Ulyins OPERATION DESERT STORM Improvements Requdred
United States General Accounting OfficeAulyinsReport to ihe Chairman, Subco'uwdiftee,on Military Forces and Personn%-.A,Committee on Armed Servi 6 e-s,'Aiýe ofRepresentativesOPERATION DESERTSTORMImprovementsRequdred in the's"rawWartime MedicalProgramou
AOUnited StatesGeneral Accounting OfficeF or- C.Acc.,'Washington, D.C. 20548NNational Security andInternational Affairs DivisionB-253207DriC TAbUi ,';o. '.t05ByDistribution IJuly 28, 1993Avadiability CodesThe Honorable Ike SkeltonstDiChairman, Subcommittee on MilitaryForces and PersonnelAval aS /orSpeclCommittee on Armed ServicesHouse of RepresentativesDear Mr. Chairman:Dhi'.3ihJ.'r'-'vD 3U, .'lAt the request of the former Chairman, we reviewed the capabilities ofNavy medical units that supported Operations Desert Shield and DesertStorm. Specifically, we determined whether the Navy's medical units(1) were prepared to perform their assigned missions, (2) experiencedproblems in identifying and deploying medical personnel, (3) were staffedwith trained personnel, and (4) had their required equipment and supplies.In addition, we examined the Navy's efforts to change medical operationsbased on lessons learned from the Persian Gulf War. We issued a report onthe Army's medical units' and will issue a report on the Air Force's medicalunits at a later date.esults in BriefNavy medical units were assigned wartime missions they were notprepared to fulfill. They were neither staffed nor equipped to care for thenumbers of casualties they were told to expect, provide noncombatmedical care, support the evacuation of casualties out of theater, orreceive large numbers of chemically contaminated casualties.The personnel information systems used to assign individuals to Navymedical units contained incomplete and outdated information. Manyphysicians and nurses who were scheduled to deploy did not do so for avariety of reasons. In addition, medical personnel had not trained duringpeacetime to perform their wartime mission. Personnel also raisedconcerns about the ability to obtain equipment and supplies necessary totreat mass casualties and to perform other missions. Fortunately, the6-month period between deployment and the start of the ground warallowed individuals and units to prepare for their wartime responsibilities.By most accounts, medical units supplied by the Navy were able toprovide adequate care for those in need. However, had the Navy incurred'Operation Desert Slorm: Full Army Medical Capability Not Achieved (GAO/NSIAD-92-175, Aug. 18,1992).Page 1GAO/NSIAI) '3 189 Operation Desert Storm
B-253207the predicted number of casualties, or had the ground war started earlieror lasted longer, these units may not have been able to provide adequatecare.The Navy has reviewed its lessons-learned reports and directed specificoffices to fix identified problems, but it did not establish time frames tocorrect these problems. According to Navy officials, time frames are nowbeing set.B-ackgroundThe Navy deployed almost 12,000 medical personnel to supportOperations Desert Shield and Desert Storm. Over two-thirds of thesepersonnel deployed to units comprising the second and third echelons ofthe Navy's five echelon system of care for war casualties. These unitsincluded two hospital ships, three combat zone fleet hospitals, threeMarine Corps medical battalions, and seven casualty receiving andtreatment ships. A general description of the Navy's medical care system isprovided in appendix I.Naval medical support to echelons II and III was deployed in two phases.Phase 1 began in early August 1990, and by the first week of November,over 4,200 active-duty personnel had deployed to Southwest Asia. Inanticipation of the air war, phase 2 began in December 1990 and extendedinto January 1991. During this phase about 4,300 personnel-a majority ofthem reservists-deployed to staff echelon II and III medical units.According to Navy officials, their deployment actions were based on thetheater command's medical requirements. These requirements consideredfactors such as the nature and duration of the operation planned, expectedcombat intensity, casualty rates, estimates of disease and non-battleinjuries, evacuation policy, and types and capabilities of medical unitsavailable. As a result, the Navy was tasked to provide specific medicalunits in support of Operations Desert Shield and Desert Storm.Medical Units WereAssigned MissionsThey Were NotPrepared to FulfillThe Navy demonstrated its ability to rapidly provide significant medicalcapabilities in-theater. Within 5 days of activation, the hospital ships weredeployed and en route to the Persian Gulf, where they arrived prepared totreat casualties. The deployment of the fleet hospitals showed thatpre-positioned deployable medical systems could be assembled and fullyoperational within a combat zone in about 2 weeks. However, Navymedical units were given missions by the theater command that they werePage 2GAO/NSIAD-93.189 Operation Desert Storm
