Operations Desert Shield and Desert Storm: neurosurgical experience and transformative legacy for operational medicine

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  • 1 Division of Neurosurgery, Connecticut Children’s, Hartford;
  • | 2 Departments of Surgery and
  • | 3 Pediatrics, UConn School of Medicine, Farmington;
  • | 4 UConn School of Medicine, Farmington, Connecticut;
  • | 5 Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda;
  • | 6 Department of Surgery, Uniformed Services University, Bethesda, Maryland;
  • | 7 Idaho College of Osteopathic Medicine, Meridian, Idaho;
  • | 8 Department of Neurosurgery, University of Washington Medical Center, Seattle;
  • | 9 Departments of Neurological Surgery,
  • | 10 Radiology, and
  • | 11 Global Health, UW School of Medicine, Seattle, Washington;
  • | 12 Department of Neurosurgery, Crouse Health, Syracuse, New York;
  • | 13 Departments of Neurology,
  • | 14 Neurosurgery,
  • | 15 Anesthesiology, and
  • | 16 Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and
  • | 17 Department of Neurosciences, Inova Fairfax Medical Campus, Falls Church, Virginia
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Operation Desert Storm (ODS) was an astounding success for combat arms and logistical units of the US Military. In contrast, Department of Defense (DOD) medical units struggled to keep pace with combat operations and were fortunate that casualty estimates for a Cold War–era battle failed to materialize. The medical support plan included a large contingent of active-duty and reserve neurosurgeons in anticipation of care requirements for more than 500,000 deploying service members engaged in a large-scale combat operation. Here, the authors review the clinical experience and operational challenges encountered by neurosurgeons deployed in support of this conflict and discuss legacies of ODS for both surgeons and the military medical system.

ABBREVIATIONS

CDAT = Casualty Data Assessment Team; COMMZ = communication zone; CONUS = Continental United States; CZ = combat zone; DNBI = disease and nonbattle injury; DOD = Department of Defense; EVAC = Evacuation Hospital; GH = General Hospital; KIA = killed in action; ODS = Operation Desert Storm; PHI = penetrating head injury; PROFIS = Professional Filler System.

Operation Desert Storm (ODS) was an astounding success for combat arms and logistical units of the US Military. In contrast, Department of Defense (DOD) medical units struggled to keep pace with combat operations and were fortunate that casualty estimates for a Cold War–era battle failed to materialize. The medical support plan included a large contingent of active-duty and reserve neurosurgeons in anticipation of care requirements for more than 500,000 deploying service members engaged in a large-scale combat operation. Here, the authors review the clinical experience and operational challenges encountered by neurosurgeons deployed in support of this conflict and discuss legacies of ODS for both surgeons and the military medical system.

Operation Desert Storm (ODS) was the first peer-to-peer conflict following the end of the Cold War and has been described as “a triumph of Coalition strategy, of international cooperation, of technology, and of people.”1 The rapid deployment of medical assets to support combat troops in this conflict was unprecedented. As the Army Surgeon General observed, “we accomplished in the first 3 weeks what it took 3 months to do in Korea, and literally years to do in World War II and Vietnam.”2 The final medical footprint included nearly 40,000 personnel and 18,530 in-theater hospital beds.1 The US Central Commander, General Norman Schwarzkopf, stated that this was the “largest medical mobilization that has taken place since World War II.”3 To our knowledge, a review of the experience of neurosurgeons contributing to this effort has not been previously reported. In the present review, in addition to topics of historical interest, we provide context for understanding the current utilization of neurosurgeons in the US Military, information that may inform future operational planning and individual readiness.

Timeline of ODS

On August 2, 1990, Iraqi Armed Forces invaded and occupied neighboring Kuwait. The Iraqi military of 1990 was formidable and battle tested. Iraq possessed the world’s fourth largest Army, along with advanced technology that included modern artillery, tanks, aircraft, ballistic missiles, a sophisticated ground-based air defense system, and active chemical/biological weapons programs.1 Figure 1 provides a timeline of the invasion and subsequent international response.4 US and coalition allies achieved a decisive victory, culminating their efforts with a ground campaign that collapsed Iraqi resistance in less than 100 hours (Fig. 2).5 Combat-related US casualties totaled 143 killed in action (KIA), 4 who died of wounds, and 467 who were wounded in action (WIA).6

FIG. 1.
FIG. 1.

Timeline of Operation Desert Shield and ODS.

FIG. 2.
FIG. 2.

Coalition forces at onset of ground campaign. Position of forces at the onset of the ground offensive in February of 1991. More than 700,000 allied forces would stand against the Iraqi military and deliver a decisive victory less than 100 hours after crossing the line of departure on February 24, 1991. Note: The Tapline (Trans-Arabian Pipeline) Road served as a geographic reference for the boundary between the CZ and COMMZ. JFCE = Joint Forces Command East; JFCN = Joint Forces Command North; MCC = Marine Corps Central Command; VII = VII Corps; XVIII = XVIII Airborne Corps.

Deployment of Neurosurgical Assets During ODS

The mission of military medicine is “to minimize the effects of disease, injuries, and wounds on unit readiness, effectiveness, and morale.”1 In 1991, the Department of Defense (DOD) medical assets were organized along a continuum extending from frontline Echelon 1 care within the combat zone (CZ) through Echelon 5 Medical Centers (MEDCENs) based in the Continental United States (CONUS) (Fig. 3). Per military doctrine, forward neurosurgical assets are positioned no closer to the CZ than Echelon 3 facilities, which are positioned within the communication zone (COMMZ). Insight into decision-making regarding the deployment of neurosurgical providers in support of ODS is limited. Estimates for the number of neurosurgical providers deployed to the Gulf region range from 35 to 47.7,8 While the Army published specific guidance regarding the required number of neurosurgeons in support of combat operations,9 the Navy and Air Force lacked similar published guidance (P. K. Carlton and Chris Neal, email, February 2022).

FIG. 3.
FIG. 3.

Echelons of care within the military healthcare system circa 1991. The military healthcare system is organized in a hierarchical fashion to facilitate operational planning based on proximity to the CZ and medical capability. The terminology (Echelons of care) and separate care levels circa 1991 are as follows. Echelon 1: Emergency lifesaving measures administered at unit level to allow for stabilization and evacuation to the next level. Typically, care is administered by the combat lifesaver or medic. Echelon 2: The civilian surgeon would consider this the equivalent of emergency department–level care similar to the primary and secondary survey in Advanced Trauma Life Support. Limited surgical intervention is available. Echelon 3: Care provided in a military treatment facility staffed and equipped for the provision of resuscitative surgery and postoperative treatment. Typically, the first level of care at which neurosurgical interventions are performed. Echelon 4: Medical treatment facility staffed for general, specialty, surgical, and rehabilitative care with a goal of possible return to duty. Typically located in rear areas well beyond the CZ. Echelon 5: Medical treatment facility in the CONUS with comprehensive services to include reconstructive and rehabilitative care. CSH = combat support hospital; FH = field hospital; MASH = mobile Army surgical hospital; MEDCEN = medical center; SH = station hospital. Note: Additional descriptions of medical facilities are included in Supplementary Table 1.

