Sponsored by 

Department of Veterans Affairs 

Employee Education System 

This is a Veterans Health Administration System-wide Training program, sponsored by 

Employee Education System. It is produced by Employee Education System. 
Hon. Anthony J. Principi -

Secretary of Veterans Affairs 

Actual statement as heard on satellite broadcast 

Hello, everyone, thank you for tuning in. As I 

speak, hundreds of thousands of America’s 

finest citizens are putting their lives on the 

line to disarm Iraq of weapons of mass 

destruction, to end Saddam Hussein’s support 

of terrorism, and to free the Iraqi people. Our 

troops are conducting themselves in the 

highest traditions of the American military. 

They are doing their jobs with skill and 

bravery. The future of peace and the hopes of 

the Iraqi people depend on them. 

In the course of defending freedom, some of 

these brave men and women will make the 

ultimate sacrifice for our nation, others will 

be wounded. Those who are injured or 

become ill, in America’s service have every 

right to expect the best possible care our 

nation can provide. It is our privilege, and our 

honor, to share with the Department of 

Defense the responsibility for providing them 

that care on behalf of a grateful nation. 

Today’s Department of Veterans Affairs is better prepared than ever to 

provide exceptional care for the range of problems war casualties, and other 

returning veterans may present to us. We are working with DoD to ensure 

that the men and women who now fight for our freedom in the Persian Gulf 

receive appropriate health care and compensation in return for their service. 

DoD is documenting the health care provided to forces deployed in the 

Gulf, monitoring the environment in which our forces are deployed, and 

will document which service members were exposed to danger in the event 

toxic exposure is detected. DoD will also provide us with rosters of service 

members who have separated from military service, and will work with us to 

develop processes to share information including individual assignments 

data, unit location data, environmental surveillance data, and medical 

surveillance data. 

Together, our two departments are working together to ensure that our 

brave men and women now serving in the Gulf will be cared for with the 

dignity and respect they earn as they place themselves in harm’s way on our 

behalf. In this satellite broadcast, and in a second broadcast to follow, you’ll 

learn additional details about our coordination with the Department of 

Defense. We’ll give you information on today’s battlefield as we understand 

it, and on specific issues that may affect the health of returning troops, as 

well as clinical information on specific types of war-related injuries caused 

by both traditional weapons like explosives, and new threats like weapons 

of mass destruction. 

ii Caring for War Wounded 
Following each broadcast, VHA will schedule a telephone conference, so 

you will have an additional opportunity to speak with, and ask questions of, 

VA experts in each of the areas under discussion. Our Department has no 

greater mission, no more sacred responsibility, than to save the lives of 

those who have borne the battle; no more important duty than to make 

whole again in mind and body those who are wounded and sick; no more 

pressing task than to devote all our efforts to enable ill and injured 

servicemen to resume their lives at the point where they were interrupted 

when America once again answered Saddam Hussein’s challenge to peace. 

I do not ask, I insist that you participate fully in this training program; and 

that you share what you have learned with your colleagues who are unable 

to take part. The care we provide to the young heroes now participating in 

“Operation Iraqi Freedom” will define the Department of Veterans Affairs 

for a new generation of Americans and their families. Our training must be 

as intense as our troops have received; our planning must be as 

comprehensive and thorough as theirs; and our victory must be as 

complete as theirs most assuredly will be. For us, as for them, failure is 

unthinkable. God bless our great country and the men and women who 

defend her. 

Caring for War Wounded iii 
Dr. Robert Roswell, MD - 

Under Secretary of Veterans Affairs for Health 

Actual statement as heard on satellite broadcast 

The first satellite in this two part series 

provided background information about 

VA/DoD collaboration designed to help us 

better meet the needs of veterans returning 

from the current war with Iraq. Included 

was information about endemic 

environmental hazards in SW Asia, pre- and 

post-deployment activities conducted by 

DoD with returnees from the war zone, and 

a discussion of VA health care benefits after 

combat deployment. 

Today’s program will focus on the clinical 

issues and situations VA clinicians will 

address when faced with returning 

casualties from the war who come to VA for 

care. These patients will have been 

stabilized to enable them to be transported 

from the war zone to the United States, but 

we believe many of these men and women 

will be in the acute stages of their illness or 

injury. While issues of wounds from 

chemical, biological, or radiological agents 

will be addressed; we will also focus on the management of wounds 

inflicted by traditional weapons such as explosives and small arms, including 

amputations, burns, and other traumatic injuries. 

Mental health needs of casualties will be discussed, but not only in the 

context of individuals with identified mental problems as the cause of 

evacuation. It will be important to provide assessment of and support for 

the emotional needs of those with physical injuries. The program will begin 

with a discussion of family support activities in DoD and the importance of 

working with the families of casualties as part of the recovery process. 

Remember, that many returnees will be members of the Reserves and 

National Guard, for whom family support structures are not so well 

established as for active duty troops living in military communities. 

Although we hope it is not the case, it is important to realize that the clinical 

skills addressed in this broadcast can also be useful in treating survivors of 

potential terrorist attack in our own cities and towns. Finally, we know that 

when this war is over, and our victorious troops return, they will have 

eligibility for care in VA, and the threats they faced in combat will be the 

kinds of situations experienced by those who have been injured, reinforcing 

the value of the information in these broadcasts and the Web sites that will 

support their back up materials. 

Thank you for participating in this learning experience and for the service 

you provide to our nation’s veterans and returning troops. 

iv Caring for War Wounded 
Table of Contents
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
 

VA/DoD Contingency Back-Up System . . . . . . . . . . . . . . . . . . . . . . . . .3
 

Environmental and endemic hazards 


DoD Pre-Deployment screening and the
 

Specific combat related injuries, including 


Independent Study Registration/Answer/Participant Satisfaction Form
 

of deployment to Southwest Asia . . . . . . . . . . . . . . . . . . . . . . . . . . .11
 

Force Health Protection Program . . . . . . . . . . . . . . . . . . . . . . . . . . .17
 

VA health care benefits after combat deployment . . . . . . . . . . . . . . .23
 

wounds from traditional weapons and high-velocity weapons . . . . .31
 

Injuries associated with chemical warfare agents . . . . . . . . . . . . . . . .35
 

Injuries associated with pesticide agents . . . . . . . . . . . . . . . . . . . . . .41
 

Injuries associated with biological warfare agents . . . . . . . . . . . . . . .47
 

Injuries associated with radiological warfare . . . . . . . . . . . . . . . . . . .63
 

Combat effects on mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
 

Family support programs for veterans and their families . . . . . . . . . .79
 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
 

Independent Study Test Questions for CME Credit . . . . . . . . . . . . . .85
 

Caring for War Wounded v 
Independent Study Outline
 

On 20 March 2003, the drive to free the people of Iraq from the tyranny of 

Saddam Hussein started when President George Bush gave the order that 

began “Operation Iraqi Freedom”. Many health care providers are engaged 

in the treatment of U.S. military members involved in “Operation Iraqi 

Freedom”. As with all previous wars where U.S. service men and women 

have participated, there will be casualties. Many of these casualties will come 

to the VA for continuing care. All VA clinicians should have an understanding 

of the experiences and exposures of these most recent of America’s combat 

veterans. This is the reason for this VHI, which was originally presented as a 

satellite videoconference on 26-27 March 2003. 

This independent study module is being released as a part of the Veterans 

Health Initiative (VHI). The VHI is a comprehensive program of continuing 

education that recognizes the connection between certain health effects and 

military service and emphasizes better military medical histories for those 

wounded during Gulf War II. 

After completing this independent study, participants will be able to: 

1.	 define the VA/DoD Contingency Back-Up System; 

2.	 list the environmental and endemic hazards of deployment to 

Southwest Asia; 

3.	 explain the purpose of DoD Pre-Deployment screening and the 

Force Health Protection Program; 

4.	 list the VA health care benefits after combat deployment; 

5.	 describe the specific combat related injuries, including wounds from 

traditional weapons and high-velocity weapons; 

6.	 identify injuries associated with chemical warfare agents; 

7.	 identify injuries associated with pesticide agents; 

8.	 identify injuries associated with biological warfare agents; 

9.	 identify injuries associated with radiological warfare; 

10.	 explain the effect of combat on mental health; and 

11.	 describe the family support programs for veterans and their families. 

This independent study is primarily designed for Department of Veterans 

Affairs clinicians and other interested VA staff. Other health care providers, 

especially those in VA health care facilities, also are encouraged to complete 

the study. 

This program is available in booklet form and on the Web at: 

http://www.va.gov/vhi. 

Purpose
 

Background 

Objectives 

Target Audience 

Format 

vi Caring for War Wounded 
Program Description
 

This program includes: 

• independent study material 

• test for CME credits 

• program evaluation 

This activity has been planned and implemented in accordance with the 

Essentials and Standards of the Accreditation Council for Continuing 

Medical Education (ACCME) through the joint sponsorship of VA Employee 

Education System and Department of Veterans Affairs Office of Public 

Health and Environmental Hazards. The VA Employee Education System is 

accredited by the ACCME to provide continuing medical education for 

physicians. 

Content Materials: 

• Introduction 

• VA/DoD Contingency Back-Up System 

• Environmental and endemic hazards 


of deployment to Southwest Asia
 

• DoD Pre-Deployment screening and the
 

Force Health Protection Program
 

• VA health care benefits after combat deployment 

• Specific combat related injuries, including 


wounds from traditional weapons and high-velocity weapons
 

• Injuries associated with chemical warfare agents 

• Injuries associated with pesticide agents 

• Injuries associated with biological warfare agents 

• Injuries associated with radiological warfare 

• Combat effects on mental health 

• Family support programs for veterans and their families 

• References 

• Independent Study Test Questions for CME Credit 

• Independent Study Registration/Answer/Participant Satisfaction Form 

Caring for War Wounded vii 
 

Program Implementation and VA Application Procedure
 

To receive credit for this course: 

1. Read the independent study materials. 

2. Complete the CME test questions. A passing score of 70% or 

higher on the CME test is required to receive credit. This test 

may be retaken. 

3. Complete the program evaluation. 

4. The estimated study time for this program is 5 hours. 

If you are using the Independent Study Registration/Answer/Evaluation Form 

(two sided) at the back of the independent study booklet, (NOTE: Scantron 

forms cannot be photocopied. For additional copies of this independent 

study, Scantron forms or other VHI independent study modules, please 

contact your facility education contact person.) please send the 

completed form within two weeks after reading the material to: 

Employee Education Resource Center
 

Attn: SDU
 

Medical Forum, Suite 500
 

950 North 22nd Street
 

Birmingham, AL 35203-5300
 

If you have attained a passing score of 70% or higher, a certificate will be 

mailed to you approximately 6-8 weeks after your test has been graded. 

The test may be retaken. 

The CME test and program evaluation can also be completed using the VA 

Internet. The address is: http://www.ees-learning.net. 

After you take the test, you will receive immediate feedback as to pass or fail. 

You will be allowed to retake the test. Upon passing the test and completing 

the program evaluation, you will be able to immediately print your certificate 

according to instructions. 

NOTE: If you experience difficulty reaching this Web site, please contact 

the Help Desk via e-mail at eeslibrixhelp@lrn.va.gov, or call 

1-866-496-0463. You may also contact your local computer support staff 

or librarian for assistance. 

NOTE: In order to complete the CME test and Evaluation, your 

computer must have Internet Explorer 4.0 or Netscape 4.0 or higher. 

If you have questions or special needs concerning this independent study, 

please contact: 

Bob Smith, EdD, MCP
 

205-731-1812, Ext. 317; E-mail - bob.smith@lrn.va.gov.
 

