REPORT
DERMATOLOGY IN A WAR ZONE: A PERSIAN GULF EXPERIENCE MAJ KEVIN PEHR, M . e . / AND MAJ BRUeE W. KORNFELD, M . e . '
Combat troops are primarily cared for by their Battalion Aid Stations, which have General Medical Officers ("GMOS" - the military term for general practitioner) assigned to provide primary care to each 600-900 man unit. The Battalion Aid Stations are expected to treat minor illnesses, and to stabilize more seriously III patients for transport to the rear for more definitive eare as needed. An Evacuation Hospital is designed to provide both resuscitive care and definitive treatment for all patients (including, but not limited to, the critically wounded, injured, or ill) in the combat zone;^ It is the highest level of care immediately supporting the combat troops. Patients expected to require greater than 45 days recovery or convalescent time are transported to larger field hospitals or to fixed hospitals out of the theater of operations. Evacuation Hospitals have bed-space for 400 patients under their canvas roofs: 45 icu beds, 300 intermediate care beds, and 55 minimal care beds. Physicians at these hospitals provide consultation services for patients referred from other medical facilities, as well as limited outpatient service on an area basis. That is, in addition to providing secondary and tertiary care for larger combat units (which have their own GMOS). Evacuation Hospitals provide primary care for support units and smaller combat units. Physicians assigned to the 93rd included 14 surgeons with numerous surgical specialties, two anesthesiologists, one psychiatrist, three general internists, and three GMOS. Although both the authors are in dermatology, we were assigned to the 93rd in the capacity of GMOS. Our responsibilities included diagnosis and treatment of the full range of general sick-call (outpatient) conditions, triage during mass casualty periods, and emergency room coverage. This use of dermatologists in a surgical assistant role was not unique to our situation, Kurban^ reported that this occurred in Beruit as well. Once it became known to adjacent medical units that dermatology services were available at our unit, a significant referral basis was established. The catchment area for our service included about 70,000 people. Diagnosis of dermatologic conditions was based almost solely on clinical accumen, as no histopathologic, and very limited chemical laboratory services were available. The hospital laboratory was designed to only provide the basics; of interest to dermatologists, they were able to perform complete blood counts, rapid plasma reagin, urinalysis, and limited serum electrolytes and liver functions. One of us (B.W.K.) was able to bring 20% potassium hydroxide for fungal scrapings, and a pre-mixed solution of toluidine blue for Tzanck smears.* Topical medications available were limited to hydrocortisone 1% cream, triamcinolone 0.1% cream, polymyxin B-bacitracin ointment, clotrimazole 1% cream, and nystatin cream. Available systemic medications included a range of oral and parenteral antibiotics, limited sup-
Abstract The clinical experience of two US Army dermatologists during the recent Gulf War (Operation Desert Shield/Storm) are presented, with comparison with dermatologic experience in previous wars and in civilian practice. Prior to the onset of hostilities in the Persian Gulf, there was some speculation in the dermatologic community as to what types of skin disease might be expected.' The harsh effects of the desert climate, with its aridity and extremes of temperature (especially in winter), were compounded by the need for protective clothing against chemical and biological threats. The limited opportunity for personal hygiene would also play an important factor in the exacerbation and development of dermatologic disorders. Although most people think of "military medicine" as primarily surgical, it is well known to Army planners that the majority of hospitalizations are for "disease and non-battle injuries." This holds true not only for the rear echelon support troops, but for combat units as well.^ The illnesses that deployed medical personnel need to diagnose and treat include the full range seen in civilian practice; however, as the population served is heavily weighed to young adults, the medical problems seen in that age group are more prevalent, and that certainly includes dermatologic problems. In this article, we attempt to catalogue cases seen during a specific time period of the Persian Gulf War, and to compare this with civilian practice and with previously described wartime experience. Materials and Methods Facilities and Dermatologists:
The authors were assigned
to the 93rd Evacuation Hospital, which was located in north central Saudi Arabia in support of the XVIIl Airborne Corps. From *McGill University Faculty of Medicine, Montreal, Quebec, Canada, and the ^Dermatology Service, Ft. Leonard Wood, Missouri. The opinions and statement herein are those of the authors, and do not necessarily reflect the views of the United States Army, the United States Department of Defense, or the United States Government. Address for correspondence: Kevin Pehr, M.D., 1296 Alexandre-DeSeve, Montreal, Quebec, Canada H2L 2V1. 494
Dcrniatoloyy in a War Zone Pchr and Kornfeki
Table 1.
