl that the corporal relayed the above treatment to a nurse who recorded it as part of the corporals medical history.
After the visit to the battalion aid station at Kibrit, the corporal took a sample of the blister fluid from his forearm with a cotton swab and tested it with the Fox vehicles mass spectrometer probe. He reported receiving the same positive reading for lewisite that he had received when testing the captured equipment the day before, and this concerned him. We have not found the spectrum analysis tapes or other documentation to verify or further analyze these readings. However, according to an Army field manual, fluid in lewisite blisters is not toxic and does not cause a burning sensation or further the spread of blistering. We cannot explain how the Fox vehicles MM-1 would alert for lewisite when the corporal placed a sample of the blister fluid to the probe.
The next day, March 14, 1991, the Fox vehicle commander called the I MEF NBC officer, the crews officer-in-charge, at Al Jubayl. The I MEF NBC officer ordered the Fox vehicle crew to return to Al Jubayl so the corporal could receive treatment from the hospital there. The Fox vehicle crew arrived at Al Jubayl late that afternoon. The corporal reported to the I MEF headquarters where he showed the I MEF NBC officer the blisters. The corporal also told the I MEF NBC officer that he planned to report to the hospital the next morning for treatment. The I MEF NBC officer had photographs taken of the injury (Figure 4), but filed no NBC report.
Figure 4. Photographs of the corporal's forearm taken in theater March 1991
On March 15, 1991, the corporal reported to the hospital operated by the 2d Medical Battalion and was screened by a corpsman. The corpsman recorded that the patient had three fluid-filled blisters and eight other blisters forming on the inside of his right forearm.[67,68]The corpsman treated the wound with Daiken's solution, a bleach and water solution developed to prevent infections on irritated skin and lesions.[69,70] He applied a dressing wetted with the solution,and covered it with a dry sterile dressing. The corpsman also prescribed 25-milligram capsules of Benadryl� to be taken twice daily and instructed the corporal to return to the medical facility after three days to be examined by a supervising nurse corps officer. The Standard Form 600 completed by the corpsman is the first dated record of the corporals medical treatment for this injury. The corpsman told investigators that a doctor also examined the corporal and assessed possible lewisite exposure. However, the physicians diagnosis was not recorded in the corporals record on this visit, and we have not found the doctor.
The medical personnel at Al Jubayl viewed a sample of the blister fluid under a microscope and did not identify any signs of infection. Another sample of the blister fluid was sent to a naval medical lab to conduct a culture in order to rule out a bacterial or viral cause for the blisters.
Three days later, on March 18, 1991, the corporal returned to the medical facility and was examined by the supervising nurse who noted an increase in the number of blisters. The nurse also noted in the medical record that the blister fluid culture was negative and that some of the affected area showed improvement. He ordered a continuation of the Daikins solution treatment coupled with Benadryl� and instructed the corporal to return to the medical facility again for a follow-up.[74,75]
In a 1998 interview, the nurse explained that they sent some tissue samples to the field hospital at Al Jubayl. The tests came back with no results at all. So they looked at what was the least harmful treatment and decided to treat the blisters with a Daikins solution of chlorine and water. A physician on our staff, who was knowledgeable of the Forward Naval Medical Laboratory operations in Al Jubayl during the Gulf War, explained that "no results at all" meant that the sample was a sterile culture and did not produce any bacterial growth in the test dish or show anything unusual when examined under the microscope.
On March 22, 1991, the corporal was seen by the same supervising nurse who treated him on March 18th. The nurse now recommended that the corporal be seen by the dermatology department of the Balboa Naval Hospital in San Diego, California, for evaluation of what he called a "known contact with mustard-type blister agent." The nurse directed that the Daikins solution and Benadryl� treatment continue until the corporal could be seen in San Diego. The next day (March 23, 1991), the assistant I MEF surgeon made an entry in the corporals medical record clarifying the nurses statement regarding a "known contact with mustard-type blister agent." The assistant I MEF surgeon wrote:
There is not known contact with blister agent. The only evidence for this is the patients interpretation . Medically we can neither confirm nor deny the possibility of cutaneous NBC agent . This is a record entry to correct a phrase on the preceding note from 22 March by [the nurse]. I have not examined [the patient].