This program will no longer be authorized for CME credit after 

31 December 2004. 

viii Caring for War Wounded 
Program Development
 

Authors 

Susan Mather, MD 

Chief Public Health & 

Environmental Hazards Officer 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Ralph DePalma, MD 

National Director of Surgery 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

LTCOL Bruno Petruccelli, 

US Army 

Director Epidemiology & 

Disease Surveillance 

US Army Center for Health 

Promotion & Preventive Medicine 

Aberdeen Proving Grounds 

Aberdeen, MD 

Lawrence Deyton, MD 

Chief Consultant, Public Health 

Strategic Healthcare Group 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Mark Brown, PhD 

Director Environmental 

Agents Service 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Larry Flesh, MD 

VISN 2, Medical Director 

Veterans Health Administration 

Albany VAMC 

Albany, NY 

Michael Kilpatrick, MD 

Deputy Director 

Deployment Health 

Support Directorate 

Office of the Secretary of Defense 

Washington, DC 

Harold Kudler, MD 

VISN 6 Mental Health Coordinator 

Veterans Health Administration 

Durham VAMC 

Durham, NC 

Artie Shelton, MD 

Chief, Allergy & Immunization 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Jill Manske, MSW 

Director, Social Work Services 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Planning Committee 

Alfonso Batres, PhD, MSSW 

Readjustment Counseling Service 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Caring for War Wounded ix 
Laurent S. Lehmann, MD 

Chief Consultant, Mental Health 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Nancy Donovan, MSW 

Program Manager 

VA Employee Education System 

Minneapolis Education 

Resource Center 

Minneapolis, MN 

Susan Mather, MD 

Chief Public Health & 

Environmental Hazards Officer 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Pamela Hebert, DrPH 

Program Manager 

VA Nurse Planner 

VA Employee Education System 

Birmingham Education 

Resource Center 

Birmingham, AL 

Neil Otchin, MD 

Program Chief for Clinical Matters 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Craig Hyams, MD, MPH 

Consultant to Office of Public Health 

& Environmental Hazards 

Veterans Health Administration 

Department of Veterans Affairs 

Washington, DC 

Robert Smith, EdD, MCP 

Program Manager 

VA Employee Education System 

Birmingham Education 

Resource Center 

Birmingham, AL 

Project Support Assistant 

Donna Burnett 

Project Support Assistant 

VA Employee Education System 

Birmingham Education 

Resource Center 

Birmingham, AL 

Learning Technology and 

Media Development 

Jeffrey L. Henry 

Media Producer 

VA Employee Education System 

North Chicago VAMC 

Chicago, IL 

Joseph Radford 

Graphic Artist 

VA Employee Education System 

Salt Lake City Education 

Resource Center 

Salt Lake City, UT 

x Caring for War Wounded 
AMA and ANCC Continuing Education Credits
 

Accreditation
 

Accreditation Council for Continuing Medical Education (ACCME)
 

The VA Employee Education System is accredited by the Accreditation 

Council for Continuing Medical Education to provide continuing medical 

education for physicians. 

American Nurses Credentialing Center (ANCC) 

VA Employee Education System is accredited as a provider of continuing 

nursing education by the American Nurses Credentialing Center’s 

Commission on Accreditation. 

Continuing Education Credit
 

Accreditation Council for Continuing Medical Education (ACCME)
 

The VA Employee Education System designates this educational activity for a 

maximum of 5 hours in category 1 credit towards the American Medical 

Association Physician’s Recognition Award. Each physician should claim only 

those hours of credit that he/she actually spent in the educational activity. 

Association of Social Work Boards (ASWB) 

VA Employee Education System, Provider Number 1040, is approved as a 

provider for social work continuing education by the Association of Social 

Work Boards (ASWB), (1-800-225-6880) through the Approved Continuing 

Education (ACE) program. VA Employee Education System maintains 

responsibility for the program. Social workers will receive 5 continuing 

education clock hours for participating in this course. 

American Nurses Credentialing Center (ANCC) 

VA Employee Education System designates this educational activity for 6 

contact hours in continuing nursing education. 

The Employee Education System maintains responsibility for the program. A 

certificate of attendance will be awarded to participants and accreditation 

records will be on file at the Employee Education System. In order to receive 

a certificate from EES, you must complete the material, complete and pass 

the CME test with a 70% or higher, and complete a program evaluation. 

Report of Training 

It is the program participant’s responsibility to ensure that this training is 

documented in the appropriate location according to his/her locally 

prescribed process. 

Caring for War Wounded xi 
Disclosure Statement 

The Employee Education System (EES) must insure balance, independence, 

objectivity, and scientific rigor for all EES sponsored educational activities. 

The intent of this disclosure is not to prevent faculty with a significant 

financial or other relationship from presenting materials, but rather to 

provide the participant with information on which they can make their own 

judgments. 

It remains for the participant to determine whether the faculty interests or 

relationships influence the materials presented with regard to exposition or 

conclusion. When an unapproved use of a FDA approved drug or medical 

device, or an investigational product not yet FDA approved for any purpose 

is mentioned, EES requires disclosure to the participants. 

Faculty have provided the following information: 

Lawrence Deyton, MD 

Recommendations for several treatment or prophylaxis strategies in 

this lecture are based on consensus recommendations developed with 

HHS, CDC, NIH, and FDA involvement. These recommendations have 

been widely published (JAMA) and presented by CDC and other 

Federal Agencies as currently recommended treatment or prophylaxis 

for response to bioterror use of these infectious agents. These 

recommendations are based on the best available evidence for 

biologic activity against these agents of bioterrorism, but do not 

represent uses currently approved by the FDA. 

Americans with Disabilities Act Policy 

The Employee Education System wishes to ensure no individual with a 

disability is excluded, denied services, segregated, or otherwise treated 

differently from other individuals attending this workshop because of the 

absence of auxiliary aids and services. If you require any special 

arrangements to fully participate in this independent study, please contact 

Bob Smith, EdD, MCP, Program Manager at: 

205-731-1812 extension 317, or e-mail bob.smith@lrn.va.gov. 

xii Caring for War Wounded 
On 20 March 2003, the drive to free the people of Iraq from the tyranny of 

Saddam Hussein started when President George Bush gave the order that 

began “Operation Iraqi Freedom”. Many health care providers are engaged 

in the treatment of U.S. military members involved in “Operation Iraqi 

Freedom”. As with all previous wars where U.S. service men and women 

have participated, there will be casualties. Many of these casualties will come 

to the VA for continuing care. All VA clinicians should have an understanding 

of the experiences and exposures of these most recent of America’s combat 

veterans. This is the reason for this VHI, which was originally presented as a 

satellite videoconference on 26-27 March 2003. 

Course Purpose: To provide valuable information to all health care 

providers engaged in the treatment of U.S. military members involved in 

“Operation Iraqi Freedom”. 

Course Goals: The 11 goals of this course are to provide issues and lessons 

learned from Gulf War I with up-to-date information on: 

Goal 1: The VA/DoD Contingency Back-Up System. 

Goal 2: Environmental and endemic hazards of deployment to 

Southwest Asia. 

Goal 3: The DoD Pre-Deployment screening and Force Health 

Protection Program. 

Goal 4: The VA health care benefits after combat deployment. 

Goal 5: Specific combat related injuries, including wounds from 

traditional weapons and high-velocity weapons. 

Goal 6: Injuries associated with chemical warfare agents. 

Goal 7: Injuries associated with pesticide agents. 

Goal 8: Injuries associated with biological warfare agents. 

Goal 9: Injuries associated with radiological warfare. 

Goal 10: Combat effects on mental health. 

Goal 11: Family support programs for veterans and their families. 

Introduction Introduction

Caring for War Wounded 1
2 Caring for War Wounded 
VHA Missions and Associated Web Sites 

Mission Intranet Web site Internet Web site 

Medical Care N/A http://www.va.gov/health_benefits/page.cfm?pg=13 

Education N/A There is no Internet Web site 

Research N/A http://www.va.gov/health_benefits/page.cfm?pg=15 

Contingency N/A http://www.va.gov/emshg 

Support 

VA/DoD Contingency Back-Up System A/DoD Contingency Back-Up System

Objectives 

Explain the VHA’s Fourth Mission “Emergency Management”; 

Define the VA/DoD Contingency Back-Up System; 

List the components of the VA/DoD Contingency Back-Up System; and 

Explain the purpose of the Federal Coordinating Centers. 

Introduction 

The mission of the Veterans Health Administration is to “provide a broad 

spectrum of medical, surgical, and rehabilitative care to its customers. Our 

goal is to share information about these benefits and services to make it as 

easy as possible for you to receive the care you need”. 

This mission consists of four distinct areas. These four areas enable VHA to 

provide the services and support for those that put themselves “in harm’s 

way” for their country. They are: 

• Medical Care 

• Education 

• Research 

• Contingency Support 

Table 1 provides the four missions of VHA, and their associated Web site. 

Table 1 

Caring for War Wounded 3 
V/A DoD Cotingency Back-Up System 

VHA’s Fourth Mission - Emergency Management 

The Veterans Health Administration is set up to respond very quickly to 

manage crises, and provide the leadership necessary to ensure continuity of 

operations. The VA Continuity of Operations Planning (COOP) plan was set 

into motion on September 11, 2001. The execution of this plan included 

manning of alternate sites, which served as command centers and gave the 

VA leadership the ability to manage this national crisis. 

VHA’s Fourth Mission “Emergency Management” is intended to ensure that 

regardless of the crisis or emergency, that medical care and support 

functions continue as needed. The emergency functions, which are outlined 

below, play an integral part in the success of VHA and Emergency 

Management. 

• VA/DoD Contingencies 

• National Disaster Medical System (NDMS) 

• Federal Response Plan (FRP) 

• Natural and Technological Hazards 

• Continuity of Government (COG)/Continuity of 


Operations Planning (COOP)
 

VA/DoD Contingencies 

The VA serves as the primary medical backup to the military health care 

system during and immediately following an outbreak of war or national 

emergency. The VA/DoD Contingency Hospital System Plan outlines how 

VHA supports that effort. 

The following are components of the VA’s response to VA/DoD Contingencies. 

• Area Emergency Managers (AEMs) 

• VAMC emergency plans 

• All-hazards approach 

• Comprehensive Emergency Management (Figure 1, top of next page) 

• Public Law 97-174 is the authorizing legislation naming VA the 

primary backup to the military health care system during 

war or other emergencies. This is accomplished through: 

° Primary Receiving Centers (65 in VA)
 

° Secondary Support Centers (66 in VA)
 

° Regular counting of bed availability of NDMS and VA beds 


For more information go to: http://www.va.gov/emshg. 

4 Caring for War Wounded 
V/A DoD Cotingency Back-Up System 

The Four Phases of Comprehensive Emergency Management 

Figure 1 

National Disaster Medical System (NDMS) 

The National Disaster Medical System (NDMS) is a federally coordinated 

initiative that augments the nation’s emergency medical response capability. 

The four federal partners in NDMS have traditionally been the Department 

of Health and Human Services (U.S. Public Health Service), Federal 

Emergency Management Agency (FEMA), DoD, and the VA. The Office of 

Homeland Security will assume responsibility for coordinating this function 

in the future. The overall purpose of NDMS is to establish a single national 

medical response capability for: 

• assisting state and local authorities in dealing with the medical 

and public health effects of major peacetime disasters; and 

• providing support to the military medical system in caring for 

casualties resulting from overseas armed conflicts. 

