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COL Duong Nguyen, MC
Operations Desert Shield/Desert Storm will go down in history as a resounding success. However, future successes will depend on how much we take away from this experience in the form of lessons learned. This article is a warning message on the need for medical preparedness. The medical personnel shortage remains a problem for both commanders of field units and medical staff. The Professional Filler System, which provides clinicians to deploying combat medical and line units, is not aggressively administered and maintained. Medical Tactical Standard Operating Procedures are not fully integrated, nor are they used in Mission Essential Task List training. LOGOVERWATCH has potential but needs refinement. Finally, important medical and communication equipment needs upgrading to current state-of-the-art standards. On the plus side, the Combat LifeSaver program works well for intensive training on chemical casualties care. Combined with the high state of training and motivation of soldiers and medical professionals, many of the current shortcomings have been masked. This situation cannot go on indefinitely without a degradation of mission capability.
Introduction
On the morning of February 27, 1991, the 1st Squadron, 1st Cavalry Tactical Operations Center (TOC) sustained an artillery attack and incurred 23 casualties. Fortunately, none had life-threatening injuries. This is one of a few examples of mass casualties that occurred to the 1st Armored Division (IAD) during the Persian Gulf War. We have to admit that we were very fortunate during that war. Total casualties for IAO were 4 dead and 52 wounded in action.1 Nevertheless future wars may not be so benign. This article will review the readiness status of medical personnel, their training, and their equipment during the war. Also, air and ground medical evacuations will be discussed as thay are to be practiced under the procedures of the new concept of LOGOVERWATCH.
Medical Personnel
In the area of medical personnel, the Professional Filler System (PROFIS) was a major problem during Operations Desert Shield/Desert Storm (DS/DS). The system is supposed to have Health Services Command medical personnel designated in peacetime and ready to report to deploying field units on short notice. In reality, the PROFIS list exists and functions well only on paper. Many designated fillers, for a wide variety of reasons, sometimes personal, failed to deploy. This finding is shared by the Army’s Director of Professional Affairs and Chief of Medical Corps Affairs.2 The delayed assignment and report date of medical mobilization augmentees resulted in a lack of coordination between gaining units and medical officers.
At division level, the medical staff had to scramble to work with a PROFIS by-name list which was continually changing. New names were being added and substituted immediately upon deployment notification. Some medical officers were notified to report to their gaining unit less than 48 hours before deployment. Continuity of patient care was disturbed as scheduled surgical operations changed. In some cases, by the time the names were released, the unit was within 1 week of deployment. The initial report date to the gaining unit of 48 hours before departure was inadequate for coordination and processing. In fact, five medical officers did not arrive until the G-Day, creating problems of transportation and location of their assigned units during the fog of war.
Our recommendation is that of a PROFIS by-name list exists during peacetime. It should be updated continuously and it should be based on actual names for specific unit slots. These mobilization augmentees should be trained, at least twice yearly, with their reporting units so that they can be familiar with their operations.
Operation Plan (OPLAN)
The lack of physician augmentees hampered the liaison/coordination between the medical section and battalion/company staff. As a result, in some units, like the 2-1 Aviation Battalion, medical planning was barely addressed during staff meetings. Subsequently, medics had no concept of the operation nor how they should support it.
At the Corps Medical Brigade and Group level, the lack of effective and timely planning caused delays in providing the necessary support to the divisions. Command and Control and Communication of Mobile Army Surgical Hospitals (MASHs), Combat Support Hospitals (CSHs), and Evacuation Hospitals (EVACs) were drawn horizontally rather than vertically, as in normal doctrine. This chain of command and communication created nightmares for the division medical staff, who had to coordinate with other divisional areas of support of MASHs, CSHs, and EVACs. The initial observation was that there was no Health Service Support (HSS) plan to direct the medial support mission. Once a tactical OPLAN was written, there were frequent changes to the task organization that left gaps in time and availability of medical care for soldiers. For example, 1022nd Air Ambulance Company was task organized under 341st Medical Group at the last minute. This gave them an inadequate amount of time to rehearse with the supported division to work out problems.
Additionally, the Corps Medical Brigade and Group did not coordinate early enough with the division to ensure a coordinated effort, which contributed to confusion and unnecessary delays in medical support.