plies of oral acyclovir, and injectable methylprednisolone sodium succinate. In addition, B.W.K. also brought limited supplies of other topical corticosteroids, topical antifungals, and injectable triamcinolone acetonide.
Dermatologic Problems Encountered
Diagnosis Acne vulgaris Allergic contact dermatitis Alopecia areata Androgenetic alopecia Aropic dermatitis C'andidal intertrigo (Candida, other Collulitis (ddx anthrax vaccine reaction) IDermatofihroma ticzema, nonspecific Epidermoid cysts Erythema multiforme (2° to HSV) Erythema nodosum Eolliculitis Furuncle Herpes simplex Herpes zoster tmpetigo Irritant contact dermatitis Keioid Keratotis pilaris Laceration tjpoma Miliaria Molluscum contagiosum Nonspecific urethritis Onychocryptosis Pitted keratolysis Pityriasis rosea Plantar hyperliydrosis Pruritus (triggered by heat) Psoriasis Pyoderma gangrenosum Pyogenic granuloma Scat")ies Seborrheic dermatitis Sycosis barbae Tinea versicolor Tinea, other Ulcers, foot Urticaria Viral exanthem Wart, plantar Wart, other
Patient Base: During the 1-month period from February 3, 1991 to March 8, 1991, 81 patients were seen for dermatologic complaints by one or both of us. This time-frame included the build-up to the ground war, the ground war itself, and the Iraqi surrender. Patients were seen before and after that period of time, but do not reflect the full operational capability of the hospital, which was being relocated. All of the patients were military, with its preponderance of young adults. The average age was 27.3 years old, with a range of 19 to 50 years old; 75% were male. The large majority of our patients were American, but our hospital (and dermatology service) received and treated on an equal basis Americans, Iraqi prisoners-of-war, and allied forces (including French Foreign Legion, regular French forces, Saudi Arabian, British, and Kuwaiti military personnel).
RESULTS
As shown in Table 1, the range of problems we encountered were similar to those that dermatologists might see in their offices. Three factors influenced the types and incidence of disease seen, limiting it mainly to the middle ground of dermatology. First, unit C;MOS were well-familiar with treatment of the simpler, more common skin conditions (including those caused or aggravated by the climate) such as tinea pedis and sunburn. At the other end of the disease spectrum, persons with serious or chronic medical problems are excluded from military service, so we did not encounter any of the more severe dermatologic conditions such as pemphigus vulgaris, psoriatic arthritis mutilans, or scleroderma. The last factor was that some diseases were not. seen due to the long latency time before they manifest (e.g., leishmaniasis or solar elastosis). Compressing the specific diagnoses listed in Table 1 to a somewhat smaller number of categories, we found that 18 closely related groups of diseases accounted for 78.3% of our patient visits. Again, this is not dissimilar to a typical dermatologic practice in the United States. Mendenhall et al.-^ found that 25 diagnoses accounted for 87% of the patient visits across the us. Nor were the findings from the US Army in the Vietnam era (both in the war zone and in the continental United States) significantly different from ours. Table 2 compares our experience with that of two different US Army field hospitals in Vietnam,* William Beaumont Army Medical Center'' in the United States (which provides care to active duty personnel, their families, and retirees), and Mendenhall's' study of civilian dermatologic practice in the United States.