B-253207neither designed, staffed, nor equipped to perform. These missionsincluded handling more casualties than they were designed for, providingnoncombat medical care, supporting the evacuation of casualties out oftheater, and receiving large numbers of chemically contaminatedcasualties.Although the Navy provided all the medical units that were requested bythe theater command, casualty predictions were about twice as high asthese units were designed to handle. For example, although hospital shipswere designed to receive up to 100 casualties per day over a sustainedperiod of time, medical personnel were told to expect between 200 to300 casualties per day. Similarly, combat zone fleet hospitals that weredesigned to receive 80 casualties per day were expected to receive up to200 casualties per day.Given the number of casualties projected, Navy medical personnel wereconcerned that there would have been staff shortages, even though Navymedical units were staffed to their authorized levels. Identified criticalshortages would have included general and orthopedic surgeons;anesthesiologists; operating room nurses and nurse anesthetists; andnonmedical personnel for security, supply, administration, and foodservice duties. For example, one fleet hospital had a combined total of11 anesthesiologists and i,urse anesthetists to support 24 surgeons.According to personnel we spoke with, at least 16 anesthesia providers areneeded to support 24 surgeons.A hospital ship's ability to receive and treat the number of expectedcasualties would have been exacerbated by difficulties in transportingpatients to the ships. All patients brought to the hospital ships had to betransported by helicopter because access to the hospital ships by sea wasnot considered a reliable option. Due to rough sea conditions, ship-to-shippatient transfers were deemed unsafe. Helicopter transport to the hospitalships was also problematic because (1) each ship had only one landingpad; (2) helicopters' capacities were limited; and (3) the ships had to stayout of harm's way, and as a result, the distance and travel time to transportpatients from the battle area increased. Under these circumstances, thehospital ships would not have been fuilly used to treat mass casualties.Fleet hospitals and hospital ships are desigi, cd to provide combat-related,surgically intensive medical care. Fortunately, these types of assets did nothave to be used because the United States and its allies had so fewcasualties. Nonetholp'o, medir",O ,mit --particularly the fleetPage 3GAO/NSIAD-93-189 Operation Desert Storm
B-253207hospitals--experienced shortages of equipment and supplies needed tosupport the vast majority of medical care that these units provided duringOperations Desert Shield and Desert Storm. Noncombat medical needsplaced a large demand on medical services, including orthopedic, dental,and gynecological services in support of a continuous flow of patients onsick call. For example, females comprised about 6 percent of the forcesdeployed to Southwest Asia, yet only one gynecologist was assigned todeployed hospitals, and no space or examination table was allocated in thefleet hospitals for gynecologic examinations. While medical units hadsome sick call items, the quantities on hand could not accommodatepatients' demands. In the absence of appropriate equipment and supplies,patients that could have been treated in-theater had to be evacuated toother facilities and were away from their operational units for significantperiods of time.The Air Force was responsible for evacuating casualties out of SouthwestAsia. During Operations Desert Shield and Desert Storm, the Air Forcerequired all services' medical units to have on hand equipment andsupplies to last 5 days for each patient being evacuated from the area, aswell as personnel to monitor patients on respirators and cardiac monitors.In addition, two of the fleet hospitals were directed to provide care forpatients assembled at an evacuation staging site. These requirements werenot anticipated by Navy medical units; consequently, equipment andstaffing to support patient evacuations were not included in the fleethospital and hospital ship authorization levels. According to medicalpersonnel assigned to these units, ventilators, intravenous fluids,medications, blankets, litters, and a host of other equipment and supplieswould have been rapidly exhausted if casualty rates had approachedpredicted levels.According to military doctrine, casualties are evaluated for chemical,biological, and radiological contamination and, if necessary,decontaminated by combat forces prior to evacuation for medicaltreatment. However, all medical units were required to be prepared toreceive contaminated casualties. Prior to the start of the ground war, thetheater command told medical personnel assigned to the hospital shipsand fleet hospitals to expect that up to 15 percent of the casualties theyreceived would be contaminated. While the ability of these medical unitsto operate in a contaminated environment was not tested, officials weinterviewed indicated that these units were not designed or staffed tohandle large numbcrs of contaminated casualties for the followingreasons:Page 4GAO/NSIAD.93-189 Operation Desert Storm