NDMS has two major components: 

1. Disaster Medical Assistance Teams (DMATs) with necessary 

supplies and equipment that will be dispatched to a disaster site 

within the U.S. from the country’s major metropolitan areas. 

2. A voluntary hospital system that will provide definitive care to 

disaster victims who are evacuated out of the disaster area to 

designated NDMS metropolitan areas. 

Caring for War Wounded 5 
V/A DoD Cotingency Back-Up System 

In peacetime, NDMS will only be activated when state resources have been
 

overwhelmed by a disaster and a request has been made for federal assistance.
 

DoD can activate the system for casualties of an overseas armed conflict. 


For more information go to:
 

http://www.va.gov/emshg.
 

Federal Response Plan (FRP) 

The FRP (Public Law 93-288), as amended, established the basis for the 

provision of federal assistance to a state and its affected local governments 

impacted by a catastrophic or significant disaster, or emergency that results 

in a requirement for federal response assistance. The VA has been assigned 

the responsibility to support four of the twelve Emergency Support 

Functions (ESFs). The Emergency Management Strategic Health Group 

(EMSHG) will coordinate VHA response to any missions that may be tasked 

under the FRP. Specifically the VA may be tasked with: 

1. Engineering Services 

2. Mass Care and Sheltering 

3. Resource Support 

4. Health and Medical Support 

Natural and Technological Hazards 

According to Executive Order 12657, the VA is responsible for: 

1. providing medical assistance using their Medical Emergency 

Radiological Response Team (MERRT); and 

2. providing temporary housing. 

As part of the Federal Radiological Emergency Response Plan (FRERP) (May 

1, 1996), the VA’s MERRT is a federal resource that is available to respond to 

radiological emergencies, which includes nuclear power plant accidents, 

and injuries associated with radiological accidents. 

Continuity of Government (COG) Operations 

VA Handbook 0320 (Emergency Preparedness Planning Procedures and 

Operational Requirements) paragraph 3 b. (1) (a) outlines the requirements 

that all VA organizations develop a plan to ensure COG and Continuity of 

Operations Planning (COOP) Operations. Executive Order 12656 (EO 

12656) and Presidential Decision Directive 67 (PDD 67) also provide 

requirements for these plans. Specifically: 

EO 12656 (Assignment of Emergency Preparedness Responsibilities) ­

Charged the VA to plan for emergency health care services for VA 

beneficiaries in VA medical facilities, active duty personnel, and, as 

6 Caring for War Wounded 
V/A DoD Cotingency Back-Up System 

resources permit, to civilians in communities affected by national 

security emergencies. Also, to provide mortuary services for eligible 

veterans and to advise on methods for internment of the dead 

during national security emergencies. 

PDD 67 (Continuity of Operations) - Tasks all Federal Departments 

and Agencies, including the VA to ensure that their critical functions 

and operations continue under all circumstances and a wide range 

of possible threats. VA works closely with FEMA to ensure 

compliance with the COG and COOP requirements in PDD 67. 

The VA has specific relocation sites set up to ensure continuity of 

operations in the case of an emergency. Refer to your facilities specific 

COOP document for the relocation site. 

Deployments 

As stated in the Introduction for this section, VHA is set up to respond very 

quickly to manage any potential crisis. The VHA also responds to 

presidentially declared disasters, such as Hurricanes Andrew, and Floyd, and 

the floods that occurred in Houston, Texas. Over 1000 VA employees were 

involved in these operations. VHA also provides on-site support for highthreat events, such as: 

• NATO 50 

• Olympics 

• Inaugurations 

• Papal Visits 

• Economic Summits of the eight world leaders 

VHA Role in Emergency Preparedness 

VHA operates the largest integrated national health care system in the 

country with 1200 sites nationwide. The VHA is ready to provide significant 

assistance should mass casualty situations arise. In the past, VHA has 

responded well to emergent needs, and is prepared to provide assistance to 

DoD should the need arise. Each facility is continuously reviewing, drilling, 

and revising, as needed their emergency plans. Part of VHA’s role is to 

ensure that each VAMC is prepared for emergencies, and that they are 

prepared to provide support to HHS. The below bullets highlight some of 

the roles of VHA. 

• VAMC Preparedness 

° AEMs around the country assisting in All-hazards approach 

° Emergency Management Program Guidebook 

° Pharmaceutical Caches 

° Mass Decontamination Capability 

° Partnership with local communities 

Caring for War Wounded 7 
V/A DoD Cotingency Back-Up System 

• Support of HHS 

° NDMS Caches
 

° CDC Stockpiles
 

° NDMS Education and Training
 

Pharmaceutical Caches 

The items below are but a few of the accomplishments of VHA and 

their mission associated with Emergency Management and 

Pharmaceutical Caches. 

1. HHS has contracted with VHA to purchase and maintain 4 

caches, which can be deployed with NDMS teams. VHA also 

maintains a special events cache and a Congressional cache. 

2. CDC uses VHA Acquisitions to purchase antibiotics and vaccine 

stockpiles, maintained by the suppliers until needed. 

3. After 9/11/01, VHA decided to stockpile pharmaceuticals for its 

own use. 

• As of 4/18/03 there are 89 caches (of the 143 planned) 

deployed to VAMCs. 

• These caches contain supplies useful in case of the use of 

weapons of mass destruction. 

• The large or small caches contain supplies for 2000 or 

1000 patients per day for 2 days. 

• They require space, inventory control system, personnel, and 

training to maintain. 

Federal Coordinating Centers 

Only specific VAMCs have responsibilities under the NDMS. These facilities 

are designated as Federal Coordinating Centers (FCCs) for the system in 

their respective NDMS area. A listing of VA FCCs by VISN is provided on the 

next page in Table 2. The principal responsibilities of the FCCs are as follows: 

1. Coordination of NDMS definitive medical care in assigned local areas. 

2. Solicitation and organization of local, private sector hospitals, and 

community support services occurs in advance of an event. 

3. VA is responsible for enrollment of non-federal local hospitals in 

NDMS in specific areas. 

4. Coordination and reporting (to Global Patient Requirements 

Movement Center or GPRMC) of NDMS area bed availability occurs 

regularly. Coordination with local/state authorities occurs with: 

• Preparing of local NDMS patient reception plans. 

• Planning and conducting annual NDMS exercises. 

• Management of NDMS operations during activation. 

8 Caring for War Wounded 
V/A DoD Cotingency Back-Up System 

Those VAMCs that are designated as FCCs for the NDMS have specific 

responsibilities for development, exercise, and activation of supporting 

plans. These VA FCCs must develop a plan with the community for the 

reception, transportation, tracking, and disposition of casualties being 

evacuated from the site of a nationally declared disaster. Table 2 lists the 

VA Federal Coordinating Centers by VISN. 

VA Federal Coordinating Centers by VISN 

VISN Coordinating Center 

1 Bedford, Northampton 

2 Albany, Buffalo, Syracuse 

3 Castle Point, Northport, Brooklyn, Lyons, Manhattan 

4 Philadelphia, Pittsburgh 

5 

6 Richmond, Salisbury 

7 Atlanta, Birmingham 

8 Miami, San Juan, Tampa, Orlando 

9 Lexington, Louisville, Memphis, Nashville, Knoxville 

10 Cleveland 

11 Detroit, Indianapolis 

12 Milwaukee 

15 Kansas City, Wichita 

16 Houston, New Orleans, Little Rock, Jackson, Shreveport, 

Oklahoma City 

17 Dallas, San Antonio 

18 Albuquerque 

19 Salt Lake City 

20 Portland 

21 San Francisco 

22 Long Beach, Riverside, San Bernardino 

23 Minneapolis, Des Moines 

Table 2 

Caring for War Wounded 9 
V/A DoD Cotingency Back-Up System 

Summary 

VA’s primary mission is veterans care - “Our goal is to provide excellence in 

patient care, veterans’ benefits and customer satisfaction. We have reformed 

our department internally and are striving for high quality, prompt and 

seamless service to veterans. Our department’s employees continue to offer 

their dedication and commitment to help veterans get the services they have 

earned. Our nation’s veterans deserve no less.” (Secretary Principi ­

http://www.va.gov/about_va/) 

As Secretary Principi said in the above statement, the VA’s success is a result 

of it’s dedicated, caring, and professional employees. With these employees, 

the VA can, and will respond in a time of disaster whether due to war, 

terrorism, or natural disaster. 

Frequently Asked Questions 

FAQ #1 - What is the VA/DoD Contingency Back-up plan? 

A: The VA serves as the primary medical backup to the military health 

care system during and immediately following an outbreak of war or 

national emergency. The VA/DoD Contingency Hospital System Plan 

outlines how VHA supports that effort. 

FAQ #2 - What structures are in place to handle these contingencies? 

A: National Disaster Medical System (NDMS), Federal Response Plan 

(FRP), National and Continuity of Government (COG)/Continuity of 

Operations Planning (COOP) plans are in place to handle 

contingencies as they arise. 

FAQ #3 - What’s unique to the military contingency plan? 

A: Only specific VAMCs have responsibilities under the NDMS. These 

facilities are designated as Federal Coordinating Centers (FCCs) for 

the system in their respective NDMS area. 

FAQ #4 - What’s the main point of this section? 

A: VA is a large integrated system that has a plan for the 

management of emergencies, both natural and manmade. Every 

VAMC has a local emergency management plan, and is prepared to 

participate in their local community plans. The VA is ready for any 

contingency that may arise. 

10 Caring for War Wounded 
Environmental and Endemic Hazards 

of Deployment to Southwest Asia

Environmental and Endemic Hazards 

of Deployment to Southwest Asia 

Caring for War Wounded 11

Objectives 

List the exposures that combat veterans may encounter; 

Define biological hazards; 

List the pathogens endemic to the Iraqi region; 

List the chemical hazards combat veterans may encounter; and 

Describe how these exposures might influence a health care 

provider’s interaction with their patients. 

Introduction 

Southwest Asia is not a particularly inhospitable environment for U.S. 

troops; it is a livable place for our troops. There are certainly geographic 

areas in the world that may be considered inhospitable, unfriendly, or very 

threatening from a disease standpoint. How hospitable an environment is, 

has as much to do with changes in the individual routines of troops as with

the translocation from North America to another continent, and specifically 

from a garrison, peacetime setting to a real-world mission. Individuals 

typically experience occupational, situational, and personal changes, so 

every piece of the medical history should be understood in this context. 

Troops are changing their daily routines. Their sleep habits are different. 

Their meals are different. The stressors that are on their bodies (greater 

physical activity, and psychological stressors) are different. Their immune 

systems are being challenged with antigens they are not familiar with. 

The questions that health care providers need to ask when receiving 

patients from Southwest Asia include: 

“Where did we put our troops?” 

“What habits did they change?” 

“What work were they doing?” 

Environmental Exposures 

Some of the environmental exposures that might have an impact on the 
Environmental and Endemic Hazards 

of Deployment to Southwest Asia 

troop’s health are rather complex. The possible environmental influences 

on human health constitute a complex subject, which can be divided into 

two categories: 

1. Natural - general atmosphere, sun, wind, dust, etc. 

2. Sources influenced by human activities - industry, occupation, 

sanitation, recreation, medical care, etc. 

Within each category, there are three distinct levels of proximity: 

1. General - typically produces lower levels of exposure. 

2. Immediate - part of the occupational exposure or the individual 

working with a substance. 