Number Seen * 3 1 2 1 1 1 1 1 1 8
3 1
1 1 1 2 1 1 3 1 1 1 1 1 •
1
1 2 1 3
1 2 1 1 1 2 1 1
3 3 1 1 1 2' 1
'•'In order r
DERMATOLOGY IN A WAR ZONE: A PERSIAN GULF EXPERIENCE MAJ KEVIN PEHR, M . e . / AND MAJ BRUeE W. KORNFELD, M . e . '
Combat troops are primarily cared for by their Battalion Aid Stations, which have General Medical Officers ("GMOS" - the military term for general practitioner) assigned to provide primary care to each 600-900 man unit. The Battalion Aid Stations are expected to treat minor illnesses, and to stabilize more seriously III patients for transport to the rear for more definitive eare as needed. An Evacuation Hospital is designed to provide both resuscitive care and definitive treatment for all patients (including, but not limited to, the critically wounded, injured, or ill) in the combat zone;^ It is the highest level of care immediately supporting the combat troops. Patients expected to require greater than 45 days recovery or convalescent time are transported to larger field hospitals or to fixed hospitals out of the theater of operations. Evacuation Hospitals have bed-space for 400 patients under their canvas roofs: 45 icu beds, 300 intermediate care beds, and 55 minimal care beds. Physicians at these hospitals provide consultation services for patients referred from other medical facilities, as well as limited outpatient service on an area basis. That is, in addition to providing secondary and tertiary care for larger combat units (which have their own GMOS). Evacuation Hospitals provide primary care for support units and smaller combat units. Physicians assigned to the 93rd included 14 surgeons with numerous surgical specialties, two anesthesiologists, one psychiatrist, three general internists, and three GMOS. Although both the authors are in dermatology, we were assigned to the 93rd in the capacity of GMOS. Our responsibilities included diagnosis and treatment of the full range of general sick-call (outpatient) conditions, triage during mass casualty periods, and emergency room coverage. This use of dermatologists in a surgical assistant role was not unique to our situation, Kurban^ reported that this occurred in Beruit as well. Once it became known to adjacent medical units that dermatology services were available at our unit, a significant referral basis was established. The catchment area for our service included about 70,000 people. Diagnosis of dermatologic conditions was based almost solely on clinical accumen, as no histopathologic, and very limited chemical laboratory services were available. The hospital laboratory was designed to only provide the basics; of interest to dermatologists, they were able to perform complete blood counts, rapid plasma reagin, urinalysis, and limited serum electrolytes and liver functions. One of us (B.W.K.) was able to bring 20% potassium hydroxide for fungal scrapings, and a pre-mixed solution of toluidine blue for Tzanck smears.* Topical medications available were limited to hydrocortisone 1% cream, triamcinolone 0.1% cream, polymyxin B-bacitracin ointment, clotrimazole 1% cream, and nystatin cream. Available systemic medications included a range of oral and parenteral antibiotics, limited sup-
Abstract The clinical experience of two US Army dermatologists during the recent Gulf War (Operation Desert Shield/Storm) are presented, with comparison with dermatologic experience in previous wars and in civilian practice. Prior to the onset of hostilities in the Persian Gulf, there was some speculation in the dermatologic community as to what types of skin disease might be expected.' The harsh effects of the desert climate, with its aridity and extremes of temperature (especially in winter), were compounded by the need for protective clothing against chemical and biological threats. The limited opportunity for personal hygiene would also play an important factor in the exacerbation and development of dermatologic disorders. Although most people think of "military medicine" as primarily surgical, it is well known to Army planners that the majority of hospitalizations are for "disease and non-battle injuries." This holds true not only for the rear echelon support troops, but for combat units as well.^ The illnesses that deployed medical personnel need to diagnose and treat include the full range seen in civilian practice; however, as the population served is heavily weighed to young adults, the medical problems seen in that age group are more prevalent, and that certainly includes dermatologic problems. In this article, we attempt to catalogue cases seen during a specific time period of the Persian Gulf War, and to compare this with civilian practice and with previously described wartime experience. Materials and Methods Facilities and Dermatologists:
The authors were assigned
to the 93rd Evacuation Hospital, which was located in north central Saudi Arabia in support of the XVIIl Airborne Corps. From *McGill University Faculty of Medicine, Montreal, Quebec, Canada, and the ^Dermatology Service, Ft. Leonard Wood, Missouri. The opinions and statement herein are those of the authors, and do not necessarily reflect the views of the United States Army, the United States Department of Defense, or the United States Government. Address for correspondence: Kevin Pehr, M.D., 1296 Alexandre-DeSeve, Montreal, Quebec, Canada H2L 2V1. 494
Dcrniatoloyy in a War Zone Pchr and Kornfeki
Table 1.
