Colonel Dunn, Medical Corps, Director, Clinical Consultation, OSD/HA, Testimony to the Presidential Advisory Committee on 16 April 1996

Good morning. I am Colonel Michael Dunn, an Army Medical Corps Officer. My present assignment is as Director of Clinical Consultation for the Assistant Secretary of Defense for Health Affairs. From April 1987 until July 1991 I commanded the U.S. Army Medical Research Institute of Chemical Defense at Aberdeen Proving Ground, MD. I was responsible for research and for providing instruction to physicians in the Department of Defense involving medical protection against chemical warfare agents. From October 1990 to March 1991 I was attached to United States Central Command as its Chemical Casualty Consultant. I advised the Command Surgeon of Central Command on medical protection of U.S. forces against chemical warfare agents in Operations Desert Shield and Desert Storm. Under his direction, I conducted instruction of U.S. and allied medical personnel on chemical casualty care, assessed use and safety of our medical countermeasures against chemical warfare agents, and was prepared to assess and report our experience with actual care of chemical casualties, should it have proved necessary.

Your Committee asked that I describe the instruction that our medical personnel had to recognize and treat chemical casualties, and that I give my assessment of our capability to have recognized and reported them. Further, you asked that I describe my evaluation of the one soldier in Operation Desert Storm whom we assessed clinically as having been exposed to a blister agent.

During peacetime, the Medical Research Institute of Chemical Defense conducts a Medical Management of Chemical Casualties Course (M2C3) at Aberdeen Proving Ground. The curriculum involves 5 days of classroom and field instruction on recognition and medical mangement of chemical casualties. About half the students are normally physicians, and instruction is keyed to their educational level. Nonphysician students include nurses, physician assistants, clinical scientists, and senior enlisted medical specialists. Traveling Institute teams conduct the M2C3 at remote locations, including Europe and the Pacific, several times annually.

With the start of Operation Desert Shield, the Institute increased its M2C3 instruction in courses at Aberdeen and at posts in the United States and Europe for the medical personnel of units identified as about to deploy to the Central Command area of responsibility (AOR) in the Middle East. In October 1990, I began work in the Central Command AOR, assisted by an instructional team from the Institute. From October to December 1990, we conducted 16 M2C3 courses in theater. The in-theater courses included all the material of the normal 5 day course presented over 3 days, ending with a demanding examination. Our pass rate in theater was over 95%, significantly higher than our normal peacetime pass rate, which we attributed to our students' perception of the immediate relevance of the course work to their needs. The majority of our 1453 graduates were U.S. military physicians and physician assistants from all 3 services. The total also included U.S. nurses and senior medical specialists and 273 allied students. Over 1000 additional graduates from Institute M2C3 courses in the U.S. and Europe, also mainly physicians and physician assistants, arrived in theater prior to Operation Desert Storm.

The M2C3 instruction was specifically tailored to the Iraqi chemical threat in several ways. We concentrated on recognition and management of exposures to nerve agents and mustard, the known major Iraqi threats, as well as to cyanide, a less prominent element of their holdings. We added to our instruction summaries of recent experience of Iranian physicians who had managed their own chemical casualties in the Iran-Iraq Gulf War, as well as our own experience from observing some of these casualties who had been evacuated to Europe. Our instructional material included the newly-published (February 1990) tri-Service field manual on

treatment of chemical agent casualties, and 4 new clinical technical bulletins by Institute authors keying on recognition and management of nerve agent and mustard casualties. We had distributed over 2500 copies of each of these publications throughout the theater by the start of Operation Desert Storm.

We added instruction on two major biological warfare threats, anthrax and botulinum toxin. In post-course surveys, our graduates expressed a high degree of confidence in their ability to protect themselves and to recognize and manage chemical casualties.

We targeted our instruction to medical personnel serving with units assessed to be at the highest risk for chemical warfare agent exposure. These were the units involved in operations within 40 kilometers of the enemy, that is, within range of known chemically capable artillery and multiple-launch rocket systems. Over 90 percent of the physicians assigned to such units, mainly ground combat divisions, were M2C3 graduates by the beginning of Operation Desert Storm. Of all U.S. military physicians in the Central Command AOR, about 50% were M2C3 graduates. In conducting training and follow-up visits, I and my team members visited every U.S. medical facility in the AOR. I am certain that there were M2C3 graduates specifically trained to recognize chemical casualties in every location where there were U.S. units stationed. In response to a specific question about the location of Al Jubail, Saudi Arabia, we conducted an M2C3 course in the area in November 1990. Its 131 graduates included about half of the medical staff of U.S. Navy Fleet Hospital Number 5, located at Al Jubail.