It is recommended that HSS planners ensure that their plans are supportive of the tactical commander’s plans, intents, and decisions and that they be mostly workable even during wartime. Task organizations should be done very early in the process so that units can have time for rehearsal. This may be due to the dissolution of the medical battalion and the incorporation of medical companies into the Main Support Battalion (MSB) and the three Forward support Battalions (FSB). Combining the National Guard (NG) and U.S Army Reserve Medevac units during the National Training Center and Joint Reserve Training Center rotations will force active units to include them in their operations plan and scheme of maneuver.
Reserve Medical Components
Designated physicians did not all come from active duty status: a sizable number of them were activated reservists and National Guard. Some had a prolific and expensive office to maintain. There were talks of filling bankruptcies because active reservist salaries cannot cover the overhead payments of their civilian practices. Others voiced a mass resignation after their tour of duty. Thanks to the victory parades and the medals leading to a surge of patriotism, it did not materialize right after their return from DS/DS. However. 12 to 18 months later, a large number of resignations did occur. It is recommended that Congress pass a law recognizing these legitimate losses for tax purposes and renumerate them like disaster-loss compensation. At the Defense Department level, it is recommended that these activated medical professional reservists receive the same pay as their active duty counterparts with pro-rated bonuses and benefits.
Medical and Communication Equipment
During DS/DS, communications continued to be a difficult problem. Proper timely evacuation of casualties requires reliable and secure radio equipment. Much of the TO&E communication capabilities were outdated and had marginal reliability. Division ambulances had only non-secure communication and corps ambulances were even worse: they did not have radios at all. Some helicopter radios could receive but not transmit. Coordination with and navigation to an unknown location of a FSB/MSB was possible only with secure communication. Also, TOC could not communicate in insecure mode, yet our ambulances were equipped with radios without secure systems (VINSON). Due to the vast distance in the desert, FM radios did not transmit far enough, yet our equipment consisted of FM radios and a few AMs that were constantly inoperable.
During our movement to contact, the rapid pace made all available communication impossible. MEDEVAC and Medical Operations were frequently out of range. There was no direct communication link with the next higher medical treatment facility, resulting in many difficulties because all messages were received through secondary channels. At times these messages were erroneous as well as misleading. We recommend that all medical radio equipment be replaced with up-to-date equipment and secure capabilities. It would be even better if medical units had a dedicated frequency. Such direct communication on internal frequencies for medical platoons between frontline medics and Battalion Aid Station (BASs) allows further internal contact and prevents confusion. Another recommendation is to field site MEDEVAC helicopters with the FSBs medical company. Also, equipping BASs with more radios enables them to monitor different nets.
Besides outdated and limited amounts of communication equipment, ambulance drivers were often lost in the vast desert. LORAN was not distributed to all medical vehicles. Precious evacuation time was wasted due to the lack of LORANs. MEDEVAC helicopters from the National Guard Bureau (NGB) were not fully mission capable. Aviation survivability equipment (infrared suppression kits and AN/APR-39 radar warning receivers) was installed at the last moment and precious training time was required prior to the ground war. UH-1 radios were also equipped with 1950-vintage FM ARC-54s and ARC-131s. We recommend that NG aircraft (especially MEDEVAC units) have a higher priority for aviation survivability equipment and train to that end. Also. NGB should expedite the existing upgrades of UH-1 radios already in line through AVSCOM.
Deployable Medical System (DEPMEDS)-equipped hospitals are wonderful, but they are not very mobile and cannot be assembled quickly (normally requiring 48 hours). With the fast pace of the modern war, a more mobile hospital is needed.
Common complaints from medical companies included outdated X-ray machines and supporting equipment, both of which were difficult to maintain and were non-functional most of the time. (This has been corrected, I was told, with the fielding of the low-capacity X-ray at clearing station level). The five-ton expando vans were very useful, functioning well in combat and in preparatory phases. It is recommended that new X-ray equipment that can meet clinical needs and can withstand austere field environments be obtained. The five-ton expando vans should be retained on the new MTO&E and not be eliminated.
Air and Ground Medical Evacuation
On aeromedical evacuation of casualties from the 1AD point of view, not only were there too few MEDEVAC helicopters, but division MEDEVAC units were also asked to perform backhaul missions from MASHs to CSHs and EVACs in addition to their original missions. This was due to the lack of backhaul support from Corps, resulting in an overuse of divisional air ambulances.