In a 1998 interview, the physician stated that he made the entry because the diagnosis was not conclusive based on available information. The entry corrected the diagnosis, but the physician did not cancel the dermatology referral to the Balboa Naval Hospital.
On April 10, 1991, the corporal returned from the Kuwait theater of operations to his duty station at the Marine Corps Air Station in Yuma, Arizona. The corporal reported to the Yuma medical treatment facility on May 6, 1991, almost two months after his initial treatment in Saudi Arabia. A doctor at the clinic examined the corporal and noted that the corporals possible exposure was well-documented in his medical record. However, he was unable to determine whether the injury resulted from possible blister agent exposure or a hypersensitivity reaction. Because there was no dermatology clinic at Yuma, he referred the corporal to the dermatology clinic in San Diego for evaluation. In a March 2000 interview, this doctor explained his analysisthe rash and blisters could have fit the pattern of a chemical warfare agent injury, but since he had never seen a chemical warfare agent injury during his time in the KTO, he doubted a chemical warfare agent caused the injury, so he referred the corporal to San Diego for a dermatology assessment and follow-up treatment.
On May 21, 1991, the corporal reported to the dermatology clinic at the Balboa Naval Hospital, where a physicians assistant (in training) examined him. The physicians assistant assessed the injury as dermatitis, possibly secondary to lewisite exposure or some other traumatic injury to the skin on the right forearm. A physician countersigned the record entry. The corporal did not seek further medical treatment for dermatitis. He stated that the condition finally healed by August or September 1991, with one slight unexplained occurrence of a single blister in May 1992 that eventually went away. The blistering left permanent scarring on the corporals right arm.
E. Physicians Opinions
In 1997 and 1998, two chemical warfare casualty treatment medical doctors and four dermatologists, who were not involved with the corporals treatment in 1991, gave their opinions as to whether a chemical warfare agent could have caused the corporals blisters. We showed these medical experts pictures taken at Al Jubayl in 1991 and shared all documentation regarding the corporals treatment. One chemical warfare casualty treatment physician and one dermatologist personally examined the Marine. These six physicians could not rule out the possibility of a chemical warfare agent injury. However, they also agreed (as presented below) that there are many possible causes for the blisters.
1. Chemical Warfare Agent Casualty Treatment Experts
The first chemical warfare casualty treatment expert has over 31 years experience at the US Army Medical Research Institute for Chemical Defense and has written extensively on the physical effects of chemical warfare agent injury. Because of his expertise, the US government sent him to Thailand and Laos in 1979 to investigate possible use of chemical warfare agents against refugees. He was also a member of the US governments medical team sent to Tokyo to advise the local government on management of casualties after nerve agent was released in the Tokyo subway system.
When we consulted this physician in 1997, he based his assessment on the corporals statements, which, at the time, indicated that the corporal had received positive MM-1 readings for mustard and lewisite. In April 1998, the corporal said that he received alarms and positive MM-1 readings for lewisite only. Nonetheless, the following observations troubled the physician in 1997:
The physician concluded that the time course of the 1991 injury was consistent with exposure to mustard. "However, few other parts of the history are. All this suggests that this injury was not due to mustard. This could be a contact dermatitis with sensitization, but evidence for this is not strong either."
This physician was not certain of the cause for the corporals blisters. His concerns about the alarms for mustard agent later proved to be unfounded, since the corporal stated in an April 1999 interview that he received alarms for lewisite only. However, because the corporal experienced no other indications of lewisite exposure, such as eye or respiratory irritation, this physician discounted lewisite as a cause as well. He also discounted that a dusty chemical warfare agent might have caused the blisters, since the corporals blisters were smaller and there were more blisters present than he would expect if the cause was a dusty chemical warfare agent.