The last conflict where U.S. forces faced a similar chemical threat was World War I. We adopted a practice from that war in order to designate a Medical Corps M2C3 graduate as the Chemical Casualty Officer for each major unit, for example, Army or Marine Division and hospital unit. This individual in every major unit was attuned to the need to seek out and report information about chemical casualties, so that we could rapidly share clinical data throughout the theater. Operation of this unit-based network involved contact with clinical expert teams from the Institute. For the ground combat phase of Operation Desert Storm, teams of two experts from the Institute, physicians or clinical scientists, were placed with the Surgeons of the Army's XVIII Airborne Corps and VII Corps, and of the Marines' Expeditionary Force. These Corps-level Surgeons had the most accurate access to real-time casualty information and were prepared to facilitate communication with unit chemical casualty officers, as well as to ensure that Institute teams were placed with ground combat units at highest risk of exposure to chemical warfare agents.

To conclude, we had over 2000 health professionals, including physicians and physician assistants, especially trained to recognize chemical casualties throughout the AOR. The majority were assigned to the ground combat units at greatest risk foe exposure. There was a strong expectation of seeing chemical casualties and a solid network in place to share immediate clinical information about them. In January 1991 we made use of this network to gather complete information on safety and potential side effects from the administration of pyridostigmine bromide to 46,000 members of the XVIII Airborne Corps who took this compound for several days during the initial SCUD missile attacks at the beginning of Operation Desert Storm. We published this information later in 1991 in the Journal of the American Medical Association.

Based on the large number of trained medical observers we had everywhere in theater looking for chemical casualties, on their ability to report information to our expert teams, and on our proven ability to collect information using our network, I have no doubt about our ability to have recognized and reported a chemical warfare agent attack. We had the strongest medical reasons to rapidly share such information all through the theater, and commanders at all levels were well prepared to help us do so. There is nothing subtle about battlefield use of chemical warfare agents, and I can state with confidence that it simply did not occur against United States forces during Operation Desert Storm. Based on what is known about the effects of chemical warfare agents on the human body, I have seen no medical information that would cause me to speculate on whether accidental, subclinical, or low-level releases or exposures may have occurred, with one exception, a soldier I evaluated on March 3, 1991.

On that date I was in Iraq with support units to the rear of the 3d Armored Division. I and another physician were the clinical expert team for VII Corps, as I described earlier. I was called to see a soldier who was a cavalry scout in a 3d Armored Division unit, the 4th Squadron, 8th Cavalry. He had soiled his clothing while exploring an underground bunker complex late on March 1, and developed 4 small blisters, 1 to 2 cm diameter each, on his left arm early the following day. He was evaluated, decontaminated, and managed as a blister agent exposure by physicians assistants and physicians in his unit, all M2C3 graduates. Testing using Fox vehicle mass spectroscopy detection showed positive spectra for mustard or mustard-related compounds from his clothing and from the bunker complex he had explored.

When I examined the soldier on March 3, he told me that he felt well and had lost no duty time. His only abnormality was the 4 small blisters, each surrounded by a rim of reddened skin. Based on his history, especially the time lapse of 8 hours between the exploration of the bunker and his first symptoms, I agreed with the diagnosis of blister agent exposure and confirmed it on clinical grounds. I obtained a urine sample for later testing for thiodiglycol, a breakdown product of mustard in the body, and discussed the event with the medical personnel in the soldier's unit, with Major Cassinelli, the 3d Armored Division Surgeon, and with Lieutenant Colonel Adams, the 3d Armored Division Chemical Officer. Chemical personnel retained the soldier's soiled clothing and the Fox vehicle spectra tapes for later analysis. I also discussed the event with officers at Central Command headquarters, and learned that the exposure was reported to the press during Central Command's daily press briefing.

Later testing to confirm the exposure as mustard by analysis of clothing samples at an analytical laboratory in the United States was negative, possibly due to evaporative loss of what was at most a minimal level of contamination. The urine sample I obtained showed no evidence of the mustard breakdown product, thiodiglycol, on analysis at my Institute's laboratory. We expected this analysis to be negative as well, based on the low level of exposure. We published the event as an unconfirmed blister agent exposure in an article in the Journal of the U.S. Army Medical Department, January/February 1992, pages 34-36.

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 importance of this episode to the Committee's work is to demonstrate for you that we really did have a large number of trained people looking for chemical casualties, and a solid system to report the medical information. Because we were so well prepared, this event was very rapidly reported and assessed, and later studied in depth and published.