Neurosurgeons were assigned to forward facilities (Supplementary Table 1) by one of three mechanisms. For larger facilities (examples include Army General Hospitals [GHs] or Navy Hospital Ships), neurosurgeons were defined members of the medical staff. In others, neurosurgeons were requested by command elements to augment a facility in order to provide neurosurgical capability (for example, the USS Nassau). Finally, Army Medical Detachments known as “K Teams,” which consisted of two neurosurgeons plus supporting anesthesia, nursing, and surgical scrub technicians as well as equipment and transportation assets, were deployed as independent units attached to facilities based on operational requirements. At least six of these K Teams were deployed during ODS.10

Neurosurgical support during the precombat phase of this deployment (Operation Desert Shield) was provided by active-duty Army and Navy assets. Members of the 359th Medical Detachment (K Team) were the first Army providers in Saudi Arabia, arriving on September 9, 1990 (John Brophy, personal communication, January 2022). This team was initially attached to the 28th Combat Support Hospital outside of Dhahran, Saudi Arabia. Navy assets arriving in August/September included providers attached to Fleet Hospital 5 as well as the hospital ships USNS Mercy and Comfort.11,12 More active-duty surgeons would arrive through November, followed by additional active-duty and reserve personnel from November to January.13 An overview of facilities with neurosurgical capability is provided in Fig. 4.14 With the exception of one provider deployed aboard the USS Nassau (Ross Moquin, email, January 2022), all other neurosurgeons were positioned at Echelon 3 or 4 facilities.

FIG. 4.
FIG. 4.

Location of forward neurosurgical assets on the battlefield during ODS. Active-duty and reserve neurosurgeons deployed to the Gulf region on a variety of platforms to include deployable medical systems (DEPMEDS) facilities, ship-based facilities, and host nation hospitals. Forward facilities were clustered along Tapline Road at the transition point between the CZ and COMMZ. Army facilities included those attached to specific Army Corps (VII and XVIII Airborne Corps) or above Corps commands. Note the close proximity of these facilities to the Iraqi border. Given known biological and chemical weapon capabilities as well as missiles capable of deploying these systems, this proximity was a cause for concern for both operational commanders and deploying neurosurgeons (Chris Smythies, Mike Carey, Allen Joseph, Richard Ellenbogen, John Brophy, Benny Brandyvold, Jim Leech, Stephen Ondra, Ross Moquin, Wink Fisher, P. K. Carlton, Guy Burrows, Mark Hadley, personal communication, January–March 2022). Note: Ship-based neurosurgical platforms included the USNS Comfort (C), USNS Mercy (M), and USS Nassau (N). *Presence of neurosurgical assets inferred, not confirmed. #Neurosurgeons attached only during the initial mobilization phase of Operation Desert Shield.

Neurosurgical Disease and Injury During ODS

Primary source materials regarding the medical care provided during ODS are unavailable. Paper medical records are challenging to maintain during deployment; such materials were frequently lost during evacuation, resulting in the loss of valuable information for clinical care and research. Equally frustrating was the lack of a US Military–employed casualty data collection system in the theater of war. The four-member Casualty Data Assessment Team (CDAT) that deployed to three US Army GHs in Germany from February 28 to March 14, 1991, performed the sole attempt at systematic collection of forward casualty data.15 This failure of large-scale systematic forward data collection coupled with the lack of a functional forward medical record system compromised efforts to both report and study care delivery from this conflict.

Case series detailing neurosurgical casualty care during ODS can be found in the literature. Carey and colleagues14,16 published two reports that included patients with penetrating head injury (PHI) treated by VII Corps facilities. The first reviewed all ballistic injuries incurred by VII Corps personnel between February 20 and March 10, 1991. Carey identified 143 soldiers with penetrating injuries, only 2 of whom had PHI. Of the 63 major surgical procedures performed in this cohort, 1 soldier underwent craniotomy for treatment. The second report by Carey et al. focused on PHI. Broadening the time window for data collection through April 15, 1990, Carey identified 2 additional US soldiers and 18 host nation casualties treated for PHI. The previously referenced CDAT report identified 2 patients with penetrating brain wounds among the 204 patients with 472 wounds described.15 In a review of the clinical experience of the 13th Evacuation Hospital (EVAC),17 the authors reported 8 neurosurgical interventions among the 125 operations performed. Similarly, a summary of care at the 148th EVAC included a reference to a soldier who “required intensive care for a severe head wound.18

Information regarding medical evacuations and combat casualties can be reconstructed through review of materials from key “choke points” in the evacuation chain between the combat theater and CONUS. The 2nd GH in Landstuhl, Germany, served as the designated neurosurgical–spinal cord injury center within the COMMZ. Swengel8 published his experience, which focused on disease and nonbattle injury (DNBI), specifically the contribution of neck and back pain to neurosurgical evacuations during Operation Desert Shield. Of 653 neurosurgical admissions to the 2nd GH between October 1990 and May 1991, 412 (63%) were patients who carried a primary diagnosis of cervicalgia or low-back pain. Twenty patients underwent surgical intervention, and all were evacuated to CONUS following evaluation and initial treatment.

Clinical data regarding the remaining 241 patients can be abstracted from previously unpublished files from the 2nd GH (Richard Swengel, written materials, reviewed July 2000) (Fig. 5A–C). More neurosurgical combat injuries were identified in these files than all prior published reports, including CDAT15 and Carey et al.14,16 Nine US soldiers with PHI were admitted to the 2nd GH (Fig. 5A). Twenty-one soldiers with combat-related and 71 with accidental injuries were admitted, representing 14% of all evacuations (Fig. 5B). As anticipated in a deployed population of 500,000, the 2nd GH received patients with diagnoses unrelated to combat operations, including neurovascular disease (n = 9), intracranial neoplasms (n = 12), hydrocephalus (n = 5), and epidural empyema (n = 1).

FIG. 5.
FIG. 5.

Neurosurgical evacuations to the 2nd GH during Operation Desert Shield and ODS. The 2nd GH in Landstuhl, Germany, served as the designated neurosurgical–spinal cord injury center in Europe, receiving casualties from the Southwest Asian combat theater during ODS. This facility received casualties from all services en route to the CONUS, and therefore provided an optimal window for identifying neurosurgical combat injuries and DNBIs. A total of 653 soldiers were admitted to the neurosurgical service at the 2nd GH during these operations. A: Trauma evacuations to the 2nd GH. In total, 92 soldiers with neurotrauma diagnoses were admitted to the 2nd GH during ODS. The injuries included 9 PHIs, 6 open depressed skull fractures (ODSF), 46 closed head injuries (CHI), and 31 spine injuries. B: Medical versus trauma evacuations to the 2nd GH. Medical diagnoses significantly outnumbered traumatic diagnoses among patients evacuated from Southwest Asia during ODS. The 561 medical diagnoses included 412 patients with cervicalgia or low-back pain. C: Evacuations for DNBI versus wounded in action (WIA). DNBIs (n = 632) outnumbered combat casualties (n = 21) by more than 30 to 1.