3. Internal - substances that are internal to the troop’s body. 

Natural Sources 

General Exposure - Southwest Asia experiences extreme 

temperature variation (cool to cold at night to extremely hot during 

the day). Not all places in Southwest Asia have very high altitudes, 

but for troops not accustomed to being at 8,000 feet or higher, their 

performance may be diminished. Also, within the general 

environment is the amount of solar radiation that affects the troops. 

Wind, which causes dust problems, can also create problems from 

blowing sand, especially if the winds are strong enough to produce a 

sand storm. 

Immediate Exposure - More immediate to the troops are 

arthropods that are either venomous or serve as vectors of infectious 

disease, as well as direct exposure to infectious agents through 

airborne or direct contact. 

Internal Exposure - The food and beverages troops consume are 

naturally occurring. There may be things about those substances a 

troop takes in that might result in contamination or can lead to 

disease because they’re harmful. 

Sources Influenced by Human Activities 

General Exposure - As a rule, many of the general exposures that 

are influenced by human activities are industry-based. Industrial 

plants that are in Southwest Asia might emit many different 

chemicals. Pollution standards in Southwest Asia do not follow the 

same pollution standards as in the United States. The general 

categories of concern include: air pollution, water pollution, and 

soil pollution. Munitions and oil fires like those experienced in 

Gulf War I are hazards that are also in the general environment. 

Immediate Exposure - Generally this is what the troops work with. 

12 Caring for War Wounded 
This includes: fuel, pesticides, and repellents applied near or on 

their bodies, such as DEET and permethrin. DEET and permethrin 

are NOT toxic agents, but one has to consider all exposures in a 

multi-factorial context. Other immediate exposure factors include 

cleaners, and noise (whether constant or impact). Noise is also an 

environmental stressor that can harm the body. Radiation is another 

factor (whether it is ionizing or non-ionizing). The troops will be 

exposed to predominantly non-ionizing radiation sources. 

Internal Exposure - Many things the troops receive internally that 

are unnatural are for good reasons. Immunization, 

chemoprophylactic medication, self-medications, particularly overthe-counter drugs, nutritional supplements, and even topical 

substances (sun screen) all contribute to the health of the troops. 

There are also other forms of unnatural substances such as 

embedded shrapnel (to be discussed in Section 5). 

Biological Hazards and Pathogens 

There are pathogens that are occurring worldwide or at least also in North 

America, and are not unusual to the troops. These pathogens still have an 

impact on their health. For example, acute respiratory diseases. The troops 

might be exposed to tuberculosis, which still occurs worldwide, including 

in the United States. It is more prevalent in Southwest Asia. 

There are other potential exposure hazards such as vivax malaria, which is 

the most prevalent vector-borne disease the troops will encounter. Another 

protozoan that is not malaria, but also vector-borne, is leishmaniasis 

(transmitted by sand flies). Figures 1-3 depict a sandfly, the leishmaniasis 

pathogen, and a skin lesion associated with leishmaniasis. 

Figure 1 Figure 2 Figure 3 

Caring for War Wounded 13 
Environmental and Endemic Hazards 

of Deployment to Southwest Asia 

There are also a variety of viruses that are borne by vectors that are unique 

to Southwest Asia as well. To see a comprehensive list of vector-borne 

diseases, see the VHI “Endemic Infectious Diseases of Southwest Asia” at: 

http://www.va.gov/vhi. 

Pathogens can also be transmitted via airborne methods. This includes 

tuberculosis and a number of other respiratory pathogens. 

Not all pathogens cause acute diseases. Acute in this circumstance means 

occurring during the operation in which the troops are involved. The 

manifestations present themselves, and presumably, they are diagnosed and 

treated. When the diagnosis is delayed, there might be chronicity, or 

complication resulting from the missed diagnosis. Diseases are not always 

easy to diagnose. More often when there is a delay in diagnosis of an 

infectious disease, it is because it is a latent period, such as tuberculosis or 

chronic, such as Hepatitis B. 

Chemical Hazards 

Chemical hazards are one area of warfare where there is quite a bit of 

interest. These hazards may occur as respirable agents (inhaled). In that 

regard one should look at three different aspects, are they soluble, very 

soluble, or are they relatively not soluble? This is important, because less 

soluble agents are actually more likely to be deeply inhaled. With soluble 

agents, the troops back off because of irritation to their upper respiratory 

tract or their eyes. This is similar to a room full of ammonia. This irritation 

prevents manifestations that are more complicated. 

Less soluble hazards - Less soluble hazards can get deep into the 

lungs and can cause parenchymal disease. Chemicals like chlorine, 

phosgene, and nitric oxide are examples of less soluble chemicals. 

These chemicals make people very ill, and when they present to an 

emergency department, a clinic, or a battalion aid station, the 

clinician may not know what is going on and have to deal with the 

symptoms immediately. The chemicals are less likely to be of great 

impact to VA hospitals. 

Oil Well Fires 

The concern with oil well fires has to do with whether or not they have a 

long-lasting impact on the health of the troops. All oil well fire effects are 

acute, and may have a secondary effect on the immune system. They may 

induce problems like asthma in someone who is predisposed. More often 

than not, the discussion centers around two classes of compounds: 

asphyxiants or irritants. 

Asphyxiants - carbon monoxide, carbon dioxide, hydrogen sulfide, 

and methane. In high concentrations, they can be quite hazardous, 

but the individual has to be in an enclosed space, such as an 

14 Caring for War Wounded 
Environmental and Endemic Hazards 

of Deployment to Southwest Asia 

occupational environment. Oil well fires do not present that 

situation. The fumes from the fires go high into the atmosphere, 

where there is much diffusion. The results from Gulf War I showed 

that there was not a lot of disease from the oil well fires, even for 

the firefighters who were right near the hazard. 

Irritants - are oxides, like nitrogen and sulfur. Irritants can have 

effects that are very subtle, so clinicians need to be aware that they 

may complicate a history in the person who says, “I was near the oil 

well fire, and I have a lot of irritation, or I have wheezing”. The 

patient remembers the obvious effects, the irritating effects of those 

chemicals. They also remember the physical effects, such as watery 

eyes and coughing. 

Many of the items discussed in this section are of high importance to health 

care providers, and are critical to the health of the troops in the region. 

Health care providers need to be aware of the manner in which they 

interact with the patient who experienced one of the environmental or 

endemic hazards of their deployment to Southwest Asia. 

Interaction with Patients 

Knowing about these exposures could influence the way providers interact 

with their patients. It is important for clinicians who do not usually think in 

epidemiological terms to take a different approach. They will need to think 

in terms such as: medical history; occupational history; what were the 

troops/patient exposed to because of their job; where were the troops 

located in the country? 

Listen to the person; even though they may be biased and affected by what 

they remembered feeling or seeing, there may be some truth to their 

statement from a medical standpoint. What they remember seeing and 

feeling has to be taken into account in trying to track what could have 

happened to this person. Use their occupational history which in the 

military is their occupation. 

Chemicals, unlike infectious agents are unlikely to present with latent 

effects. Troops are in an environment, which is relatively short term in 

duration. Even if they are there for six months, or 12 months, there is no 

comparison between their exposure and the exposure of a worker who has 

a life-long career working around a certain chemical. 

Standards are applied in the U.S. for the ambient environment; however, 

there is much greater pollution in certain parts of Southwest Asia, especially 

where base camps may have been set up. All the black smoke that was in 

the air needs to be kept in perspective, because what the troops were 

exposed to, in country, or in the theater, was for a relatively short duration. 

The duration needs to be kept in mind at all times. 

Caring for War Wounded 15 
16
 
r r Program

DoD Pre-Deployment Screening and

Fo ce Health P otection 

DoD Pre-Deployment Screening and 

Force Health Protection Program 

Caring for War Wounded 17

Objectives 

Define how DoD ensures military members are healthy when 

deployed; 

List the DoD pre-deployment procedures; 

Describe how DoD prevents military members from getting sick 

while on deployment; and 

Explain how DoD ensures that sick and injured military members 

get the care and treatment they need while on the battlefield. 

Introduction 

The top priority of medical leadership in DoD is to protect the health of the 

men and women in uniform, particularly when they are deployed. The Force 

Health Protection Program is based on the lessons learned from Gulf War I 

and subsequent deployments. From these lessons learned, DoD will do a 

better job protecting those who go in harm’s way. 

The Force Health Protection Program consists of three very important parts: 

1. A fit and healthy force 

2. Prevention of disease and injury 

3. Treatment and care for ill or injured individuals 

Part 1 - A Fit and Healthy Force 

Since the U.S. military is a fighting force, it is required that all who desire to 

serve are medically fit. This starts with making sure we recruit and maintain 

a fit and healthy force. The military has created a continuum of health care 

once an individual enters active duty. This continuum is critical for the first 

part of the Force Health Protection Program. The continuum has three parts: 

1. A very rigorous entrance physical examination and a 

comprehensive medical history is completed on each individual. 

2. Health promotion is emphasized. Physical training is emphasized 

from the first day an individual enters the military. Recruit training 
DoD Pre-Deployment Screening and Force Health Protection Program 

uses a system of incremental physical training to strengthen 

the force. 

3. Physical fitness testing is a requirement. Depending on the branch 

of military, each individual must complete at a minimum an annual 

physical fitness test. Inability to pass this test can lead to 

separation from service. 

Part 2 - Prevention of Disease and Injury 

The DoD educates its service members about the medical threat(s) during 

deployment and combat. The identification of the threat(s) is accomplished 

through intelligence reports or measuring what environmental danger(s) 

may be in their deployed areas. (Section 2 provided information on the 

environmental dangers service members will experience, and Sections 6-9 

outline some of the chemical, biological, and radiological weapons that are 

used in combat). 

The identification is comprehensive in nature, and attempts to determine 

whether the threat is: 

• Chemical 

• Industrial 

• Biological 

• Natural-occurring diseases 

Once the determination has been made concerning the threat, DoD ensures 

that the troops understand what protective measures are required, to 

include vaccinations, chemical and biological protective clothing, or 

pesticides to reduce insect or pest exposure. 

Part 3 - Treatment and Care for Ill or Injured Individuals 

Part 3 of the Force Health Protection Program is accomplished by providing 

care far-forward in the theater of operations. This care consists of providing 

far-forward surgical care, medical evacuation with intensive care in the air, 

and most importantly, by ensuring that health concerns are addressed 

directly with the individual. The DoD has developed the capability for 

electronic capture of medical care in a deployment theater. 

Health and War 

DoD ensures when the need arises to send young men and women into 

harm’s way, that they are fit and ready to do their job. This is successful 

because DoD has recruited volunteers who are fit and meet the required 

standards for deployment. 

When a military member deploys for war, his or her health and fitness have 

been maintained by involvement in very rigorous training. If service 

members are not deployed, they are training to deploy. As a cohesive unit, 

18 Caring for War Wounded 
DoD Pre-Deployment Screening and Force Health Protection Program 

they know if someone is not able to do his/her job, and the ingrained 

medical component in the military is there to provide care on a free and 

easy access basis. 

If a military member has a disqualifying medical condition, he/she can no 

longer stay on active duty. Those who are on active duty are considered 

worldwide deployable. This is the foundation of knowing that there is a fit 

and healthy force. 

Pre-deployment Medical Procedures 

When individuals are identified for deployment, a number of predeployment health related issues must be completed. This includes: 

1. Review of medical records/history 

a. Ensure that the member has an up-to-date periodic 

physical examination. 

b. Has the member had an annual dental examination? 

c. Has an HIV screening test been completed within the last 

12 months? 

d. Is the member’s health record up-to-date (i.e., vaccines, 

PPD skin test)? 