The second chemical warfare casualty treatment expert has more than nine years in the fields of chemical casualty treatment and prevention and has published several pamphlets and reports on chemical warfare agent exposure. In his report, written after he examined the corporal, this physician provided several possibilities for the cause of the blistersone was mustard agent. He noted the size and pattern of the blisters were atypical of mustard agent exposure, but not inconsistent. After drafting his first report, he met with the corpsman and a nurse who treated the corporal at Al Jubayl. Following that meeting, he met with a dermatologist from the US Army Medical Research Institute for Chemical Defense. In a report written after these meetings, the doctor stated that, in his opinion, the burns were not "mustard-induced." He further stated, "he could not rule out that the burns were mustard-induced, but in his opinion it was possible but unlikely."
In order to clarify the possibilities of the dermatological conditions suggested by the two previously mentioned experts, we consulted four dermatologists.
The first dermatologist is currently the chief of the chemical casualty care division at the US Army Medical Research Institute of Chemical Defense. Members of the Office of the Special Assistant for Gulf War Illnesses met with this dermatologist on April 29, 1998. He had read materials summarizing the witnesses accounts and was inclined to say that exposure to a vesicant (blister-type chemical warfare) agent was a likely cause of the corporals injury. However, after this dermatologist was shown the 1991 pictures of the corporals blistered arm, he changed his opinion. He then believed that a mustard agent definitely did not cause the blisters. He noted that the lesions were in different stages of healing, suggesting "that the lesions occurred at different times and over an extended period of time (several weeks or months.) With the intervening normal skin and wide variation in healing stages, the lesions appear to be independent of one another although similar." This dermatologist suggested that the lesions could have been produced by heat, drops of a corrosive substance, or repeated trauma by picking at the skin in these areas.
We showed the pictures of the corporals blisters and the assessments of the chemical warfare agent casualty treatment experts to a second dermatologist at the National Naval Medical Center, Bethesda, Maryland. This dermatologist noted that the blisters were too discrete to be caused by contact with a blister agent but were compatible with any type of contact dermatitis. She explained that the various stages of healing were not completely inconsistent with blister agents, especially mustard. Cases of mustard injury have been seen where trauma to the injury site has initiated a new round of blisters weeks after the first blisters occur. In her opinion, the blisters could have been caused by repeated exposure to a hot object, but she also suggested that the blistering may have been caused by multiple insect bites.
The third dermatologist, who had been trained in military chemical casualty care, has since retired from the Army and is active in civilian practice. He focused on the corporals history and the opinions of the medical personnel who actually observed and treated him. He felt strongly that the most weight should be given to those witnesses and that it was likely that the corporal was exposed to a chemical warfare agent.
The fourth dermatologist is an internationally recognized civilian expert who is on the faculty of a major academic medical center and who has considerable expertise in the effects of chemicals on the skin. He had the opportunity to review all historic and photographic material relevant to the case and also to interview and examine the corporal in August 1998. This dermatologist spoke with our Director of Medical Outreach and Issues (an Army physician) about the case and said that such blisters could be caused by several factors, to include blister agent, contact dermatitis, and burns. The dermatologist said that the pattern of the lesions and the fact that new ones appeared over a considerable length of time made it unlikely that a one-time exposure to a chemical warfare agent could be the cause. He stated that, in the absence of confirmatory historical or physical evidence, it would be difficult to say which of the several possible causes was responsible for the lesions.
Two biochemists also reviewed the case research and physicians comments, both knowledgeable in industrial hygiene issues and hazards. A biochemist on our staff has assessed the bleach and water washing on March 12th as a potential cause of the redness, itching, and the first blister the Marine experienced. A Defense Intelligence Agency biochemist also suggested that the corporals use of the bleach and water wash and the personal decontamination kit was responsible for the blistering. He did not change his opinion based on the corporals January 2000 recollection of using the bleach and water wash the day before the M258 kit use. The biochemist observed that by the time the corporal used the M258 kit, the corporal had already experienced a blister. Had the corporal been exposed to mustard or some other blister-type chemical warfare agent, he would have expected multiple blisters by the next morning. The biochemist went on to suggest that the corporal should not have had the first blister with proper rinsing after the bleach and water washing. He still believed it unlikely that a chemical warfare agent caused the corporals blisters.
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