Autopsy reports were another source of casualty data for service members KIA. The Medical Examiner’s office at Dover Air Force Base served as the autopsy site for all Gulf War fatalities. Unfortunately, details recorded in autopsy reports often provided limited insight into key aspects of wounding. Authors of the CDAT report noted, “There were not enough data recorded on the KIAs [troops killed in action] to determine what percentage of the deaths were from failure of the protective vest or helmet.”15 The primary author of this paper was likewise able to review autopsy reports of 141 US servicemen from the Gulf War Theater listed as KIA (Jonathan Martin, personal observations, July 2000). A total of 66 autopsies revealed evidence of blunt force injury or PHI. Only 11 autopsies showed isolated head injuries. While free text reports included details regarding PHI and blunt force injuries, the contribution of head injury to cause of death could not be determined in 55 of the 66 autopsies.

Summary of Operation Desert Shield and ODS Clinical Experience

Casualty statistics (Supplementary Table 2) are available for every armed conflict involving US forces dating back to the Civil War. The authors’ focused review of autopsy data through a neurosurgical lens allowed for the assembly of statistics for both general combat casualties and PHIs for ODS in comparison to conflicts involving US Armed Forces over the latter half of the 20th century (Table 1).19,20 While the (fortunately) small casualty totals from ODS are striking compared to those for Korea and Vietnam, the relative contribution of DNBI to these totals bears emphasis (Fig. 5). DNBI is known as a leading contributor to soldier noneffectiveness and evacuation; the number of casualties related to DNBI essentially matched combat-related injuries in prior conflicts of the late 20th century, with a ratio of 1.4 to 1 for Korea and 1 to 1 for Vietnam.21 In contrast, the impact of DNBI greatly exceeded combat injury–related noneffectiveness in ODS. Neurosurgical evacuations for DNBI (n = 632) exceeded combat-related injuries (n = 21) by more than 30 to 1 (Fig. 5C). This profound reduction in the proportion of casualties from combat injuries would serve to validate doctrinal changes for a smaller deployed medical footprint in the years following ODS.

TABLE 1.

Comparative statistics between ODS and latter–20th-century armed conflicts involving US Armed Forces19,20

Total DeathsKIADOWWIA%KIAhead%WIAhead%KIA%DOW
Korea36,57423,6132460103,28437.918.618.62.4
Vietnam58,22040,9345299153,303331721.13.5
Operation Desert Shield/ODS38214344677.7–45.8*1.523.40.9

DOW = died of wounds, personnel receiving a combat-related wound who die after first receiving care at a medical treatment facility; KIAhead = KIA as a result of a head injury; WIA = wounded in action; WIAhead = WIA as a result of head injury.

ODS saw a small fraction of the casualties documented in prior conflicts of the latter 20th century. Despite the challenges inherent in statistics involving such small denominators, standard measures of wound lethality (%KIA) and efficacy of the medical system (%DOW) remain remarkably conserved.

Only 11 of the 66 KIAs with head injuries had injuries isolated to the head. Thus, the use of a range rather than a defined value was reported for %KIAhead for Operation Desert Shield/ODS.

ODS as Viewed by Deploying Neurosurgeons

Following the Gulf War, individuals and government agencies criticized the performance of DOD medical assets during ODS. Trunkey22 provided a summary of challenges he encountered as the commander of the 50th GH, which included a pointed critique of the interaction between Medical Corps (physician) assets and Medical Service Corps (administrative) assets. Many of Trunkey’s observations are familiar to civilian medical leaders who have inherited systems constructed with limited clinician input: lack of cohesiveness leading to poor unit morale, inadequate equipment, and insufficient personnel to achieve the assigned mission were concerns that were featured prominently in his observations. Clinician-leader involvement in the development and sustainment of medical plans was cited as essential to operational success. Other parties cited the lack of a functional medical record and real-time casualty data collection as critical failures in ensuring optimal casualty care.15 The Government Accounting Office examined the performance of the Army,13 Navy,23 and Air Force24 medical assets in the conduct of mobilization, provision of care, medical evacuation, and supply operations; significant deficiencies were identified in each of these areas. Their conclusions were bluntly stated, identifying “many weaknesses in medical capabilities of U.S. Forces … shortcomings in the DOD’s ability to provide adequate, timely medical support during contingencies and problems with the planning and execution of these efforts.”25

These formal reports provide context for understanding challenges experienced by physicians on the ground. Deployment exposed many surgeons to novel facilities (Fig. 6)13,2628 and circumstances (Fig. 7).29 The authors contacted neurosurgeons deployed in support of ODS and curated recollections in order to illustrate the deployment from their perspective.

FIG. 6.
FIG. 6.

Forward medical facilities during Operation Desert Shield and ODS. ODS was the first deployment utilizing DEPMEDS, which replaced Vietnam-era Medical Unit Self-Contained inflatable systems in this conflict. DEPMEDS consisted of two components: TEMPER (Tent Extendable Modular Personnel) tents, which were magnesium alloy–framed tents with vinyl-covered exterior and fabric floors, and ISO (International Organization for Standardization) shelters, which were foldable, expandable, metal boxes that were easily packed and shipped by container. Although heavy and challenging to move at Echelon 2 facilities that were tasked to follow combat units, DEPMEDS performed well at Echelon 3 and provided a capable home for neurosurgical interventions during ODS. A: Aerial view of the 86th EVAC hospital in Operation Iraqi Freedom, demonstrating a typical layout of a DEPMEDS facility. Both TEMPER tents and ISO shelters are visible within the hospital layout. B: Field neurosurgery in action during ODS. Majors Richard Ellenbogen and Paul Maurer operate on a patient with a PHI. Note the limited operating room space in this configuration of an ISO shelter. C: A typical TEMPER patient ward. D: ODS was the first US conflict to use CT scanners in a forward environment. CT scanners were fielded in ISO shelters with the 12th and 86th EVAC hospitals, as well as on Navy Hospital Ships and Fleet Hospitals. Photographs by Richard G. Ellenbogen. © Richard G. Ellenbogen, published with permission.

FIG. 7.
FIG. 7.

Experience of the neurosurgeon in ODS. Neurosurgery in an austere forward environment provided military neurosurgeons with experiences well outside of those encountered in civilian practice. A: ODS was the first conflict to field PASGT (Personnel Armor System for Ground Troops) Kevlar helmets and body armor for deploying troops. Seen here, Majors Richard Ellenbogen and Eric Scott wear their PASGT on the 1st day of the ground war in February 1991. © Richard G. Ellenbogen, published with permission. B: Deployed neurosurgeons may be tasked with duties to which they are unaccustomed. Here, members of the 359th Medical Detachment stand ready to move with their equipment. The 359th colocated with the 28th Combat Support Hospital during Operation Desert Shield, and the 15th EVAC hospital during ODS. © John Brophy, published with permission. C: Forward neurosurgery may require the use of austere surgical equipment. Drs. Brandvold and Brophy perform a craniotomy using a Hudson brace and Gigli saw at the 28th Combat Support Hospital in October 1990. © Benny Brandvold, published with permission. D: Deployed medical facilities may receive casualties other than US Military personnel. Civilians and enemy combatants are frequently transported to facilities for care, creating unanticipated challenges and opportunities for reflection by deploying providers. Here, an Iraqi child with a PHI is prepared for a CT scan at the 86th EVAC hospital. © Richard G. Ellenbogen, published with permission.