2. Complete a health assessment (Ask the member the following) 

a. “How would you rate your health?” 

b. “Do you have any medical conditions that aren’t in your 

health record?” 

c. “Do you have a medical board process going on where you 

have a medical condition that perhaps is disqualifying?” 

d. “In the past year, have you sought counseling or care for your 

mental health?” 

e. “Do you have any health concerns at this time?” 

3. Based on the results of these questions, which is reviewed by a 

medical provider with the individual present, a determination is 

made if the member is ready and fit for deployment. If they are, 

the medical provider will certify that the person is fit and ready 

to deploy. 

Prevention Training and Deployment 

Prevention is a multi-layered approach. The success of the prevention is 

based on the use of valuable intelligence, understanding what threat the 

enemy has, and where the chemical and biological agents are located. 

Caring for War Wounded 19 
DoD Pre-Deployment Screening and Force Health Protection Program 

Understanding the threat and knowing the diseases endemic to the area is 

also part of the protection mission. Prior to deployment, the troops receive 

a thorough medical briefing on what they may encounter. If they are going 

into an area of malaria, malaria prophylaxis is given, and they are told the 

importance of the prophylaxis. 

The troops are briefed on the use of insect repellent. This critical 

information is provided to prevent any of the vector-borne diseases. There is 

extensive training on the use of chemical and biological protective 

equipment. This equipment has been greatly improved over the last decade. 

The new uniforms are much lighter; the new gas mask has better vision 

capability. In addition, every troop has at least two of these outfits, ready to 

go. Therefore, training is really key and critical to protect the individuals. 

There is also an environmental assessment. This assessment provides 

information on chemical or biological agents, as well as industrial chemicals, 

or any other pollutant in the areas where the troops will deploy. Samples of 

the soil, air, and water are taken. These data are archived. An electronic 

medical surveillance capability is established for the theater of operations. 

The information obtained from this surveillance program will be extremely 

valuable. It will provide information about the troops current medical 

problems in theater. DoD is working very hard to track unit locations, 

and to keep track of where people were during the time they were 

deployed. This focus is to make sure an electronic record is started and to 

have the record available for any question, whether immediately or 

subsequent to deployment. 

Battlefield Medical Care 

Today’s military footprint is much smaller than the past. The high 

technology weapon systems available, such as the bombs and guidance 

systems, allow the military to have fewer troops in the theater. This is also 

true for the medical assets in the theater. Surgeons with a backpack can go 

far-forward, set up a surgical theater, and do surgery on a seriously 

wounded person, right behind the firing line. The capability exists to get 

airplanes into the forward area to load this critically ill person into an 

intensive care unit and fly them out of the theater. This is done very quickly. 

In addition, the medical assets are designed to move forward. The medical 

assets are modular and have the ability to set up facilities with several beds 

or a 200 bed hospital, if need be, in the theater. 

20 Caring for War Wounded 
DoD Pre-Deployment Screening and Force Health Protection Program 

Post-Deployment Care 

The DoD performs an important Post-Deployment Health Assessment as 

troops are leaving the deployment area, or as soon as they get back. They 

are asked: 

1. “How would you rate your health?” 

2. “Do you have any unresolved medical or dental problems?” 

3. “Have you sought, or do you intend to seek, counseling or 

care for your mental health?” 

4. “Do you have concerns about possible exposures or events 

during this deployment?” 

5. “Do you currently have any questions or concerns about 

your health?” 

DoD and the VA have trained their primary care providers to ask individuals 

seeking care if they believe their health concerns may be related to a 

deployment. If the patient answers “Yes,” then the Post-Deployment Health 

Clinical Practice Guidelines (http://www.va.gov/environagents) developed 

jointly by DoD and VA will be used to allow the primary care provider to 

focus the medical examination, order medical testing for the individual if 

needed, utilize data from the theater to answer questions, and provide the 

individual appropriate health care. 

Caring for War Wounded 21 
22
 
VA Health Care Benefits 

after Combat Deployment

VA Health Care Benefits 

after Combat Deployment 

Caring for War Wounded 23

Objectives 

Describe the VA’s clinical care programs for veterans with difficult to 

diagnose, or disabling diseases; 

Describe the VA training and educational materials developed to 

help VA health care providers provide care for Gulf War veterans; 

Describe the VA/DoD Post-Deployment Health Clinical Practice 

Guidelines; 

Explain how the VA provides information on environmental health 

concerns to veterans and families, and to health care providers; 

Define special VA compensation authority for Gulf War veterans with 

difficult to diagnose diseases; 

Explain what the VA has done to improve access to health care for all 

combat veterans; 

Describe how the VA’s Vet Center Program helps veterans from all 

wars/conflicts; 

Explain how the VA has worked with DoD to improve surveillance 

and medical record keeping; and 

Explain how a veteran obtains health care benefits. 

Introduction 

With recent military action putting U.S. service members back in Iraq, and 

similar military actions in nearby Afghanistan, many people are asking VA 

about the health issues involved. Specifically, people want to know how VA 

is better prepared today to handle the problems with undiagnosed illness 

such as we saw after Gulf War I? 

The VA has learned a lot from our experiences taking care of veterans from 

Gulf War I, and before that, from the Vietnam War. Today, we understand that 

the majority of veterans returning from combat and peacekeeping missions 

abroad are able to make the transition to civilian life with few problems. 

Most who come to VA for health care receive conventional diagnoses and 

treatments, and leave satisfied with the quality of their health care. 
VA Health Care Benefits after Combat Deployment 

Nevertheless, we have also learned that some veterans have more problems 

in their return to civilian life and a small percentage develop difficult to 

diagnose illnesses that can be disabling. 

The following are some specific examples of VA’s transformation since the 

end of Gulf War I. These changes leave us better prepared today than we’ve 

ever been to handle health care, compensation and information issues for 

veterans from all deployments who may have difficult to diagnose illnesses, 

and their families. VA has developed a number of cutting-edge programs to 

respond to these needs, both for veterans of Gulf War I/II, and of future 

combat and peacekeeping missions wherever they occur. 

Difficult to Diagnose, or Disabling Illnesses 

The VA is constantly looking for ways to improve care for veterans with difficult 

to diagnose or disabling illnesses. Combat veterans suffering from chronic 

and ill-defined illnesses are a significant concern for VA, veterans, and their 

families. The VA’s experience treating veterans from Gulf War I and the 

Vietnam War illustrated the need to develop new specialized health services 

for all combat veterans with difficult to diagnose health problems. In 2001, 

the VA established two War-Related Illness and Injury Study Centers (WRIISCs) 

at the Washington, DC, and East Orange, NJ VAMCs. This follows VA’s 

tradition of establishing specialized clinical and research programs for the 

special health care needs of veterans, including VA’s Mental Illness Research, 

Education and Clinical Centers (MIRECCs) and the National Center for PTSD. 

Equally important, the WRIISCs are also charged with conducting research 

to develop better diagnoses and treatments for difficult to diagnose 

illnesses. They also provide clinical education for VA and other health care 

providers, and appropriate risk communication and outreach tools for 

interacting with patients and their families who have health concerns related 

to environmental exposures experienced while on deployment. 

An emphasis on good risk communication and outreach were identified as 

critical needs following the VA’s experience treating veterans from Gulf War 

I. For example, the WRIISCs have developed a range of materials outlining 

the environmental and other health risks for military service in new 

deployments such as to the Persian Gulf, Afghanistan, and the former country 

of Yugoslavia. These materials are designed to effectively communicate this 

information to veterans, their families, and other concerned Americans. 

Following start-up staffing, and construction, the WRIISCs are providing 

in-depth clinical care and evaluation for veterans with debilitating symptoms 

that remain unexplained after thorough medical examinations by local 

VAMCs. The WRIISCs accept veteran patient referrals from all across the 

country, and from all combat eras. Just recently, one center received the first 

World War 2 veteran patient, who apparently had been suffering from 

difficult to diagnose illnesses for decades. The clinical load of the two 

centers is expected to reach about 100 inpatients and several hundred 

outpatients per year. 

24 Caring for War Wounded 
VA Health Care Benefits after Combat Deployment 

The unique clinical components of these programs are available for any 

combat veteran with a referral. Information, and how to make a referral is 

available at http://www.va.gov/environagents. 

Training Health Care Providers for Post-Deployment Care 

The VA has trained their health care providers to provide the most 

appropriate care for veterans including Gulf War veterans after military and 

peacekeeping missions. Fortunately, the VA has good evidence-based 

medical approaches for treating veterans after deployment. Since Gulf War I, 

the VA has developed in collaboration with DoD, some new Clinical Practice 

Guidelines (CPGs) that provide our clinicians with the information they 

need to take advantage of the best scientifically supported practices for 

treating their patients. This includes: 

• the general purpose Post-Deployment Health CPGs; and 

• a new CPG on unexplained fatigue and pain. 

These CPGs provide information on how to provide care to the patient who 

presents with a particular set of health complaints or concerns that they 

believe are associated with their military deployment. The CPGs can be 

accessed at: http://www.va.gov/environagents. 

Through experience, the VA has learned that many combat veterans have 

concerns about the hazardous exposures they may have experienced during 

their deployment. Specifically, veterans and their families want information 

about what they (the veterans) were exposed to while deployed and how 

such exposures may have affected their health or even the health of their 

families. In response, the VA has developed a range of special training 

programs that address issues related to deployment environmental health 

concerns. These special programs are designed to train our health care 

providers to be knowledgeable about the hazards and health concerns 

related to specific deployments. 

For example, the VA has developed new Independent Study Guides for 

physicians on Gulf War & Health, on service in Vietnam, POW health issues, 

and on many related topics. The Independent Study Guides are available at: 

http://www.va.gov/environagents. 

Veterans Health Initiatives 

In partial response to addressing the educational needs of VA health care 

providers, VA has developed a program called the “Veterans Health 

Initiative” (VHI). One of the basic reasons for the VHI is to make sure that 

every veteran patient who comes to VA will be met by health care providers 

who are knowledgeable about their particular deployment, about what 

happened, and what exposures were involved. Inevitably, many VA health 

care providers have had little or no military service, and are not always 

aware of issues related to military deployment. For example, many health 

Caring for War Wounded 25 
VA Health Care Benefits after Combat Deployment 

care providers providing health care to Vietnam Veterans were born after the 

Vietnam War was over! Lack of information can lead to credibility problems 

for the health care provider. 

One major product of this effort is a comprehensive group of independent 

study modules (paper-based and web-based) that may be taken for CME 

credit. In fact, this course you are presently doing is part of this initiative. 

These modules provide information on subjects such as Gulf War Illness; 

Vietnam War and Agent Orange; American Ex-Prisoners of War; and others. 

The VHI’s, can be accessed at: http://www.va.gov/vhi. 

Post-Deployment Health Clinical Practice Guidelines 

The Post-Deployment Health Clinical Practice Guidelines (available at 

http://www.va.gov/environagents) were developed jointly by VA and DoD 

following Gulf War I to help veterans and their health care providers deal 

with deployment related health concerns. These guidelines were developed 

to implement the lessons learned after Gulf War I and the Vietnam War. 

These guidelines focus particularly on those instances where diagnoses for 

health problems are not obvious. The VA recognizes that many wounds 

veterans come back with are not as obvious as should be; for example, the 

result of a wound from shrapnel or a bullet. The exposure, the risks that 

they encountered while they were deployed might not leave obvious scars. 

In some cases, a critical health concern for the veteran revolves around what 

he or her family believes has happened to the veteran. If they are concerned 

about a particular environmental exposure, or something that happened to 

them during their deployment, even if it is not necessarily clinically relevant, 

if the veteran believes it is relevant, then it is something that the clinician 

has to deal with to ensure effective health care. 

