What happened after the war, however, caught the military medical community off guard: A significant number of both veterans and civilian workers returning from the Persian Gulf began to experience a chronic multi-symptom disorder that became known as Gulf War Syndrome. Studies revealed much higher rates of chronic multi-symptom illness among Gulf War veterans than among the general population: About 250,000 of the 700,000 U.S. personnel deployed to the region, the report said, suffered from persistent, unexplained symptoms including fatigue, muscle and joint pain, rashes, and cognitive problems.
DOD and VA investigations into the nature and causes of these illnesses were severely hindered by a lack of health and deployment data. It wasn’t until six years after the war’s end, in the National Defense Authorization Act of 1998, that Congress directed the DOD to establish a system to assess the medical condition of service members before and after deployment.
Vice Adm. Michael Cowan, MC, USN (Ret.), Executive Director of AMSUS, began his career in 1971 at Camp Lejeune, North Carolina, and completed his medical residency at the National Naval Medical Center in Bethesda, Maryland. He retired in 2004 after serving as the 34th Surgeon General of the Navy and Chief, Bureau of Medicine and Surgery. The lack of preparation for Gulf War Syndrome, said Cowan, wasn’t a new flaw in the Military Health System; since World War II, it had excelled at preventive medicine, at combat casualty care, and in the care of family members and dependents. But like the branch-specific medical departments themselves, these fields of practice didn’t mesh in a way that allowed federal health professionals to embrace the entire continuum of care.
Lt. Larry Franklin, center, a nurse with the 146th Aeromedical Evacuation Squadron, California Air National Guard, takes steps to prevent an injured Iraqi prisoner of war from going into shock as attending medical technicians observe during Operation Desert Storm. DOD photo by Sgt. Kimberly Yearyean
“I remember vividly the Vietnam era,” said Cowan. “I was at Bethesda and helped take care of amputees. We treated every amputation the best we could, did everything medically possible. And when the scab fell off the stump, we essentially said: ‘OK, you’re cured. Now you can go home.’ And everybody made the assumption that the person would be a burden for the rest of his life, and off he went to the VA. We had treated them – medically – just fine. But we failed them as people.”
A series of discussions followed among the professionals who cared for service members before, during, and after their deployments. “The idea of a different kind of medical department, and what it would look like, began to be chewed on by the thinkers in the medical departments,” Cowan said. “And AMSUS facilitated that. People brought their presentations to the meetings, and gave talks. Articles on the topic by various authors were published in Military Medicine.”
“The survival in the wars since Force Health Protection was implemented has been well over 90 percent. If you’re not killed instantly, if you don’t lose a vital organ instantly, you’re more than likely going to live.”
The doctrine now known as Joint Vision 2020, and famous for the phrase “full-spectrum dominance,” contained a medical annex that has become known as Force Health Protection (FHP). Though the concept of FHP continues to evolve, it still seeks to balance the Military Health System’s three primary responsibilities: to promote and sustain health and wellness throughout each person’s military service; to prevent acute and chronic illnesses and injuries during training and deployment; and to rapidly stabilize, treat, and evacuate casualties.
Cowan described FHP as a series of doctrinal changes that were more tactical than strategic – “changes in how we use logistics, how we perform preventive medicine, how we deploy medical units. Instead of 500-bed hospitals, we would deploy forward-based, highly mobile, micro surgical units, capable of holding maybe five or 10 people at a time but able to go right up to the front line and do surgery. We wouldn’t keep patients in theater, but move them as quickly to the rear as possible. The Air Force would put intensive care units on aircraft and fly stabilized patients to the rear as quickly as possible. And we would engage families in care immediately, so that the first person most wounded warriors saw when they woke up would be either their spouse or their mom.”
The intellectual exchanges that led to the FHP doctrine – which encompasses prevention, resilience, and health promotion as well as surgical care and rehabilitation – allowed it to take shape quickly. This proved fortunate as the military was called to war again in September 2001. The wars in Afghanistan and Iraq, where up to two-thirds of injuries to service members have been caused by improvised explosive devices, have given added currency to an all-too-common term in military medicine: polytrauma, or injuries to multiple body parts and organ systems, which can include limb loss, burns, auditory and visual damage, spinal cord injury (SCI), brain injury, post-traumatic stress disorder (PTSD), and other conditions.
Advances in battlefield medicine, casualty transport and evacuation, and joint operations, however, have resulted in unprecedented survival rates, often for those suffering polytrauma. “The change in doctrine,” Cowan said, “has resulted in the spectacular save rates that the military is so justifiably proud of. The highest survival from combat wounds ever was about 80 percent. The survival in the wars since Force Health Protection was implemented has been well over 90 percent. If you’re not killed instantly, if you don’t lose a vital organ instantly, you’re more than likely going to live.”
Military Medicine and AMSUS Today
While the 1990s were a time of increasing jointness in the strategy and planning of military medical operations, medical personnel in Afghanistan and Iraq achieved an unprecedented level of tactical collaboration. Forward Surgical Teams were formed of Army, Navy, and Air Force personnel from active duty, National Guard, and Reserves. Wounded service members were transported by Air Force personnel to the Army’s Landstuhl Regional Medical Center in Germany, with Navy hospitals serving as backup in Kuwait. Combat medics and shock-trauma teams, practicing the standards codified in the concept of Tactical Combat Casualty Care (TCCC), made use of lifesaving devices such as tourniquets and hemostatic agents in the field. The Joint Trauma System, established within U.S. Central Command in 2005, enabled evidence-based recommendations for pre-hospital trauma care based on the Joint Theater Trauma Registry, the world’s largest combat data set.