Challenges With Identification of Qualified Personnel for Deployment

Military deployment requires the rapid identification and mobilization of personnel for service. Individuals must be qualified for their assigned duties vocationally, militarily, and medically. Automated rosters designed to expedite this process failed during the initial deployment of Operation Desert Shield. The Army Professional Filler System (PROFIS), an automated system for the assignment of specialty personnel to deploying units, was able to identify only 46% of the physicians and nurses required for the 40 active-duty units that deployed during the initial phase of ODS.13 Several neurosurgeons discussed the impact of PROFIS failure on their eventual deployment. Major James Leech was deployed and assigned to the 85th EVAC based on nondeployable status of the initially designated PROFIS provider, who had not completed his Officer Basic Course, a requirement for deployment to a combat theater (James Leech, personal communication, January 2022). Captain Benny Brandvold, a postgraduate 5-year resident in neurosurgery at Walter Reed Army Medical Center, was deployed with the XVIII Airborne Corps in August 1990 based on a similar failure of the PROFIS system (Benny Brandvold, personal communication, January 2022). Brandvold was 1 of 30 active-duty and 45 reserve resident physicians who was mobilized and deployed to the Persian Gulf despite having not completed residency training.30 Lack of a functional personnel management system contributed to unnecessary chaos during the early phase of this deployment.

Frustrations With the Variable Tempo of Deployment

The temporal desynchrony of deployment has been described as “hours of boredom, moments of terror.”31 One surgeon commented: “The boredom was mind-numbing while we waited to be assigned a site to set up the hospital (didn’t they know we were coming?)” (Jim Leech, email, February 2022). While the majority of military officers understand the concept of “hurry up and wait,” the structure of resident training in hospital clinics and operating rooms, or reserve time spent backfilling at a medical center, serves to focus physicians on clinical care. Operational medicine can involve extended periods of time focused outside of a soldier’s military occupational specialty. In some cases, these lulls can create conflict, including potential challenges with order and discipline. More commonly, surgeons found novel activities to combat boredom; one provider recalled his colleagues building a bunker to pass time (Christopher Smythies, personal communication, February 2022).

Mission-Essential Surgical Equipment Unavailable at the Outset of ODS

Within the Army system, “deployable hospital sets that had been stored for emergencies were short of critical equipment … of the 19 hospital sets deployed from storage facilities in Europe, the average set contained only 60% of its required equipment.”13 The lack of serviceable surgical equipment was a common observation of Gulf War veterans. Review of Major John Brophy’s deployment journal is notable for the following entry: “at supply- footlockers opened. No neurosurgical supplies, although listed by MASH as C-1 [authors’ note: “C-1” is shorthand for mission capable] for equipment. No itemized list of instruments available" (John Brophy, written materials provided, January 2022). This entry, dated August 31, 1990, would not be fully remedied until October 31, when Brophy commented: “Germany shipment arrives, C-1.” Deploying providers should be aware of the limited knowledge nonsurgeons have regarding neurosurgical operative equipment as well as requirements allowing for the delivery of effective care. An active role in set inspection, ideally prior to mobilization, is suggested as best practice to avoid challenges during the early stages of deployment when logistical systems are likely to be focused on combatant commander’s needs.

Neurosurgeons Had a Limited View of the Battlefield

Neurosurgeons are critical members of the trauma team, often with valuable insights in casualty flow and management. Trunkey22 observed, “a medical unit is comprised of highly intelligent people who perform better when given information and logical explanations that relate to the mission. No less is demanded by other special units within the US Army." Most neurosurgeons interviewed had limited insight into the battlefield beyond the walls of their facilities. Illustrative of a typical response, “I really didn’t know anything about land forces—at least we were not told about them.… There were Navy guys on the beach but at least while I was there we had little interaction with them" (Wink Fisher, email, February 2022). For deployed neurosurgeons, access to technology was at times essential to facilitate patient care. ODS was the first US conflict to utilize CT scanners in a forward environment. CT scanners were fielded with the 12th and 86th EVAC hospitals, as well as on Navy Hospital Ships and Fleet Hospitals.27,28 Major Brophy recalled transporting a comatose patient to Fleet Hospital 5, and subsequently to the USNS Mercy in search of a functional CT scanner (John Brophy, verbal communication, January 2022). A clear understanding of available assets, capacity, and capability is essential for the deployed neurosurgeon.

Psychological, Ethical, and Logistical Aspects of Care for Civilian Casualties on the Battlefield

The presence and volume of host nation casualties was surprising to many neurosurgeons interviewed. Several series discuss significant numbers of host nation casualties seen by field medical facilities.17,18,32 Their presence presented both unanticipated challenges and opportunities for reflection by deploying providers. “Civilians arrived in large batches.… Not all were patients; families often accompanied an injured member. The situation presented more of a nursing challenge than a treatment problem because the families expected to stay together and to help care for their loved ones.”32 In one recollection, a neurosurgeon stated, “I remember hanging out with the older kids, playing desert golf with them etc. Sometimes we were sorry to see them leave and wondered what kind of lives they were going to have, especially the maimed ones" (Christopher Smythies, email, February 2022). The care of civilians at forward facilities introduces logistical and ethical considerations that require careful consideration on the part of the individual provider and hospital command.33

Impact of Deployment on Neurosurgical Reservists

Reserve neurosurgeons faced additional challenges as they deployed, leaving their practices behind. At times, their frustrations were visible to their active-duty counterparts. “Maybe it wouldn’t have been so bad for them if we had been busy, but we weren’t and they ended up wiling away the time in the sand while their practices back home were shriveling up and going out of business. They were quite bitter about it, especially when the war was over and they were sitting around forever, waiting for a plane to take them home" (Christopher Smythies, email, February 2022). One survey of reservist dissatisfaction was documented by the Army Medical Reserve Command.10 Frustrations were noted in three domains: unit fragmentation, poor communication, and financial loss. Whether based on these dissatisfiers or another cause, Medical Reserve Corps officer resignations increased from 99 for fiscal year 1990 to 435 for fiscal year 1991.

The Role of the Military Neurosurgeon

General Schwarzkopf’s characterization of the military neurosurgeon ("Essential, but useless") (Richard G. Ellenbogen, personal communication, April 2022) is a wry observation by an experienced combat commander. There is pragmatism at work here; neurosurgeons provide the combatant commander with no tactical advantage and seldom return sick or injured troops to the fight. Yet the neurosurgeon’s value to the military medical system is undeniable. Beyond the practical value of providing care for the sick and wounded, the neurosurgeon’s impact on soldier morale is profound;34 effective medical care is a means of assurance that a soldier’s sacrifice is valued and appreciated, and for many, that is enough, for them to carry the message. For surgeons privileged to have seen both desperation and hope in the face of a wounded soldier’s comrades in a trauma bay, there are few experiences more gratifying than delivering on the promise to do one’s best to get that wounded soldier home.