The Post-Deployment Clinical Practice Guidelines serve as a tool kit that 

provides some basic information to help primary care clinicians deal with 

the patients suffering from difficult to diagnose illnesses. Many health 

care providers will encounter these concerned patients and families, and 

these guidelines offer an important tool to help deal with the veteran and 

their family. 

When veterans and their families have concerns about possible exposure to 

environmental hazards during deployment, the health care provider is often 

put in the position of needing some basic information on the nature and 

health effects of a particular exposure. Sometimes available scientific and 

medical information is the key to a meaningful discussion between health 

care provider and patient. However, many times the critical factor is what 

others are telling the veteran about the exposure. What did their officers tell 

them? What did their buddies tell them? And what have they seen on the 

subject in the news and on the Internet? Most important of all, is 

determining the symptoms and problems they had, and why they think this 

is due to the exposure. 

26 Caring for War Wounded 
 

VA Health Care Benefits after Combat Deployment 

In summary, the veteran who comes in and has concerns about the use or 

exposure to a specific deployment environmental hazard will probably not 

be satisfied if the clinician responds, “I don’t know about it,” or “I don’t 

think that caused your problem.” The provider has to be able to deal with 

the veteran’s health concerns in a reasonable and forthright manner, and, if 

necessary, do some basic background research on the details of a specific 

deployment. The Post-Deployment Health Clinical Practice Guidelines are a 

tool describing various straightforward approaches to achieve this. 

The VA provides basic information about environmental health concerns to 

veterans and their families. We understand that outreach to veterans and 

their families is critical! Many combat veterans and their families have 

specific concerns about the health impact of environmental exposures 

during their deployment. To meet those needs, VA has developed a wide 

range of outreach products, most of which are aimed at health care 

providers as well as veterans and their families. These include: 

• Newsletters to veterans covering health and compensation issues, 

including environmental health issues; 

• The same information contained in the newsletters can be 

accessed at: at http://www.va.gov/environagents; and 

• New fact sheets on health concerns related to deployment on 

the war on terrorism in Afghanistan and Southwest Asia including 

Gulf War II – for both veterans and their health 

care providers. 

Current VA Health Care Programs 

Access to VA health care and other benefits are naturally the most critical 

issues for most veterans. The VA has learned how to better meet those 

critical issues in the years since Gulf War I. In particular, the VA recognized 

that there was a problem in health care access, especially among Reserve 

and National Guard members. For these service members, as soon as they 

separated from active duty after coming back from Gulf War I, they lost the 

military health care access they previously had enjoyed. Once they were 

discharged, health care in many instances was available only from VA. Many 

veterans reported frustrating delays and other obstacles in getting the 

health care from VA that they justifiably felt they had earned. 

To get around these difficulties in accessing VA health care, the VA sought 

legislation from Congress. In 1998, VA received authority to provide health 

care for combat veterans for up to two years after the veteran separates 

from active duty. What was particularly useful in this authority is that this 

health care is available regardless of whether or not it can be proven that 

the illness or injury, particularly a difficult to diagnose illness, was due to 

the military experience. This eliminated the burden previously placed upon 

the veteran. The veteran no longer has to prove that their health problem 

was combat related before they could receive free health care from VA. This 

Caring for War Wounded 27 
VA Health Care Benefits after Combat Deployment 

law is a major breakthrough for veterans because now VA can always give 

the veteran the benefit of the doubt and get them in for the health care they 

may need after hazardous deployments. For more information about this 

important program, go to http://www.va.gov/environagents. 

VA’s Vet Center 

The VA’s Vet Centers, originally developed to provide a wide variety of social 

services to Vietnam veterans, have been invaluable in providing similar 

readjustment and counseling services to veterans from more recent combat 

and peacekeeping missions. In fact, more than 115,000 Gulf War I veterans 

have made use of their services, and over 200,000 veterans from the conflict 

in Bosnia and Herzegovina have used these services as well. There are over 

200 Vet Centers in the United States serving deserving veterans. For more 

information, go to http://www.va.gov/RCS. 

Compensation for Difficult to Diagnose Illnesses 

The VA’s experience of caring for Gulf War I veterans has also led to a 

greater appreciation of the need to assist veterans with unexplained 

symptoms. Disabled Gulf War I veterans are entitled to equitable 

compensation for illnesses and injuries experienced during military service. 

However, the paucity of scientific knowledge regarding the relationship 

between military environmental exposures and human health consequences 

originally hindered VA’s ability to establish the required connection between 

Gulf War I service and veterans’ health problems. This difficulty was further 

exacerbated by the reality that some veterans have disabling multi-symptom 

illnesses for which no established medical diagnosis can be found. 

These complex health issues have also come under close scrutiny by 

Congress and veterans’ service organizations. In a precedent-setting 

development, Congress passed Public Law 103-446 in 1995 which gave the 

VA the authority to compensate veterans with difficult to diagnose illnesses. 

The VA can now provide compensation to Gulf War I veterans who exhibit 

objective evidence of 10 percent or greater disability for at least six months, 

which may include disability due to fatigue, skin conditions, headache, 

muscle and joint pain, sleep disturbances, abnormal weight loss, menstrual 

disorders, neurologic, neuropsychological, respiratory, gastrointestinal, and 

cardiovascular illnesses. Approximately 3,200 Gulf War I veterans have 

received compensation based upon this law. 

Surveillance and Record Keeping 

For veterans to be able to take advantage of VA health care and benefits 

programs, veterans and VA need access to the records documenting their 

military experiences. Toward that end, the VA has worked with DoD to 

improve surveillance (to improve data collection during deployment) and 

28 Caring for War Wounded 
VA Health Care Benefits after Combat Deployment 

medical record keeping and record transmittal. One example is the 

development of a lifelong medical record for veterans who are on active 

duty. Once they separate from military service, their military record will go 

with them, providing a continuum of medical and other relevant 

information. 

VA has also collaborated with DoD in developing baseline health data for 

active duty military personnel. This data includes critical initial information 

taken when individuals first join the military service, (the baseline) followed 

by their health status during their military career. VA also worked with 

DoD to develop more accessible physical examinations, and separation 

physical examinations. 

A major change to record administration is the process of getting the 

records to the VA. In the past, the medical record went to St. Louis, and if 

needed the VA would request them. Now, DoD hands them over to the VA 

without going through a middleman. In addition, as electronic records 

become more of the standard, the systems will be able to share information 

instantaneously when a person leaves active duty and becomes eligible for 

VA care. 

Obtaining Benefits 

Information on obtaining benefits can be found at: http://www.va.gov. This 

Internet site was designed for easy use by veterans. The user can get 

information on how to fill out a compensation claim. The Web site is a good 

place to start. 

For those that are not Web savvy, there are Veteran’s Benefits Counselors at 

all VA Regional Offices and VA Medical Centers. These counselors bring the 

important human interaction that many veterans prefer. 

As a health care provider, it is important that you are aware of the system of 

benefits the VA has for the veteran. More importantly, as a health care 

provider, you must know whom to refer the veteran to within the VA system 

so the veteran gets the help that is outside your area of expertise. 

Caring for War Wounded 29 
30
 
and High-Velocity Weapons Weapons 

Specific Combat Related Injuries, 

including Wounds from Traditional Weapons 

Specific Combat Related Injuries, 

including Wounds from Traditional Weapons 

and High-Velocity 

Caring for War Wounded 31

Objectives 

Explain the need to train VA staff in treating wounds from 

traditional weapons; 

List the type of injuries the health care provider will treat; 

Explain the significance of wounds from high-velocity weapons; 

Describe the treatment the wounded veteran received from 

DoD prior to transfer to a VAMC; 

List the treatment types the VA will provide for the 

wounded veteran; 

Describe the range of medical specialists the VA has on staff 

to treat the war wounded; and 

Explain how VA uses community resources to assist the 

war wounded. 

WARNING 

The pictures presented in this section are graphic, however, it 

is important for the health care providers to actually see, 

experience, and know what many of our troops have had 

to endure during their deployment and combat. 

Introduction 

Some of the health care providers in VA have experience with combat 

related injuries, both as a VA employee, and as a field physician. However, 

many VA and DoD health care providers have not seen traumatic injuries 
Specific Combat Related Injuries, including Wounds from 

Traditional Wheapons and High-Velocity Weapons 

that might result from Gulf War II. This section is a good introduction for 

the providers who have never seen injuries from a war. 

Some of the injuries of deployed veterans result in treatment at routine 

sick call. Environmental type of exposures and traditional accidents are 

also injuries that happen to deployed troops. However, in time of war, 

troops will experience more complex and critical injuries especially from 

high-velocity projectiles or anti-personnel mines. 

Environmental Exposure and Minor Accidents 

Injuries experienced by troops, especially in a combat situation depend 

upon where the troops are deployed. In Somalia, the injuries ranged from 

heat injuries (Figure 1), to soldiers experiencing death (Figure 2) from 

high-velocity projectiles. 

Figure 1 Figure 2 

High-Velocity Weapons Injuries 

Wounds from high-velocity weapons are different wounds than from 

traditional weapons. There is tremendous tissue damage to the body due to 

the high-velocity and the caliber of the weapon. Figure 3 is a graphic of an 

AK-47, a weapon that will cause the types of injuries this section describes. 

Figure 4 depicts an individual who was shot in the right posterior part of 

the arm by an AK-47, with a large exit wound in the forearm. 

Figure 3 Figure 4 

32 Caring for War Wounded 
Specific Combat Related Injuries, including Wounds from 

Traditional Wheapons and High-Velocity Weapons 

Figure 5 depicts a soldier who was shot by a high-velocity weapon round to 

the head and eye area. 

Figure 5 

Unusual Weapons of War 

Many unusual weapons and combat devices 

will cause serious injury to individuals who 

encounter them. Booby traps, grenades, 

rocket propelled grenades (RPG’s), and the 

anti-personnel mine are but a few of the 

devices used to maim and kill people. 

In Somalia, the U.S. forces experienced these 

devices first hand. Figure 6 depicts a soldier 

who has a fuse from a booby trap in his left 

hand. Figure 7 is the fuse that was removed 

from the soldier’s hand. The surgeons in the 

field were able to save the soldiers hand. 

Figure 6 Figure 7 

Figure 8 

Probably one of the most 

dangerous devices used 

in warfare is the antipersonnel mine. Many of 

the areas where there 

have been wars within 

the last 20 years have 

seen extreme use of these 

mines. Figure 8 

demonstrates the damage 

an anti-personnel mine 

will do to a soldier. 

Caring for War Wounded 33 
Specific Combat Related Injuries, including Wounds from 

Traditional Wheapons and High-Velocity Weapons 

VA Treatment of Wounded Veterans 

Veterans being treated at a VA hospital are part of a continuum of treatment. 

This starts at the site where the veteran is wounded - field treatment. The 

wounded individual is evacuated from the battle zone by helicopter, truck, 

etc. After they are evacuated from the battle zone, they receive treatment in 

the combat theater hospital, with subsequent transfer to an evacuation 

hospital if needed. This treatment will continue at a military treatment 

facility with their final stop at a VAMC. 

Treatment in the field is fairly advanced. There are now advanced 

deployment groups, five individuals that are likely to perform more complex 

surgery in the field than has been done before. Many of the patients VA sees 

are patients that have received relatively less fluid than they would have in 

the past in order to treat shock. VA will also see more vascular repair of 

extremities with so-called external fixators. 