Concerning ground MEDEVAC, our Division Support Command (DISCOM Commander, anticipating mass casualties at the FLOT (Forward Line of Own Troops), directed that additional FSG medical resources be pushed forward in order to provide timely medical evacuation while allowing tactical commanders to continue combat operations. Such a directive involved combining FSB medical assets with forwarded maintenance support teams. Actual doctrine states that evacuation is always to the front with organic assets historically supporting one echelon below themselves. Our DISCOM Commander’s LOGOVERWATCH concept pushed medical assets further forward and combined them with non-organic resources to meet massive evacuation requirements. Designated cargo trucks from combat trains were used to evacuate patients to the rear. Although this concept was designed to clear a highly mobile battlefield, without coordination and practice at all levels, its implementation became difficult to achieve. For example, designated trucks appeared on lists at battalion and higher headquarters but were not known at company level. Since each unit did not seem to have enough haul capability for their organic equipment, all trucks were loaded to capacity. The obvious questions include: Which trucks? Will we have time to upload them ? Who will unload? Where do we put the cargo? Who is in charge? etc.
We recommend that if the LOGOVERWATCH concept for medical support is to be used in future conflicts, it must be practiced during peacetime by all involved units. The medical officer should be in charge and exercise the plan in conjunction with mass casualties (MASSCAL) training (to include unloading the trucks).
Training
Finally, on the positive side, the buddy aid/combat life savers (CLS) seemed to work well. Medics were in excellent spirits. Thanks to the 2 months in Saudi Arabia in the Intermediate Staging Area and Tactical Assembly Area, we had time for retraining in CLS skills. Combat medics were well trained and their performance was excellent. Also, with the expectation of chemical warfare, training in the management of chemical casualties was intensified. Training, retraining, and updates in chemical agents were given to all levels of division medical personnel. MASSCAL exercises were pit in higher priority. Forward Area Surgical Team deployment, after a few glitches in the beginning. Mostly in transportation and the selection of equipment, were corrected, was a plus note for medical support.
Miscellaneous
Although not directly related to mass casualties, patient tracking was a persistent problem. There was no system in place to track patients by name once they were medically evacuated out of the division. Despite this being mainly a G1 function, medical personnel felt, directly and indirectly, an inherent need to find this information. We recommend that future G1 planners include medical personnel in developing a system to resolve this nagging problem. On the other side, mental health care was at its best not only during DS/DS but also during our preparation of Operation Coming Home.
Conclusion
In terms of lessons learned, we must realize the limitations of any conclusions. Medical personnel and equipment still have to fight to find their niche in this downsizing Army. Naturally, for field commanders, bombs and bullets are infinitely more important than band-aids, but medical staff should be pro-active and not adopt a passive stance. The PROFIS system needs to be updated and prioritized. Universal tactical SOPs should be developed. HSS task organization should be formatted early in any conflict. Better communications are needed as a more mobile DEPMEDS, as well as updated X-ray equipment and upgraded MEDEVAC helicopters. The LOGOVERWATCH concept should be worked out and refined. Lastly, thanks to our dedicated soldiers and officers, field medical training has never been so successful: these efforts should not go unrecognized. The face that we were never overburdened by mass casualties during DS/DS may reinforce in the minds of field commanders that their emphasis on bombs and bullets was correct. This may not happen in the next war: even in the austere environment to come, we should provide the best medical support possible to our brave and patriotic sons and daughters who are protecting our country.
Acknowledgment
.
The author is indebted to the 1st Armored Division medical staff: without them, the redaction of this article will be impossible. Also, my sincere thank to LTG R. Griffith, The Army Inspector General and his staff, and to COL L. Dievendorf of The Office of the Surgeon General for the invaluable input in the preparation of this manuscript.
References
1.Ironsides Operation Desert Storm. February 24, 1991. Special issue for Iron Soldiers of Desert Storm
2.HSC Mercury May 1992.
______________________________________________________________________________________________
COL Nguyen served as Division Surgeon,1st Armored Division (US) during the Gulf War. He is now Chief. Preventive Medicine. DeWitt Army Community Hospital. Fort Belvoir. VA 22060.
The views expressed are the personal views of the author and do not necessarily represent the views of the U.S. Army of the Department of the Defense.
This Manuscript was received for review in November 1993. The revised manuscript was accepted for publication in October 1884.
Reprint & Copyright @ by Association of Military Surgeons of U.S.,1994.