Legacies of ODS

ODS served as a transition point for the evolution and modernization of the military healthcare system. Following the Gulf War, DOD medical services would complete objectives defined in the Medical Force 2000 (MF2K)35 initiative to overhaul communications, logistics, and personnel management. Doctrinal changes allowing for the fielding of a smaller, more maneuverable medical footprint that could keep pace with the speed of modern operations36,37 required innovation driven by the ODS experience. Key evolutions included the development of Air Force Critical Care Air Transport Teams, otherwise known as “critical care in the air,”38 as well as the Joint Theater Trauma System,39 which incorporated design aspects of civilian trauma systems, including improved medical records and a trauma registry for research to deliver “the right care, to the right casualty, at the right locations, at the right time.” The resulting system allowed theater-wide neurosurgical support by two neurosurgeons during the height of the 2007 “surge” of Operation Iraqi Freedom (Jonathan Martin, personal observation, 2007). This increase in flexibility and mobility also achieved MF2K goals to reduce forward hospital bed capacity requirements. As of fiscal year 2021, the Army was capable of fielding no more than 4000 total hospital beds between both active-duty and reserve units.37 Of note, this devaluation of theater bed capacity may be a liability in future conflicts against more capable peers. In the absence of air superiority, the ability to evacuate casualties could be delayed, resulting in the accumulation of casualties in or near the CZ with insufficient beds to care for them.

On an individual level, ODS would again demonstrate the challenge of preparing surgeons for practice in a deployed environment. As John Slater noted, “Each war involves neurosurgeons who are inexperienced for the tasks at hand. Each war involves relearning principals [sic] that were useful in the past but which have been forgotten.40 The ideal means of preparing a surgeon for war remain unknown. Military residency training programs attempt to address this task by incorporating military-centric topics within their curriculum, including the study of neurosurgical participation in prior deployments and courses in officer leadership and principles of care delivery in an austere environment.41 Independent pursuit of this education requires deliberate effort on the part of the military officer.

Conclusions

Operation Desert Shield and ODS were the first major medical deployments following the end of the Cold War and employed a massive neurosurgical footprint that was underutilized given the limited casualty load. DNBIs greatly outnumbered combat-related injuries. Deploying neurosurgeons experienced challenges alongside their peers that drove subsequent evolution of the DOD medical system and highlighted challenges in preparing clinically focused surgeons for deployed environments. The study of successes and failures in past medical deployments is critical to the development of intrepid military neurosurgeons for support of future humanitarian missions and armed conflict.

Acknowledgments

We thank and acknowledge ODS veterans who generously provided their stories and time, including John Brophy, Jim Leach, Christopher Smythies, Michael Carey, Steve Ondra, Allen Joseph, Joseph Allen, Wink Fisher, Mark Hadley, Guy Burrows, and P. K. Carlton. We also thank Jay “MC” Wellons, Markus Bookland, and David Hersh for their insights regarding accessibility of the text to nonmilitary providers. Finally, we thank Ms. Kate Martin for her assistance with graphic art within the figures.

Disclaimer

The views expressed are those of the authors and do not reflect the official policy or position of the US Army, Navy, Air Force, Marines, Department of Defense, or the US Government. Neither the Department of the Navy nor any other component of the Department of Defense has approved, endorsed, or authorized this product.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Martin, Ling, Ecklund. Acquisition of data: Martin, Brandvold, Ellenbogen, Moquin. Analysis and interpretation of data: Martin. Drafting the article: Martin, Neal. Critically revising the article: all authors. Reviewed submitted version of manuscript: Martin, Neal. Approved the final version of the manuscript on behalf of all authors: Martin. Administrative/technical/material support: Dean.

Supplemental Information

Online-Only Content

Supplemental material is available online.

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    Schubert FN, Kraus TL. The Whirlwind War: The United States Army in Operations Desert Shield and Desert Storm. Center of Military History, US Army; 2001.

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    • Export Citation
  • 6

    Persian Gulf War. Conflict Casualties. Defense Casualty Analysis System. Accessed July 19, 2022. https://dcas.dmdc.osd.mil/dcas/app/conflictCasualties/gulf/shieldsum

    • Search Google Scholar
    • Export Citation
  • 7

    Masferrer R. The Gulf War syndrome: is it really a new disorder? Barrow Neurological Institute. Accessed July 19, 2022. https://www.barrowneuro.org/for-physicians-researchers/education/grand-rounds-publications-media/watch-neuroscience-grand-rounds/gulf-war-syndrome-really-new-disorder/

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  • 8

    Swengel RM. Operation Desert Shield/Storm neurosurgery—2nd General Hospital—place, process-lessons learned. J US Army Med Dep. 1992;(September/October):1116.

    • Search Google Scholar
    • Export Citation
  • 9

    FM 8-10 Department of the Army Field Manual: Medical Support Theater of Operations. Department of the Army Headquarters; 1978:E-33. Accessed July 19, 2022. https://archive.org/details/FM8-10_201212/page/n113/mode/1up?view=theater

    • Search Google Scholar
    • Export Citation
  • 10

    Brinkerhoff JR, Silva T, Seitz J. United States Army Reserve in Operation Desert Storm: Reservists of the Army Medical Department September 1993. Accessed July 19, 2022. https://www.researchgate.net/publication/235084704_United_States_Army_Reserve_in_Operation_Desert_Storm_Reservists_of_the_Army_Medical_Department

    • Search Google Scholar
    • Export Citation
  • 11

    Mayo RA. Fleet Hospital Five—ashore in Saudi Arabia. J US Army Med Dep. 1992;(March/April):5052.

  • 12

    Pentzien RJ, Barry PD. First to aid: USNS Mercy (T-AH 19) and USNS Comfort (T-AH 20) deploy to the Persian Gulf. J US Army Med Dep. 1992;(January/February):1316.

    • Search Google Scholar
    • Export Citation
  • 13

    US General Accounting Office. Operation Desert Storm: Full Army Medical Capability Not Achieved. US General Accounting Office; 1992. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-92-175.pdf

    • Search Google Scholar
    • Export Citation
  • 14

    Carey ME. Analysis of wounds incurred by U.S. Army Seventh Corps personnel treated in Corps hospitals during Operation Desert Storm, February 20 to March 10, 1991. J Trauma. 1996; 40(3 suppl):S165S169.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Uhorchak JM, Rodkey WG, Hunt MM, Hoxie SW. Final Report—Casualty Data Assessment Team Operation Desert Storm. US Army Medical Research and Development; 1992. Accessed July 19, 2022. https://apps.dtic.mil/sti/pdfs/ADA250436.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Carey ME, Joseph AS, Morris WJ, et al. Brain wounds and their treatment in VII Corps during Operation Desert Storm, February 20 to April 15, 1991. Mil Med. 1998; 163(9):581586.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Lee YT, Alvarez JD, Wilson JA, Harned LB. Operation Desert Storm: clinical experiences at the 13th Evacuation Hospital, a Wisconsin National Guard unit. Wis Med J. 1992; 91(8):480482.

    • Search Google Scholar
    • Export Citation
  • 18

    Woodall JR, Easter MD, McDaniel CP, et al. 148th Evacuation Hospital, Desert Storm story. Arkansas Mil J. 1996; 4(3):37.

  • 19

    Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984; 149(2):5562.