In cases where primary amputations are necessary, the patients VA will 

receive will have orthodox circular amputation and skin traction. Therefore, 

VA will be responsible for tissue reconstructions, but some stabilizations will 

be done as they pass rapidly through the system, such as flaps, revisions of 

bypasses, nerve repairs, tendon transfer, and orthopedic revisions of stumps. 

For further information on amputation, refer to the VHI module “Traumatic 

Amputation and Prosthetics” at: http://www.va.gov/vhi. 

VA Clinical Staff 

The VA is staffed very well, and in terms of specialists, the VA is prepared to 

handle the individuals who are sent to their facilities. 

The VA currently has about 450 full-time general surgeons and up to 900 

FTE’s in general surgery. Each of the 130 facilities have contract 

arrangements or full-time arrangements with orthopedics, urology, 

neurosurgery, plastic surgery, and the like. For the conventional injuries, the 

VA is well prepared. 

Community Resources 

The VA is also prepared to tap into community resources if needed. The use 

of community resources will be particularly necessary in burns. In the past, 

most of the burns have been referred to burn centers. For example, in 

Washington, when the Pentagon was struck, the burn victims were sent to a 

civilian hospital, the Washington Hospital Center. To support the needs of 

each respective VAMC, there are arrangements and affiliations in place. In 

addition, each major VA is equipped with a large cache of appropriate fluids 

and antibiotic types. 

34 Caring for War Wounded 
Injuries Associated with 

Chemical Warfare Agents

Injuries Associated with 

Chemical Warfare Agents 

Caring for War Wounded 35

Objectives 

List the most common chemical agents our service members 

might be exposed to while in combat; 

Describe the differences and similarities in potential exposures to 

chemical weapons from Gulf War I to Gulf War II; 

Explain how chemical agents are absorbed into and eliminated 

from the body; 

List the signs and symptoms of exposure to different chemical 

agent classes; 

Explain how exposure to chemical agents affect reproductive health; 

Identify the way veterans can and cannot be tested to verify if they 

were exposed to chemical agents; 

Describe the long-term injuries from exposure to chemical agents 

and how VA will treat them; and 

List the other available resources for information on chemical 

warfare agents and injuries associated with their use. 

Introduction 

During Gulf War I, U.S. service members were potentially exposed to a 

variety of chemical warfare agents that were known to be in the Iraqi 

arsenal at that time. Given the concern about chemical warfare agents in 

Iraq today, it seems likely U.S. soldiers deployed during Gulf War II may be 

at risk from exposure to these same agents. 

This section will provide a brief description of these agents, how service 

members can be exposed to them, what health effects including 

reproductive health effects they can cause, what various groups that have 

reviewed Gulf War I health effects have said about these agents, and their 

impact on the health of Gulf War I veterans. 
Injuries Associated with Chemical Warfare Agents 

Chemical Warfare Agents - What are they? 

Chemical warfare agents are materials that are deliberately designed to 

cause lethal and debilitating toxic effects in humans. In the last decade the 

most common chemical warfare agents of concern include: 

• OrganoPhosphorus (OP) Nerve Agents; for example: 

° Sarin 

° Soman 

° VX 

• Vesicant (blistering) Agents; for example: 

° Mustard Agent

The OP military nerve agents have a chemistry and a cholinergic mode-ofaction essentially identical to the commonly used OP pesticides, described 

in the next section. The main difference is that the military nerve agents are 

designed to be more toxic to humans. 

How might Gulf War veterans have been exposed? 

In 1991, Iraq was known to possess both chemical and biological weapons, 

a fact later confirmed from inspections by United Nations inspection teams. 

However, the U.S. Department of Defense (DoD) has reported that neither 

chemical nor biological weapons were intentionally used by Iraqi forces 

against coalition forces during Gulf War I. 

DoD has indicated that one U.S. soldier might have received a burn from 

mustard agent (on his arm), caused by accidental exposure while exploring 

a captured bunker in southern Iraq. The British Ministry of Defence has also 

concluded that Iraqi forces used neither chemical nor biological agents 

during Gulf War I. 

Although there was no deliberate use of chemical weapons during Gulf War I, 

some Gulf War I veterans may have been exposed to trace levels of chemical 

warfare agents. The most notorious example happened in March 1991. 

Following the Gulf War I cease-fire, U.S. service members used explosives to 

destroy a large ammunition depot in southern Iraq, known as Khamisiyah. 

This site was later found to have contained chemical agent munitions that 

contained Sarin and the closely related agent Cyclosarin (both OP agents). 

Small amounts of these agents were released into the atmosphere during 

demolition. Other munitions at that site contained mustard agent, but DoD 

has concluded that their destruction did not lead to any release of the agent. 

Based upon atmospheric transport modeling carried out by the CIA, in 1997 

the DoD notified nearly 100,000 Gulf War I veterans who had been in the 

vicinity of Khamisiyah at the time of the demolitions, that they may have 

been exposed to trace levels of military OP agents. This model provided data 

that showed some veterans could have been exposed to low-levels of Sarin 

and Cyclosarin chemical agents, levels which were too low to cause any 

36 Caring for War Wounded 
Injuries Associated with Chemical Warfare Agents 

acute (immediate) cholinergic poison signs and symptoms. 

The exact levels of exposure have been estimated to be very low or trace, 

and DoD has clinically confirmed this estimate with the observation that no 

cases of acute cholinergic poisoning symptoms related to exposure to OP 

nerve agents were reported during Gulf War I. 

Nevertheless, low-level (below that required to cause any signs or 

symptoms) exposures from inhalation may have occurred to some U.S. 

service members in the Gulf War I region in the days following the cease-fire 

in 1991. 

How are chemical warfare agents absorbed and eliminated from 

the body? 

Chemical warfare agents can be absorbed either by inhalation of vapors, or 

through dermal contact. 

Sarin and Cyclosarin are relatively volatile agents, and the primary exposure 

concern for these agents is via inhalation. 

Mustard agent is much less volatile, and the primary exposure is dermal 

contact, although inhalation of aerosolized mustard agent also can be an 

important route of exposure. 

All of these chemical warfare agents are rapidly metabolized and excreted, 

primarily in the urine, following any route of exposure. 

What are the signs and symptoms of exposure? 

The OP chemical warfare agents cause symptoms that are virtually identical 

to those caused by OP pesticides. These agents cause inhibition of the 

enzyme acetylcholineesterase (AChE), which is crucial to normal nerve and 

nerve/muscle functioning. The inhibition is irreversible, and complete 

recovery involves the body’s production of new enzyme to replace the 

inhibited AChE. This production can take days to weeks. 

Acute cholinergic poisoning symptoms usually develop within minutes or 

hours of exposure, and include miosis, headache, nausea, dizziness, anxiety, 

and restlessness. 

Life-threatening symptoms may include muscle fasciculation, weakness, 

tremor, uncoordination, vomiting, abdominal cramps, diarrhea, sweating, 

salivation, and excessive tearing, and death can occur by respiratory paralysis. 

According to DoD, in-theater medical personnel did not report any acute 

cholinergic poisoning symptoms consistent with acute poisoning from these 

chemical warfare agents in service personnel during Gulf War I. This is 

significant because some patients surviving severe OP poisoning later go on 

to develop subtle, chronic neurological abnormalities that can be detected 

using standardized neurological tests. For example, subtle deficiencies are 

Caring for War Wounded 37 
Injuries Associated with Chemical Warfare Agents 

reported for survivors of acute OP poisoning in tests for intellectual 

functioning, academic skills, abstraction, and flexibility of thinking, and 

simple motor skills. 

Although certain OP chemicals used in the past have been known to cause 

delayed neuropathies (or polyneuropathies) following recovery from acute 

cholinergic poisoning, the OP chemical warfare agents as a class are not 

normally considered to cause such effects. 

Exposure to mustard agent can cause severe irritation and tissue damage, 

which includes typical blistering to eyes, skin, the respiratory track and 

gastrointestinal tracks. 

Signs and symptoms from mustard agent are delayed for some hours 

following exposure. The mustard agents are considered to be likely human 

carcinogens, and humans exposed to mustard agent are at increased risk of 

leukemia, and respiratory and skin cancers in decades following exposure. 

How may exposure to these agents affect reproductive health of Gulf 

War veterans? 

OP nerve agents, including pesticides and chemical warfare agents, are not 

considered to be teratogenic agents. Although mustard agents are 

considered to be likely human carcinogens, current information is not 

sufficient to conclude that they have human reproductive health effects, 

especially following exposure to males. 

Is there a test to verify exposure? 

OP and mustard chemical weapon nerve and blister agents are rapidly 

metabolized and excreted from the body, and metabolites indicating 

exposure can be detected in urine in hours following exposure. Metabolism 

and excretion of these compounds will be complete within days of an 

exposure in cases where the individual survives the initial exposure. 

NOTE: Consequently, there is no test available today that can 

confirm exposure to these chemical warfare agents that may have 

occurred several months or years in the past. 

What have independent review groups concluded about the risks? 

A number of independent scientific groups have reviewed the potential 

health impacts from exposure to chemical warfare agents during Gulf War I. 

There are numerous references available (see reference section) that will 

provide more valuable information concerning chemical warfare agents. 

38 Caring for War Wounded 
Injuries Associated with Chemical Warfare Agents 

STUDIES OF IMPORTANCE 

The Presidential Advisory Committee on Gulf War Veterans’ Illnesses (PAC) 

concluded in their 1996 report that “[b]ased on available data, it is unlikely 

the health effects reported by Gulf War veterans today are the result of 

exposure to OP or mustard CW agents during the Gulf War.” 

The Defense Science Board Task Force on Persian Gulf War Health Effects 

(DSB) concluded in their 1994 report that “ . . . there is no indication from 

research that there would be chronic sequelae from low level exposure 

even if it had occurred.” 

The Institute of Medicine 1996 report “Health Consequences of Service 

During the Persian Gulf War” (IOM) concluded that “ . . . there is no 

available evidence in human or animal studies to date that exposure to 

nerve agents at low levels that do not produce any detectable acute clinical 

or physiological manifestations results in any chronic or long-term adverse 

health effects.” 

NOTE: Nevertheless, it is important to note that all of these 

independent review groups caution that we do not have a great deal 

of information to base conclusions about long-term effects of 

exposure to low-levels of chemical warfare agents, and that further 

research may be justified. 

Caring for War Wounded 39 
40
 
Injuries Associated with Pesticide Agents Injuries Associated with Pesticide Agents

Caring for War Wounded 41

Objectives 

List the pesticides our service members might be exposed to while 

on deployment; 

Describe the difference in exposure to pesticides from Gulf War I to 

Gulf War II; 

Explain how pesticides are absorbed into and eliminated from 

the body; 

List the signs and symptoms of exposure to pesticides; 

Explain how exposure to pesticides may affect reproductive health; 

Identify the way veterans can be tested to verify if they were exposed 

to pesticides; 

Describe the long-term injuries from exposure to pesticides and how 

VA will treat them; and 

List the other available resources for information on pesticides and 

injuries associated with their use. 

Pesticides - What are they? 

Pesticides are products containing chemicals that are designed to prevent, 

destroy, repel, or reduce pests. 

In the U.S., pesticides are mainly regulated by the U.S. Environmental 

Protection Agency (EPA). The EPA is charged with evaluating the safety of 

pesticides before they can be marketed and used in the U.S., and to ensure 

that they will NOT pose unreasonable adverse effects to human health and 

the environment. The EPA grants those pesticides that meet their 

requirements a license or “registration” which permits their distribution, 

sale, and use. In general, pesticides are regulated and licensed for specific 

uses, such as with a specific crop, by a licensed applicator. 

