V. LESSONS LEARNED
We have several key observations from this investigation. These observations are intended to highlight issues that have arisen that DoD should ensure have been addressed since the end of the Gulf War. They do not represent opinions or positions of other departments or agencies outside the US Department of Defense.
A. Operational Reporting and Investigation
NBC records are generally regarded as a reliable source of information. However, since the corporal and Fox vehicle commander never submitted a formal incident report, there was no operational record of a suspected chemical warfare agent exposure in this incident. I MEF operations and NBC defense personnel had no basis upon which to conduct an investigation and report any findings to potentially affected units. Likewise, with no NBC reports, the medical support administrators did not submit a chemical casualty report. Therefore, the injury was handled through routine, administrative channels. In order for a possible chemical warfare agent exposure to be properly and aggressively investigated and passed on through operations and intelligence channels, suspected incidents must be reported with appropriate commitment and a sense of urgency. Specifically, Fox vehicle procedures should be revised to direct that crews archive all MM-1 Fox vehicle tapes as part of a units records and report all suspected chemical warfare agent incidents in the field, including what may be false positive readings.
B. Organizational and Administrative Recordkeeping
Organizational and administrative medical records to corroborate interviews were not available in this case. The 2d US Navy Medical Battalion had destroyed its Gulf War records in compliance with Navy directives. Navy instruction at the time of the Gulf War dictated that morning reports of the sick, sign in/sign out logs, appointment records, etc., be destroyed after two years. Current policy maintains the two-year retention requirement. The Department of Defense should consider requiring the maintenance of unit operational records from contingency deployments on electronic media for ten years.
C. Medical Treatment Recordkeeping
Corpsmen, nurses, and doctors are a crucial part of the medical treatment and record keeping process. They should ensure that treatment is properly documented in patient records. All treatment should be recorded on the Standard Form 600 and a copy posted to the record. Alternatively, development and fielding of the personal information carrier would facilitate timely diagnostic and treatment history for the record. The personal information carrier (an identification tag-sized computer disk containing personal medical information) would capture an electronic version of the Standard Form 600 for reference and later use.
D. M258 Decontamination Kit and Hazard to Skin
The M258 Decontamination Kit contains strong chemicals necessary for decontaminating skin exposed to chemical warfare agents (Tab E). These chemicals are caustic and can burn the skin. Bleach, when used as a field expedient decontamination solution, can also burn the skin. Individual soldier training includes warnings on the caustic effects of the decontamination packet solutions if not used properly. When military personnel are trained in the use of personal and collective decontamination procedures, their training should emphasize the hazards of using field expedients in combination with the M258 kit.
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 1-800-497-6261.
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