  • 20

    Sunshine I. Analysis of 500 US Army Combat Fatalities in Vietnam. Department of the Army; 1970. Accessed July 19, 2022. https://archive.org/details/DTIC_AD0711528

    • Search Google Scholar
    • Export Citation
  • 21

    Carey ME. Learning from traditional combat mortality and morbidity data used in the evaluation of combat medical care. Mil Med. 1987; 152(1):613.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Trunkey D. Excelsior Surgical Society Edward D Churchill Lecture. Changes in combat casualty care. J Am Coll Surg. 2012; 214(6):879891.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    US General Accounting Office. Operation Desert Storm Improvements Required in the Navy’s Wartime Medical Care Program. US General Accounting Office; 1993. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-93-189.pdf

    • Search Google Scholar
    • Export Citation
  • 24

    US General Accounting Office. Operation Desert Storm Problems With Air Force Medical Readiness. US General Accounting Office; 1993. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-94-58.pdf

    • Search Google Scholar
    • Export Citation
  • 25

    US General Accounting Office. Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but Challenges Remain. US General Accounting Office; 1996. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-96-224.pdf

    • Search Google Scholar
    • Export Citation
  • 26

    Sarnecky MT. Preparing for Action. In: Sarnecky MT. A Contemporary History of the U.S. Army Nurse Corps. Office of the Surgeon General, Borden Institute, Walter Reed Army Medical Center; 2010:255-285.

    • Search Google Scholar
    • Export Citation
  • 27

    Bess DW, Roberge EA. Battlefield teleradiology. Curr Trauma Rep. 2016; 2:173180.

  • 28

    Grabowski CM. Ready to assist—the one Navy medical department in Operation Desert Shield/Storm. J US Army Med Dep. 1992;(September/October):4648.

    • Search Google Scholar
    • Export Citation
  • 29

    Committee on Review of Test Protocols Used by the DoD to Test Combat Helmets. Review of Department of Defense Test Protocols for Combat Helmets. Board on Army Science and Technology, Division on Engineering and Physical Sciences, National Research Council; 2014.

    • Search Google Scholar
    • Export Citation
  • 30

    Blanck RR, Bell WH. Medical support for American troops in the Persian Gulf. N Engl J Med. 1991; 324(12):857859.

  • 31

    Hancock PA, Krueger GP. Hours of Boredom, Moments of Terror: Temporal Desynchrony in Military and Security Force Operations. National Defense University, Center for Technology and National Security Policy; 2010. Accessed July 19, 2022. https://peterhancock.ucf.edu/wp-content/uploads/sites/12/2012/06/Hancock_Krueger-Hours-of-Boredom-Moments-of-Terror.pdf

    • Search Google Scholar
    • Export Citation
  • 32

    Marble S. Operation Desert Shield/Desert Storm. In: Skilled and Resolute: A History of the 12th Evacuation Hospital and the 212th MASH, 1917-2006. Progressive Management; 2015:91115.

    • Search Google Scholar
    • Export Citation
  • 33

    Martin JE, Harkness W, Edwards M. Letter to the Editor. Humanitarian care: a plea for the consideration of ethical foundations and secondary effects. Neurosurg Focus. 2019; 47(2):E19.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Vogt KS. Origins of military medical care as an essential source of morale. Mil Med. 2015; 180(6):604606.

  • 35

    Robertson JT, Glazier CJ. The Medical System Program Review: new methods to improve medical readiness. Army Research, Development and Acquisition Magazine. July-August 1985:1720.

    • Search Google Scholar
    • Export Citation
  • 36

    Marble S. Larger war, smaller hospitals? Mil Rev. 2020; 100(4):2331.

  • 37

    Sheets JJ. Army Medical Capacity: Ready to Meet the LSCO Challenge?. US Army Heritage and Education Center, Army War College; 2021.

  • 38

    Air Force Surgeon General Public Affairs. Persian Gulf War Pushed Modernization of Critical Care Transport. Dayton Daily News. February 3,2021. Accessed July 19, 2022. https://www.daytondailynews.com/local/persian-gulf-war-pushed-modernization-of-critical-care-transport/HTZBA6GLCZEGBCVEOEF4TRLFR4/

    • Search Google Scholar
    • Export Citation
  • 39

    Bailey J, Spott MA, Costanzo GP, Dunne J, Dorlac W, Eastridge B. Joint Trauma System: Development, Conceptual Framework, and Optimal Elements. US Army Institute of Surgical Research; 2012.

    • Search Google Scholar
    • Export Citation
  • 40

    Slater J. Neurosurgery at War. Presidential address presented at: Annual Meeting of the Western Neurological Society; September 2005. Accessed July 19, 2022. http://www.westnsurg.org/pdfs/presidential_address2005.pdf

    • Search Google Scholar
    • Export Citation
  • 41

    An Officer and a Resident: Unique Aspects of Neurosurgery Training in the Military. AANS Neurosurgeon. June 9, 2020. Accessed July 19, 2022. https://aansneurosurgeon.org/feature/an-officer-and-a-resident-unique-aspects-of-neurosurgery-training-in-the-military/

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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

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    Timeline of Operation Desert Shield and ODS.

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    Coalition forces at onset of ground campaign. Position of forces at the onset of the ground offensive in February of 1991. More than 700,000 allied forces would stand against the Iraqi military and deliver a decisive victory less than 100 hours after crossing the line of departure on February 24, 1991. Note: The Tapline (Trans-Arabian Pipeline) Road served as a geographic reference for the boundary between the CZ and COMMZ. JFCE = Joint Forces Command East; JFCN = Joint Forces Command North; MCC = Marine Corps Central Command; VII = VII Corps; XVIII = XVIII Airborne Corps.

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    Echelons of care within the military healthcare system circa 1991. The military healthcare system is organized in a hierarchical fashion to facilitate operational planning based on proximity to the CZ and medical capability. The terminology (Echelons of care) and separate care levels circa 1991 are as follows. Echelon 1: Emergency lifesaving measures administered at unit level to allow for stabilization and evacuation to the next level. Typically, care is administered by the combat lifesaver or medic. Echelon 2: The civilian surgeon would consider this the equivalent of emergency department–level care similar to the primary and secondary survey in Advanced Trauma Life Support. Limited surgical intervention is available. Echelon 3: Care provided in a military treatment facility staffed and equipped for the provision of resuscitative surgery and postoperative treatment. Typically, the first level of care at which neurosurgical interventions are performed. Echelon 4: Medical treatment facility staffed for general, specialty, surgical, and rehabilitative care with a goal of possible return to duty. Typically located in rear areas well beyond the CZ. Echelon 5: Medical treatment facility in the CONUS with comprehensive services to include reconstructive and rehabilitative care. CSH = combat support hospital; FH = field hospital; MASH = mobile Army surgical hospital; MEDCEN = medical center; SH = station hospital. Note: Additional descriptions of medical facilities are included in Supplementary Table 1.