Military Medicine. Vol. 159, November 1994
Operations Desert Shield/Desert Storm will go down in history as a resounding success. However, future successes will depend on how much we take away from this experience in the form of lessons learned. This article is a warning message on the need for medical preparedness. The medical personnel shortage remains a problem for both commanders of field units and medical staff. The Professional Filler System, which provides clinicians to deploying combat medical and line units, is not aggressively administered and maintained. Medical Tactical Standard Operating Procedures are not fully integrated, nor are they used in Mission Essential Task List training. LOGOVERWATCH has potential but needs refinement. Finally, important medical and communication equipment needs upgrading to current state-of-the-art standards. On the plus side, the Combat LifeSaver program works well for intensive training on chemical casualties care. Combined with the high state of training and motivation of soldiers and medical professionals, many of the current shortcomings have been masked. This situation cannot go on indefinitely without a degradation of mission capability.
Introduction
On the morning of February 27, 1991, the 1st Squadron, 1st Cavalry Tactical Operations Center (TOC) sustained an artillery attack and incurred 23 casualties. Fortunately, none had life-threatening injuries. This is one of a few examples of mass casualties that occurred to the 1st Armored Division (IAD) during the Persian Gulf War. We have to admit that we were very fortunate during that war. Total casualties for IAO were 4 dead and 52 wounded in action.1 Nevertheless future wars may not be so benign. This article will review the readiness status of medical personnel, their training, and their equipment during the war. Also, air and ground medical evacuations will be discussed as thay are to be practiced under the procedures of the new concept of LOGOVERWATCH.
Medical Personnel
In the area of medical personnel, the Professional Filler System (PROFIS) was a major problem during Operations Desert Shield/Desert Storm (DS/DS). The system is supposed to have Health Services Command medical personnel designated in peacetime and ready to report to deploying field units on short notice. In reality, the PROFIS list exists and functions well only on paper. Many designated fillers, for a wide variety of reasons, sometimes personal, failed to deploy. This finding is shared by the Army’s Director of Professional Affairs and Chief of Medical Corps Affairs.2 The delayed assignment and report date of medical mobilization augmentees resulted in a lack of coordination between gaining units and medical officers.
At division level, the medical staff had to scramble to work with a PROFIS by-name list which was continually changing. New names were being added and substituted immediately upon deployment notification. Some medical officers were notified to report to their gaining unit less than 48 hours before deployment. Continuity of patient care was disturbed as scheduled surgical operations changed. In some cases, by the time the names were released, the unit was within 1 week of deployment. The initial report date to the gaining unit of 48 hours before departure was inadequate for coordination and processing. In fact, five medical officers did not arrive until the G-Day, creating problems of transportation and location of their assigned units during the fog of war.
Our recommendation is that of a PROFIS by-name list exists during peacetime. It should be updated continuously and it should be based on actual names for specific unit slots. These mobilization augmentees should be trained, at least twice yearly, with their reporting units so that they can be familiar with their operations.
Operation Plan (OPLAN)
The lack of physician augmentees hampered the liaison/coordination between the medical section and battalion/company staff. As a result, in some units, like the 2-1 Aviation Battalion, medical planning was barely addressed during staff meetings. Subsequently, medics had no concept of the operation nor how they should support it.
At the Corps Medical Brigade and Group level, the lack of effective and timely planning caused delays in providing the necessary support to the divisions. Command and Control and Communication of Mobile Army Surgical Hospitals (MASHs), Combat Support Hospitals (CSHs), and Evacuation Hospitals (EVACs) were drawn horizontally rather than vertically, as in normal doctrine. This chain of command and communication created nightmares for the division medical staff, who had to coordinate with other divisional areas of support of MASHs, CSHs, and EVACs. The initial observation was that there was no Health Service Support (HSS) plan to direct the medial support mission. Once a tactical OPLAN was written, there were frequent changes to the task organization that left gaps in time and availability of medical care for soldiers. For example, 1022nd Air Ambulance Company was task organized under 341st Medical Group at the last minute. This gave them an inadequate amount of time to rehearse with the supported division to work out problems.
Additionally, the Corps Medical Brigade and Group did not coordinate early enough with the division to ensure a coordinated effort, which contributed to confusion and unnecessary delays in medical support.