B-253207" The hospital ship's collective protection systems were inadequate. Awash-down system was improvised to reduce the concentration ofairborne contaminants; however, coverage would have been spotty andundependable. There was no reliable plumbing system to remove waterfrom the decontamination stations. Contaminated water would havecollected in pools and spilled onto lower decks, potentially spreadingcontamination. Decontamination station exhaust vents were located nearthe ship's air intake vents, posing the risk of airborne contamination to theentire ship." Fleet hospitals did not contain decontamination stations. Consequently,they had to establish makeshift stations. One of the fleet hospitals had notcompleted its station when the ground war started and therefore, couldnot have handled contaminated casualties."* Prior to deployment, very few fleet hospital and hospital ship personnelwere trained in either patient decontamination or in the treatment ofchemically contaminated casualties. Navy officials estimated that very fewof the Navy physicians (less than 10 percent) who deployed to SouthwestAsia were trained to treat chemically contaminated casualties, in spite ofNavy guidance that medical personnel must be trained to overcomedifficulties imposed by a chemical environment.oymen andsJJLL nof dThe Medical Personnel Unit Augmentation System monitors the staffingSsignment ofidentified active duty personnel are drawn from medical facilities in thecontinental United States to augment deployed medical units to specifiedstaffing levels. Many revisions were made to the rosters of personnel whowere to deploy during the first phase of the operations. An official at onePersonnelr Not EfficientlySdicalmagedrequirements of deploying medical units. For a deployment, previouslyunit estimated that between one-third and one-half of the assignedpersonnel were replaced in the 3 days between the posting of the originalroster and the deployment to Southwest Asia. In another unit, over20 percent of the personnel identified through the augmentation systemdid not deploy. Although these problems did not ultimately delay theactivation of medical units in-theater, they did result in the deployment ofsome unqualified personnel. In some cases, personnel deployed and had tobe returned to the United States for medical, administrative, andhumanitarian reasons.Deployment rosters were modified for two principal reasons. First, fullmobilization did not occur. For a full mobilization, requirements tomaintain comprehensive health care for military personnel and theirdependents and medical residency programs cease. Consequently, medicalPage 5GAO/NSIAD-93-189 Operation Desert Storm
B-253207personnel needed to support beneficiary care in Navy medical facilities,medical residents, and graduate education instructors were considerednondeployable and had to be replaced on the rosters. A methodology tostaff the hospital facilities at less than full operating status did not exist.Second, staff selection was often based on outdated, inaccurateinformation. Medical facilities are responsible for maintaining anup-to-date readiness checklist for each individual assigned to a deployingmedical unit. This checklist documents an individual's ability-orreadiness-to deploy. Readiness checklists dating back to 1990 weredestroyed prior to our audit and thus were not available for review.However, according to Navy officials, some individuals on the rosters werefound to be nondeployable for reasons that should have been documented,including illnesses and injuries, pregnancies, and ongoing legal issues. Insome cases these individuals were no longer assigned to their medicalfacility of record. 2 Contrary to policy, medical personnel indicated thatmany of the individuals assigned to deploying medical units were unawareof their wartime assignments. This was particularly true among thejunior-level officers and enlisted personnel. As a result, personnel wereless prepared to deploy than they should have been. In some instances,individuals reported for deployment without service, health, and payrecords; documentation of security clearances; and uniforms. One unit, forexample, indicated that almost no one had powers of attorney or wills onrecord prior to deployment. (Administrative support personnel were ableto assist in solving these problems and contributed to the rapiddeployment of Navy medical units.)During the second deployment phase, about 95 percent of the medicalpersonnel who mobilized to serve in fleet hospitals and on hospital shipswere reserve personnel. Naval Reserve commands received advancenotice to designate personnel to deploy. Therefore, when the officialnotification was issued, they had already completed comprehensivereviews and corrected deployment rosters. Matching the qualifications ofreservists to unit requirements was a problem, however, because thereserve personnel data bases did not identify physicians and nurses bytheir areas of expertise. Further, the decision to assign reservists to thetwo hospital ships, until then an unassigned mission, meant that they hadnot satisfied training requirements specific to the hospital ships.'Medical facilities are reqiiired to verify the readincss ('hCeklisZs at least annually. In addition, medicalfacilities are required to track events that reduce an individual's readiness, inclu(ling reassignment.Page 6GAO/NSIAD-93-189 Operation Desert Storm