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    Location of forward neurosurgical assets on the battlefield during ODS. Active-duty and reserve neurosurgeons deployed to the Gulf region on a variety of platforms to include deployable medical systems (DEPMEDS) facilities, ship-based facilities, and host nation hospitals. Forward facilities were clustered along Tapline Road at the transition point between the CZ and COMMZ. Army facilities included those attached to specific Army Corps (VII and XVIII Airborne Corps) or above Corps commands. Note the close proximity of these facilities to the Iraqi border. Given known biological and chemical weapon capabilities as well as missiles capable of deploying these systems, this proximity was a cause for concern for both operational commanders and deploying neurosurgeons (Chris Smythies, Mike Carey, Allen Joseph, Richard Ellenbogen, John Brophy, Benny Brandyvold, Jim Leech, Stephen Ondra, Ross Moquin, Wink Fisher, P. K. Carlton, Guy Burrows, Mark Hadley, personal communication, January–March 2022). Note: Ship-based neurosurgical platforms included the USNS Comfort (C), USNS Mercy (M), and USS Nassau (N). *Presence of neurosurgical assets inferred, not confirmed. #Neurosurgeons attached only during the initial mobilization phase of Operation Desert Shield.

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    Neurosurgical evacuations to the 2nd GH during Operation Desert Shield and ODS. The 2nd GH in Landstuhl, Germany, served as the designated neurosurgical–spinal cord injury center in Europe, receiving casualties from the Southwest Asian combat theater during ODS. This facility received casualties from all services en route to the CONUS, and therefore provided an optimal window for identifying neurosurgical combat injuries and DNBIs. A total of 653 soldiers were admitted to the neurosurgical service at the 2nd GH during these operations. A: Trauma evacuations to the 2nd GH. In total, 92 soldiers with neurotrauma diagnoses were admitted to the 2nd GH during ODS. The injuries included 9 PHIs, 6 open depressed skull fractures (ODSF), 46 closed head injuries (CHI), and 31 spine injuries. B: Medical versus trauma evacuations to the 2nd GH. Medical diagnoses significantly outnumbered traumatic diagnoses among patients evacuated from Southwest Asia during ODS. The 561 medical diagnoses included 412 patients with cervicalgia or low-back pain. C: Evacuations for DNBI versus wounded in action (WIA). DNBIs (n = 632) outnumbered combat casualties (n = 21) by more than 30 to 1.

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    Forward medical facilities during Operation Desert Shield and ODS. ODS was the first deployment utilizing DEPMEDS, which replaced Vietnam-era Medical Unit Self-Contained inflatable systems in this conflict. DEPMEDS consisted of two components: TEMPER (Tent Extendable Modular Personnel) tents, which were magnesium alloy–framed tents with vinyl-covered exterior and fabric floors, and ISO (International Organization for Standardization) shelters, which were foldable, expandable, metal boxes that were easily packed and shipped by container. Although heavy and challenging to move at Echelon 2 facilities that were tasked to follow combat units, DEPMEDS performed well at Echelon 3 and provided a capable home for neurosurgical interventions during ODS. A: Aerial view of the 86th EVAC hospital in Operation Iraqi Freedom, demonstrating a typical layout of a DEPMEDS facility. Both TEMPER tents and ISO shelters are visible within the hospital layout. B: Field neurosurgery in action during ODS. Majors Richard Ellenbogen and Paul Maurer operate on a patient with a PHI. Note the limited operating room space in this configuration of an ISO shelter. C: A typical TEMPER patient ward. D: ODS was the first US conflict to use CT scanners in a forward environment. CT scanners were fielded in ISO shelters with the 12th and 86th EVAC hospitals, as well as on Navy Hospital Ships and Fleet Hospitals. Photographs by Richard G. Ellenbogen. © Richard G. Ellenbogen, published with permission.

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    Experience of the neurosurgeon in ODS. Neurosurgery in an austere forward environment provided military neurosurgeons with experiences well outside of those encountered in civilian practice. A: ODS was the first conflict to field PASGT (Personnel Armor System for Ground Troops) Kevlar helmets and body armor for deploying troops. Seen here, Majors Richard Ellenbogen and Eric Scott wear their PASGT on the 1st day of the ground war in February 1991. © Richard G. Ellenbogen, published with permission. B: Deployed neurosurgeons may be tasked with duties to which they are unaccustomed. Here, members of the 359th Medical Detachment stand ready to move with their equipment. The 359th colocated with the 28th Combat Support Hospital during Operation Desert Shield, and the 15th EVAC hospital during ODS. © John Brophy, published with permission. C: Forward neurosurgery may require the use of austere surgical equipment. Drs. Brandvold and Brophy perform a craniotomy using a Hudson brace and Gigli saw at the 28th Combat Support Hospital in October 1990. © Benny Brandvold, published with permission. D: Deployed medical facilities may receive casualties other than US Military personnel. Civilians and enemy combatants are frequently transported to facilities for care, creating unanticipated challenges and opportunities for reflection by deploying providers. Here, an Iraqi child with a PHI is prepared for a CT scan at the 86th EVAC hospital. © Richard G. Ellenbogen, published with permission.

  • 1

    Final Report to Congress: Conduct of the Persian Gulf War. Department of Defense; 1992. Accessed July 19, 2022. https://www.globalsecurity.org/military/library/report/1992/cpgw.pdf

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  • 2

    Ledford FF Jr. From the Surgeon General of the Army: medical support for Operation Desert Storm. J US Army Med Dep. 1992;(January/February):36.

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    • Export Citation
  • 3

    Hearing Before the Committee on Veterans’ Affairs, 105th Cong, 1st Sess (1997). (testimony of Herbert Norman Schwarzkopf, General, US Army).

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    • Export Citation
  • 4

    Leyden A. The War Against Saddam Hussein. In: Leyden A, ed. Gulf War Debriefing Book: An After Action Report. Hellgate Press; 1997:124.

  • 5

    Schubert FN, Kraus TL. The Whirlwind War: The United States Army in Operations Desert Shield and Desert Storm. Center of Military History, US Army; 2001.

    • Search Google Scholar
    • Export Citation
  • 6

    Persian Gulf War. Conflict Casualties. Defense Casualty Analysis System. Accessed July 19, 2022. https://dcas.dmdc.osd.mil/dcas/app/conflictCasualties/gulf/shieldsum

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Masferrer R. The Gulf War syndrome: is it really a new disorder? Barrow Neurological Institute. Accessed July 19, 2022. https://www.barrowneuro.org/for-physicians-researchers/education/grand-rounds-publications-media/watch-neuroscience-grand-rounds/gulf-war-syndrome-really-new-disorder/

    • Search Google Scholar
    • Export Citation
  • 8

    Swengel RM. Operation Desert Shield/Storm neurosurgery—2nd General Hospital—place, process-lessons learned. J US Army Med Dep. 1992;(September/October):1116.

    • Search Google Scholar
    • Export Citation
  • 9

    FM 8-10 Department of the Army Field Manual: Medical Support Theater of Operations. Department of the Army Headquarters; 1978:E-33. Accessed July 19, 2022. https://archive.org/details/FM8-10_201212/page/n113/mode/1up?view=theater

    • Search Google Scholar
    • Export Citation
  • 10

    Brinkerhoff JR, Silva T, Seitz J. United States Army Reserve in Operation Desert Storm: Reservists of the Army Medical Department September 1993. Accessed July 19, 2022. https://www.researchgate.net/publication/235084704_United_States_Army_Reserve_in_Operation_Desert_Storm_Reservists_of_the_Army_Medical_Department

    • Search Google Scholar
    • Export Citation
  • 11

    Mayo RA. Fleet Hospital Five—ashore in Saudi Arabia. J US Army Med Dep. 1992;(March/April):5052.