It is recommended that HSS planners ensure that their plans are supportive of the tactical commander’s plans, intents, and decisions and that they be mostly workable even during wartime. Task organizations should be done very early in the process so that units can have time for rehearsal. This may be due to the dissolution of the medical battalion and the incorporation of medical companies into the Main Support Battalion (MSB) and the three Forward support Battalions (FSB). Combining the National Guard (NG) and U.S Army Reserve Medevac units during the National Training Center and Joint Reserve Training Center rotations will force active units to include them in their operations plan and scheme of maneuver.
Reserve Medical Components
Designated physicians did not all come from active duty status: a sizable number of them were activated reservists and National Guard. Some had a prolific and expensive office to maintain. There were talks of filling bankruptcies because active reservist salaries cannot cover the overhead payments of their civilian practices. Others voiced a mass resignation after their tour of duty. Thanks to the victory parades and the medals leading to a surge of patriotism, it did not materialize right after their return from DS/DS. However. 12 to 18 months later, a large number of resignations did occur. It is recommended that Congress pass a law recognizing these legitimate losses for tax purposes and renumerate them like disaster-loss compensation. At the Defense Department level, it is recommended that these activated medical professional reservists receive the same pay as their active duty counterparts with pro-rated bonuses and benefits.
Medical and Communication Equipment
During DS/DS, communications continued to be a difficult problem. Proper timely evacuation of casualties requires reliable and secure radio equipment. Much of the TO&E communication capabilities were outdated and had marginal reliability. Division ambulances had only non-secure communication and corps ambulances were even worse: they did not have radios at all. Some helicopter radios could receive but not transmit. Coordination with and navigation to an unknown location of a FSB/MSB was possible only with secure communication. Also, TOC could not communicate in insecure mode, yet our ambulances were equipped with radios without secure systems (VINSON). Due to the vast distance in the desert, FM radios did not transmit far enough, yet our equipment consisted of FM radios and a few AMs that were constantly inoperable.
During our movement to contact, the rapid pace made all available communication impossible. MEDEVAC and Medical Operations were frequently out of range. There was no direct communication link with the next higher medical treatment facility, resulting in many difficulties because all messages were received through secondary channels. At times these messages were erroneous as well as misleading. We recommend that all medical radio equipment be replaced with up-to-date equipment and secure capabilities. It would be even better if medical units had a dedicated frequency. Such direct communication on internal frequencies for medical platoons between frontline medics and Battalion Aid Station (BASs) allows further internal contact and prevents confusion. Another recommendation is to field site MEDEVAC helicopters with the FSBs medical company. Also, equipping BASs with more radios enables them to monitor different nets.
Besides outdated and limited amounts of communication equipment, ambulance drivers were often lost in the vast desert. LORAN was not distributed to all medical vehicles. Precious evacuation time was wasted due to the lack of LORANs. MEDEVAC helicopters from the National Guard Bureau (NGB) were not fully mission capable. Aviation survivability equipment (infrared suppression kits and AN/APR-39 radar warning receivers) was installed at the last moment and precious training time was required prior to the ground war. UH-1 radios were also equipped with 1950-vintage FM ARC-54s and ARC-131s. We recommend that NG aircraft (especially MEDEVAC units) have a higher priority for aviation survivability equipment and train to that end. Also. NGB should expedite the existing upgrades of UH-1 radios already in line through AVSCOM.
Deployable Medical System (DEPMEDS)-equipped hospitals are wonderful, but they are not very mobile and cannot be assembled quickly (normally requiring 48 hours). With the fast pace of the modern war, a more mobile hospital is needed.
Common complaints from medical companies included outdated X-ray machines and supporting equipment, both of which were difficult to maintain and were non-functional most of the time. (This has been corrected, I was told, with the fielding of the low-capacity X-ray at clearing station level). The five-ton expando vans were very useful, functioning well in combat and in preparatory phases. It is recommended that new X-ray equipment that can meet clinical needs and can withstand austere field environments be obtained. The five-ton expando vans should be retained on the new MTO&E and not be eliminated.
Air and Ground Medical Evacuation
On aeromedical evacuation of casualties from the 1AD point of view, not only were there too few MEDEVAC helicopters, but division MEDEVAC units were also asked to perform backhaul missions from MASHs to CSHs and EVACs in addition to their original missions. This was due to the lack of backhaul support from Corps, resulting in an overuse of divisional air ambulances.