B-253207Irsonnel Arrived-Theater Withoutlequate TrainingMany personnel assigned to hospital ships and fleet hospitals arrivedin-theater without completing necessary operational training. Peopleassigned to hospital ships are required to complete instruction in firefighting; shipboard orientation; damage control; and chemical, biological,and radiological defense. Yet prior to deployment, less than half of thoseassigned to the ships were trained in these areas, and over 75 percent hadno prior shipboard experience.Operational training shortfalls were also reported for personnel assignedto the fleet hospitals. The Navy expects at least 40 percent of thepersonnel to be trained in constructing and operating a fleet hospital.While this level was achieved for the reserve personnel assigned to fleethospitals, less than 20 percent of the active duty personnel who deployedwith the first fleet hospital had received this training. Medical personnelsaid that fleet hospital training was instructive but should be broadened tooffer participants an opportunity to practice medicine under fieldconditions.Unlike the hospital ships, which contained state-of-the-art medicalequipment, the fleet hospitals were equipped with technology from the1970s and early 1980s. Because of the equipment's age, most of thepersonnel assigned to the fleet hospitals had not trained with severalpieces of equipment before they arrived in-theater. This factor contributedto a lack of confidence in the quality of the equipment and suppliesavailable and a belief among the medical staff with whom we spoke thatthey would have provided less than adequate care based on present daystandards.Another operational deficiency involved the lack of training andexperience in treating trauma patients. Although the physicians and nurseswho deployed were described as experienced and competent, many ofthem had never treated trauma patients-or not for a considerable periodof time-and a majority of them had not completed training in combatcasualty care. This lack of training was magnified for reserve corpsmenand nurses, many of whom held nonmedical civilian jobs and thus did notperform their medical duties during peacetime. Fortunately, the prolongedbuildup of forces allowed fleet hospital personnel to familiarizethemselves with the equipment and all Navy medical personnel tocomplete medical and operational training.Page 7GAO/NSIAD-93-189 Operation Desert Storm
B-253207LackInventoryofControls Hamperedthe Flow ofEquipment aovermandSuppliesControl of medical equipment and supplies prior to and during OperationsDesert Shield and Desert Storm was inadequate. Units reported thatout-of-cycle calibration of equipment had to be completed, and someequipment was not kept in its required state of readiness. For example,half of one unit's 40 ventilators did not work and needed repair afterthey arrived in-theater. Units also had unanticipated compatibilityproblems with supplies. For example, cartridges issued with surgical gunsdid not fit, and the film issued with x-ray machines did not match,necessitating a stronger dosage of radiation to be given to patients.Medical units' equipment and supplies are required to be inventoriedperiodically; however, all of the units we visited reported discrepanciesbetween the recorded and the actual inventories. Missing items rangedfrom patient care documentation forms, spare parts, and repair sets, to anarray of diagnostic laboratory equipment and supplies. One unit had nowritten record of what supplies and equipment were present, in whatquantities, and where they were stored. This necessitated taking a physicalinventory and comparing what was in stock against what wasauthorized-a process not completed until after the medical unit haddeployed. At the termination of hostilities, the unit still had not receivedits complete inventory.Fleet hospital personnel reported that equipment and supplies often werenot packed according to their manifests, making field assembly moretime-consuming. Contrary to policy, materiel from different functionalareas was packed together, and in one case, materiel that was supposed tobe in 1 or 2 containers was dispersed among 30. When filled requisitionsarrived in-theater, the supplies frequently we
'Operation Desert Slorm: Full Army Medical Capability Not Achieved (GAO/NSIAD-92-175, Aug. 18, 1992). Page 1 GAO/NSIAI) '3 189 Operation Desert Storm. B-253207 the predicted number of casualties, or had the ground war started earlier . Page 3 GAO/
Problems However, during Operation Desert Shield/Desert Storm, they were also required to act as initial supply points for Army medical units and as resupply points for Air Force, Navy, and Marine Corps medical units. . Page 6 GAO/NSIAD-92-175 Army Medical Capability in Desert Storm
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- 10-15% will be on Natural History of the Sonoran Desert You already have a study guide (outlines and key concepts) Review session: Wed the 10th 11 AM Koffer 204 Natural History of the Sonoran Desert Natural History of the Sonoran Desert 1. What is a desert? 2. Desert regions and desert habitats 3. Adaptation in deserts (generally) 4.
Deserts range from: hot deserts, such as the Sonoran Desert, Mojave Desert and Chihuahua Desert of North . America, and the Sahara Desert of Africa; temperate deserts, as in the Takla Makan Desert of China; and cold deserts, where precipitation falls mainly as snow or fog, such as the Atacama Desert of South America, the Gobi
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BATTLE ON THE BOOKSHELVES: HISTORY, DESERT STORM, AND THE UNITED STATES ARMED FORCES, by MAJ Michael R. Eastman, 121 pages. After the Persian Gulf War of 1991, the Department of Defense presented the United States Congress with an official, joint account of Desert Storm. At the same time, each of
Theme 7: Astrophysics The situation at the end of the 19th century can be pictured by reading Agnes Clerke’s authoritative Popular History of Astronomy During the Nineteenth Century. There was much factual knowledge, and a start on classification, but very little understanding. Sir Norman Lockyer (1836 1920) had begun to argue, based on observations of solar and stellar spectra, that .