  • 12

    Pentzien RJ, Barry PD. First to aid: USNS Mercy (T-AH 19) and USNS Comfort (T-AH 20) deploy to the Persian Gulf. J US Army Med Dep. 1992;(January/February):1316.

    • Search Google Scholar
    • Export Citation
  • 13

    US General Accounting Office. Operation Desert Storm: Full Army Medical Capability Not Achieved. US General Accounting Office; 1992. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-92-175.pdf

    • Search Google Scholar
    • Export Citation
  • 14

    Carey ME. Analysis of wounds incurred by U.S. Army Seventh Corps personnel treated in Corps hospitals during Operation Desert Storm, February 20 to March 10, 1991. J Trauma. 1996; 40(3 suppl):S165S169.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Uhorchak JM, Rodkey WG, Hunt MM, Hoxie SW. Final Report—Casualty Data Assessment Team Operation Desert Storm. US Army Medical Research and Development; 1992. Accessed July 19, 2022. https://apps.dtic.mil/sti/pdfs/ADA250436.pdf

    • Search Google Scholar
    • Export Citation
  • 16

    Carey ME, Joseph AS, Morris WJ, et al. Brain wounds and their treatment in VII Corps during Operation Desert Storm, February 20 to April 15, 1991. Mil Med. 1998; 163(9):581586.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Lee YT, Alvarez JD, Wilson JA, Harned LB. Operation Desert Storm: clinical experiences at the 13th Evacuation Hospital, a Wisconsin National Guard unit. Wis Med J. 1992; 91(8):480482.

    • Search Google Scholar
    • Export Citation
  • 18

    Woodall JR, Easter MD, McDaniel CP, et al. 148th Evacuation Hospital, Desert Storm story. Arkansas Mil J. 1996; 4(3):37.

  • 19

    Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984; 149(2):5562.

  • 20

    Sunshine I. Analysis of 500 US Army Combat Fatalities in Vietnam. Department of the Army; 1970. Accessed July 19, 2022. https://archive.org/details/DTIC_AD0711528

    • Search Google Scholar
    • Export Citation
  • 21

    Carey ME. Learning from traditional combat mortality and morbidity data used in the evaluation of combat medical care. Mil Med. 1987; 152(1):613.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Trunkey D. Excelsior Surgical Society Edward D Churchill Lecture. Changes in combat casualty care. J Am Coll Surg. 2012; 214(6):879891.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    US General Accounting Office. Operation Desert Storm Improvements Required in the Navy’s Wartime Medical Care Program. US General Accounting Office; 1993. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-93-189.pdf

    • Search Google Scholar
    • Export Citation
  • 24

    US General Accounting Office. Operation Desert Storm Problems With Air Force Medical Readiness. US General Accounting Office; 1993. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-94-58.pdf

    • Search Google Scholar
    • Export Citation
  • 25

    US General Accounting Office. Wartime Medical Care: DOD Is Addressing Capability Shortfalls, but Challenges Remain. US General Accounting Office; 1996. Accessed July 19, 2022. https://www.gao.gov/assets/nsiad-96-224.pdf

    • Search Google Scholar
    • Export Citation
  • 26

    Sarnecky MT. Preparing for Action. In: Sarnecky MT. A Contemporary History of the U.S. Army Nurse Corps. Office of the Surgeon General, Borden Institute, Walter Reed Army Medical Center; 2010:255-285.

    • Search Google Scholar
    • Export Citation
  • 27

    Bess DW, Roberge EA. Battlefield teleradiology. Curr Trauma Rep. 2016; 2:173180.

  • 28

    Grabowski CM. Ready to assist—the one Navy medical department in Operation Desert Shield/Storm. J US Army Med Dep. 1992;(September/October):4648.

    • Search Google Scholar
    • Export Citation
  • 29

    Committee on Review of Test Protocols Used by the DoD to Test Combat Helmets. Review of Department of Defense Test Protocols for Combat Helmets. Board on Army Science and Technology, Division on Engineering and Physical Sciences, National Research Council; 2014.

    • Search Google Scholar
    • Export Citation
  • 30

    Blanck RR, Bell WH. Medical support for American troops in the Persian Gulf. N Engl J Med. 1991; 324(12):857859.

  • 31

    Hancock PA, Krueger GP. Hours of Boredom, Moments of Terror: Temporal Desynchrony in Military and Security Force Operations. National Defense University, Center for Technology and National Security Policy; 2010. Accessed July 19, 2022. https://peterhancock.ucf.edu/wp-content/uploads/sites/12/2012/06/Hancock_Krueger-Hours-of-Boredom-Moments-of-Terror.pdf

    • Search Google Scholar
    • Export Citation
  • 32

    Marble S. Operation Desert Shield/Desert Storm. In: Skilled and Resolute: A History of the 12th Evacuation Hospital and the 212th MASH, 1917-2006. Progressive Management; 2015:91115.

    • Search Google Scholar
    • Export Citation
  • 33

    Martin JE, Harkness W, Edwards M. Letter to the Editor. Humanitarian care: a plea for the consideration of ethical foundations and secondary effects. Neurosurg Focus. 2019; 47(2):E19.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Vogt KS. Origins of military medical care as an essential source of morale. Mil Med. 2015; 180(6):604606.

  • 35

    Robertson JT, Glazier CJ. The Medical System Program Review: new methods to improve medical readiness. Army Research, Development and Acquisition Magazine. July-August 1985:1720.

    • Search Google Scholar
    • Export Citation
  • 36

    Marble S. Larger war, smaller hospitals? Mil Rev. 2020; 100(4):2331.

  • 37

    Sheets JJ. Army Medical Capacity: Ready to Meet the LSCO Challenge?. US Army Heritage and Education Center, Army War College; 2021.

  • 38

    Air Force Surgeon General Public Affairs. Persian Gulf War Pushed Modernization of Critical Care Transport. Dayton Daily News. February 3,2021. Accessed July 19, 2022. https://www.daytondailynews.com/local/persian-gulf-war-pushed-modernization-of-critical-care-transport/HTZBA6GLCZEGBCVEOEF4TRLFR4/

    • Search Google Scholar
    • Export Citation
  • 39

    Bailey J, Spott MA, Costanzo GP, Dunne J, Dorlac W, Eastridge B. Joint Trauma System: Development, Conceptual Framework, and Optimal Elements. US Army Institute of Surgical Research; 2012.

    • Search Google Scholar
    • Export Citation
  • 40

    Slater J. Neurosurgery at War. Presidential address presented at: Annual Meeting of the Western Neurological Society; September 2005. Accessed July 19, 2022. http://www.westnsurg.org/pdfs/presidential_address2005.pdf

    • Search Google Scholar
    • Export Citation
  • 41

    An Officer and a Resident: Unique Aspects of Neurosurgery Training in the Military. AANS Neurosurgeon. June 9, 2020. Accessed July 19, 2022. https://aansneurosurgeon.org/feature/an-officer-and-a-resident-unique-aspects-of-neurosurgery-training-in-the-military/

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    • Export Citation

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