Concerning ground MEDEVAC, our Division Support Command (DISCOM Commander, anticipating mass casualties at the FLOT (Forward Line of Own Troops), directed that additional FSG medical resources be pushed forward in order to provide timely medical evacuation while allowing tactical commanders to continue combat operations. Such a directive involved combining FSB medical assets with forwarded maintenance support teams. Actual doctrine states that evacuation is always to the front with organic assets historically supporting one echelon below themselves. Our DISCOM Commander’s LOGOVERWATCH concept pushed medical assets further forward and combined them with non-organic resources to meet massive evacuation requirements. Designated cargo trucks from combat trains were used to evacuate patients to the rear. Although this concept was designed to clear a highly mobile battlefield, without coordination and practice at all levels, its implementation became difficult to achieve. For example, designated trucks appeared on lists at battalion and higher headquarters but were not known at company level. Since each unit did not seem to have enough haul capability for their organic equipment, all trucks were loaded to capacity. The obvious questions include: Which trucks? Will we have time to upload them ? Who will unload? Where do we put the cargo? Who is in charge? etc.
We recommend that if the LOGOVERWATCH concept for medical support is to be used in future conflicts, it must be practiced during peacetime by all involved units. The medical officer should be in charge and exercise the plan in conjunction with mass casualties (MASSCAL) training (to include unloading the trucks).
Training
Finally, on the positive side, the buddy aid/combat life savers (CLS) seemed to work well. Medics were in excellent spirits. Thanks to the 2 months in Saudi Arabia in the Intermediate Staging Area and Tactical Assembly Area, we had time for retraining in CLS skills. Combat medics were well trained and their performance was excellent. Also, with the expectation of chemical warfare, training in the management of chemical casualties was intensified. Training, retraining, and updates in chemical agents were given to all levels of division medical personnel. MASSCAL exercises were pit in higher priority. Forward Area Surgical Team deployment, after a few glitches in the beginning. Mostly in transportation and the selection of equipment, were corrected, was a plus note for medical support.
Miscellaneous
Although not directly related to mass casualties, patient tracking was a persistent problem. There was no system in place to track patients by name once they were medically evacuated out of the division. Despite this being mainly a G1 function, medical personnel felt, directly and indirectly, an inherent need to find this information. We recommend that future G1 planners include medical personnel in developing a system to resolve this nagging problem. On the other side, mental health care was at its best not only during DS/DS but also during our preparation of Operation Coming Home.
Conclusion
In terms of lessons learned, we must realize the limitations of any conclusions. Medical personnel and equipment still have to fight to find their niche in this downsizing Army. Naturally, for field commanders, bombs and bullets are infinitely more important than band-aids, but medical staff should be pro-active and not adopt a passive stance. The PROFIS system needs to be updated and prioritized. Universal tactical SOPs should be developed. HSS task organization should be formatted early in any conflict. Better communications are needed as a more mobile DEPMEDS, as well as updated X-ray equipment and upgraded MEDEVAC helicopters. The LOGOVERWATCH concept should be worked out and refined. Lastly, thanks to our dedicated soldiers and officers, field medical training has never been so successful: these efforts should not go unrecognized. The face that we were never overburdened by mass casualties during DS/DS may reinforce in the minds of field commanders that their emphasis on bombs and bullets was correct. This may not happen in the next war: even in the austere environment to come, we should provide the best medical support possible to our brave and patriotic sons and daughters who are protecting our country.
Acknowledgment
.
The author is indebted to the 1st Armored Division medical staff: without them, the redaction of this article will be impossible. Also, my sincere thank to LTG R. Griffith, The Army Inspector General and his staff, and to COL L. Dievendorf of The Office of the Surgeon General for the invaluable input in the preparation of this manuscript.
References
1.Ironsides Operation Desert Storm. February 24, 1991. Special issue for Iron Soldiers of Desert Storm
2.HSC Mercury May 1992.
______________________________________________________________________________________________
COL Nguyen served as Division Surgeon,1st Armored Division (US) during the Gulf War. He is now Chief. Preventive Medicine. DeWitt Army Community Hospital. Fort Belvoir. VA 22060.
The views expressed are the personal views of the author and do not necessarily represent the views of the U.S. Army of the Department of the Defense.
This Manuscript was received for review in November 1993. The revised manuscript was accepted for publication in October 1884.
Reprint & Copyright @ by Association of Military Surgeons of U.S.,1994.
Military Medicine. Vol. 159, November 1994
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