plies of oral acyclovir, and injectable methylprednisolone sodium succinate. In addition, B.W.K. also brought limited supplies of other topical corticosteroids, topical antifungals, and injectable triamcinolone acetonide.
Dermatologic Problems Encountered
Diagnosis Acne vulgaris Allergic contact dermatitis Alopecia areata Androgenetic alopecia Aropic dermatitis C'andidal intertrigo (Candida, other Collulitis (ddx anthrax vaccine reaction) IDermatofihroma ticzema, nonspecific Epidermoid cysts Erythema multiforme (2° to HSV) Erythema nodosum Eolliculitis Furuncle Herpes simplex Herpes zoster tmpetigo Irritant contact dermatitis Keioid Keratotis pilaris Laceration tjpoma Miliaria Molluscum contagiosum Nonspecific urethritis Onychocryptosis Pitted keratolysis Pityriasis rosea Plantar hyperliydrosis Pruritus (triggered by heat) Psoriasis Pyoderma gangrenosum Pyogenic granuloma Scat")ies Seborrheic dermatitis Sycosis barbae Tinea versicolor Tinea, other Ulcers, foot Urticaria Viral exanthem Wart, plantar Wart, other
Patient Base: During the 1-month period from February 3, 1991 to March 8, 1991, 81 patients were seen for dermatologic complaints by one or both of us. This time-frame included the build-up to the ground war, the ground war itself, and the Iraqi surrender. Patients were seen before and after that period of time, but do not reflect the full operational capability of the hospital, which was being relocated. All of the patients were military, with its preponderance of young adults. The average age was 27.3 years old, with a range of 19 to 50 years old; 75% were male. The large majority of our patients were American, but our hospital (and dermatology service) received and treated on an equal basis Americans, Iraqi prisoners-of-war, and allied forces (including French Foreign Legion, regular French forces, Saudi Arabian, British, and Kuwaiti military personnel).
RESULTS
As shown in Table 1, the range of problems we encountered were similar to those that dermatologists might see in their offices. Three factors influenced the types and incidence of disease seen, limiting it mainly to the middle ground of dermatology. First, unit C;MOS were well-familiar with treatment of the simpler, more common skin conditions (including those caused or aggravated by the climate) such as tinea pedis and sunburn. At the other end of the disease spectrum, persons with serious or chronic medical problems are excluded from military service, so we did not encounter any of the more severe dermatologic conditions such as pemphigus vulgaris, psoriatic arthritis mutilans, or scleroderma. The last factor was that some diseases were not. seen due to the long latency time before they manifest (e.g., leishmaniasis or solar elastosis). Compressing the specific diagnoses listed in Table 1 to a somewhat smaller number of categories, we found that 18 closely related groups of diseases accounted for 78.3% of our patient visits. Again, this is not dissimilar to a typical dermatologic practice in the United States. Mendenhall et al.-^ found that 25 diagnoses accounted for 87% of the patient visits across the us. Nor were the findings from the US Army in the Vietnam era (both in the war zone and in the continental United States) significantly different from ours. Table 2 compares our experience with that of two different US Army field hospitals in Vietnam,* William Beaumont Army Medical Center'' in the United States (which provides care to active duty personnel, their families, and retirees), and Mendenhall's' study of civilian dermatologic practice in the United States.
Number Seen * 3 1 2 1 1 1 1 1 1 8
3 1
1 1 1 2 1 1 3 1 1 1 1 1 •
1
1 2 1 3
1 2 1 1 1 2 1 1
3 3 1 1 1 2' 1
'•'In order r