Some pesticides are considered sufficiently safe to be licensed for essentially 

unrestricted use in the U.S. for home and personal protection. Such 

pesticides are commonly available at garden stores and even supermarkets. 
Injuries Associated with Pesticide Agents 

In 1991 during Gulf War I, DoD shipped a variety of pesticides to protect 

U.S. service members from endemic pests. These included carbaryl 

(Sevin®), chlorpyrifos (Dursban®), DEET (for example OFF® and 

Cutters®), diazanon, dichlorvos (Vapona®), lindane, Malathion, methomyl 

(Lannate®), permethrin, propoxur (Baygon®), pyrethroids, and rodenticide 

baits. 

These pesticides represent four major pesticide categories, including 

organophosphorus (OP), methyl carbamate (MC), organochlorine (i.e., 

lindane), and pyrethroid (i.e., permethrin). The insect repellent DEET is 

unique in that it is not part of a broader chemical class of pesticides. 

At the time of Gulf War I, all of these specific pesticide products were each 

registered by the EPA for general unrestricted use by private citizens in the 

U.S., that is, anyone could purchase these materials for home use without 

restrictions. The EPA made this determination based on scientific studies 

demonstrating that these pesticides can be used without posing 

unreasonable risks to people or the environment. 

Most of these pesticides are still readily available today. However, 

chlorpyrifos (Dursban®) was removed from general household use by the 

EPA in June 2000. This decision was based on acute toxicity health risk 

concerns, particularly to exposed children. 

There have been anecdotal reports of pesticides that may have been 

purchased locally in the Gulf War I Theater. The potential significance of 

these anecdotes is difficult to evaluate today, more than 12 years after 

Gulf War I. 

How might Gulf War I veterans have been exposed? 

U.S. service members may have been exposed to any of the pesticides 

shipped to the Gulf during Gulf War I in the same manner that civilians in 

the U.S. may be exposed. 

Even careful conventional use of these pesticides will result in some small 

exposure to those using the products, or those in the immediate vicinity, 

although the health risks in such normal use are considered to be 

negligible. That is why these pesticides are considered safe for unrestricted 

home use. 

Most of these products are used as sprays, which can result in exposure 

from inhalation of vapors, or from skin contact and absorption. 

Contrary to some reports, military clothing was not pretreated with insect 

repellents prior to shipment. 

According to DoD policy at the time of Gulf War I, most U.S. service 

members had access ONLY to permethrin in a spray can for treating 

clothing, and DEET liquid or stick for personal protection against 

mosquitoes and flies. Unrestricted use or even potential misuse of these two 

42 Caring for War Wounded 
Injuries Associated with Pesticide Agents 

pesticides would have resulted in exposure by those using the materials, 

and possibly those in the immediate vicinity where they were used. 

According to DoD, all the other pesticides shipped to Gulf War I were to be 

used only by specifically trained personnel, or for special applications. For 

example, in Gulf War I, lindane was reportedly used as a delousing agent 

for Iraqi prisoners of war. 

Other pesticides were used for sanitation or insect control purposes (e.g., 

Malathion and Dursban®(chlorpyrifos)) at military facilities. 

Personnel involved with applying these materials and those in the 

immediate vicinity would have had some exposure to them, although 

exposure levels under these controlled conditions would presumably be 

quite small. 

How are pesticides absorbed and eliminated from the body? 

Most of these pesticides are applied as sprays. Any material used as a spray 

can enter the body through breathing the aerosolized and vapor form of the 

material. DEET applied as a liquid or stick to the skin can enter the body by 

absorption through the skin. 

Most Gulf War I service members would be most likely to have pesticides 

enter their bodies through accidental breathing of vapors produced from 

spray application of the insecticide, but absorption from skin contact during 

application operations may also have occurred. 

In general, once these pesticides enter the body, they are quickly 

metabolized (broken down) in the body and excreted in urine and feces. 

Their rapid metabolism and excretion from the body is one reason why this 

group of pesticides is considered to be sufficiently safe for unrestricted use 

in the United States. 

Lindane, the only organochlorine pesticide in this group, is metabolized and 

excreted relatively more slowly than the other non-organochlorine pesticides. 

What are the signs and symptoms of exposure? 

As a class, the organophosphorus (OP) pesticides cause inhibition of the 

enzyme acetylcholineesterase (AChE), just like the OP military nerve agents 

described earlier. AChE is crucial to normal nerve and nerve/muscle 

functioning. 

Inhibition of AChE by OP pesticides is generally irreversible, and complete 

recovery involves the body’s production of new enzyme over a period of 

days or weeks. In contrast, inhibition by methyl carbamate pesticides is a 

reversible process. 

Caring for War Wounded 43 
Injuries Associated with Pesticide Agents 

Thus, acute (immediate) cholinergic poisoning symptoms usually develop 

within hours of exposure, and include miosis, headache, nausea, dizziness, 

anxiety, and restlessness. 

Life-threatening symptoms from acute cholinergic poisoning may include 

muscle fasciculation, weakness, tremor, uncoordination, vomiting, 

abdominal cramps, diarrhea, sweating, salivation, and excessive tearing, and 

death can occur by respiratory paralysis. 

Acute cholinergic poisoning by more toxic OP pesticides is a serious health 

issue. Recently, the EPA restricted the use of Dursban® (chlorpyrifos); one 

of the OP pesticides used in Gulf War I, to trained applicators only, based on 

concerns about excessive acute toxicity risks. Previously, and during Gulf 

War I, Dursban® had been approved for unrestricted home use. 

Some patients who survive severe acute OP poisoning show subtle, chronic 

neurological abnormalities that can be detected using standardized 

neurological tests. These effects can remain for months or perhaps even 

years following the acute poisoning event. 

For example, subtle deficiencies are reported for survivors of acute OP 

poisoning in tests for intellectual functioning, academic skills, abstraction 

and flexibility of thinking, and simple motor skills. 

However, according to DoD, in-theater medical personnel did not report 

any acute symptoms in Gulf War I service personnel consistent with acute 

cholinergic poisoning that would be caused by either OP pesticides or 

related chemical warfare agents. 

Although a few OP pesticides are known to cause delayed neuropathies (or 

polyneuropathies) following recovery from acute cholinergic poisoning, 

none of the OP pesticides used in Gulf War I are considered normally to 

cause such effects. 

The methyl carbamate (MC) pesticides cause reversible inhibition of the 

enzyme AChE, and acute poisoning results in symptoms that are very similar 

to that seen with OP pesticides, but with shorter duration. Acute MC 

poisoning has not been associated with chronic neurologic effects. 

Permethrin has very low human toxicity. This is a major reason why it is 

licensed by EPA for unrestricted use in personal care products such as 

shampoos and lotions, or for treating clothing. There are few reported 

human poisonings from this pesticide. 

DEET, introduced as an insect repellent in the 1950s, remains widely used 

in the U.S. today in brands such as OFF® and Cutters®. 

According to EPA, there are 225 DEET registered repellent products to be 

applied directly to the skin and clothing in various forms including aerosol 

and non-aerosol sprays, creams, lotions, sticks, foams, and towelettes. 

DEET generally is of low acute toxicity, and based on the available 

toxicological data, the EPA reports that the normal use of DEET does not 

present a health concern to the general U.S. population. 

44 Caring for War Wounded 
Injuries Associated with Pesticide Agents 

Although DEET’s use has been implicated in causing seizures among 

children, the EPA reports that the data are insufficient to establish DEET as 

the cause of the reported effects. However, because of DEET’s unusual use 

pattern (direct application to human skin and clothing) and its possible 

association with seizure incidents, the EPA considers it prudent to require 

clear, common sense use directions and improved label warnings with 

restrictions on all DEET product labels. 

How may exposure to these pesticides affect reproductive health 

of Gulf War I veterans? 

In general, the EPA requires information from manufacturers demonstrating 

a pesticide does not cause birth defects or other reproductive and 

developmental toxic effects to allow licensing it for unrestricted general use 

by the U.S. public. 

As pesticide classes, the OP, MC, permethrin, and DEET are not considered 

to be teratogenic in laboratory animals. The risk of birth defects in children 

of men who were exposed to any agents prior to conception of the child is 

clearly much lower than to women or to men within months of conception, 

only about 7 percent of veterans from Gulf War I were women. 

Finally, it seems likely that overall pesticide exposure by U.S. service members 

during Gulf War I would have been similar to pesticide exposure to a 

similar group of U.S. civilians who remained in the United States. 

Thus, it appears unlikely that birth defects in offspring of Gulf War I 

veterans are related to pesticide exposures that occurred during the war. 

Is there a test to determine exposure? 

All of these pesticides, including the organochlorine agent lindane, are 

rapidly metabolized and excreted following exposure. 

NOTE: Therefore, there is no test available today that can detect an 

exposure to any of these pesticides that may have occurred in 1991. 

Furthermore, all these pesticides are widely used within the U.S., and 

essentially all Americans are likely to have some exposure. 

NOTE: Consequently, even if a test for exposure were available it 

would be difficult to distinguish exposures that may have occurred 

during Gulf War I from exposures that may have occurred after 

returning to the United States. 

What have independent review groups concluded about the risks? 

Several scientific review committees have also reviewed the health 

consequences of possible exposure to pesticides by U.S. service members 

during Gulf War I. There are numerous references available (see reference 

section) that will provide more valuable information concerning pesticides. 

Caring for War Wounded 45 
Injuries Associated with Pesticide Agents 

STUDIES OF IMPORTANCE 

The Presidential Advisory Committee on Gulf War Veterans’ Illness 

concluded in their 1996 report that “it is unlikely that health effects and 

symptoms reported today by Gulf War veterans are the result of exposures 

to pesticides during the Gulf War.” 

The 1996 IOM report concluded that “[in] general, it appears that the 

average personal usage of the pesticides available in the PGW Theater of 

operations was low and unlikely to be associated with induction of 

chronic disease.” 

In addition to these reports, the 1994 NIH Technology Assessment 

Workshop Statement concluded that “chronic responses to OP are 

considered unlikely because of the absence of reported polyneuropathies 

among the examined veterans.” 

Lastly, the 1994 Defense Science Board report concluded “ . . . there were 

no reports of acute pesticide poisoning during the war. If continued analysis 

of the VA registry indicates a higher incidence of neurophysical disorders in 

those veterans whose duties included routine application of pesticides, 

pesticide exposure may come under closer scrutiny as an etiological factor 

for other participants.” However, neurophysiologic diagnoses do not appear 

to be unusual in VA’s registry data. 

46 Caring for War Wounded 
Injuries Associated with 

Biological Warfare Agents

Injuries Associated with 

Biological Warfare Agents 

Caring for War Wounded 47

Objectives 

List the agents that might be involved in biological warfare; 

Explain the symptoms of biological warfare agents; 

Explain how clinicians can prevent the spread of pathogens within 

their medical centers; and 

List the long-term issues associated with biological warfare. 

Introduction 

VA clinicians have to recognize that mass exposures to biological agents are 

possible in the battlefield. When patients are admitted to a VA hospital, the 

clinician may already know the etiology of the exposures because of 

treatment rendered on the battlefield. However, combat injuries may send a 

soldier to the hospital and, due to the incubation period of some of these 

agents, symptoms may only begin to develop once hospitalized. All staff 

need to be aware of these possibilities so they can recognize illnesses due 

to these agents and take action when needed. 

Post-deployment health care needs related to possible exposure of 

biological warfare agents are a major concern for the VA and the Department 

of Defense. This section is important and valuable for those that will treat 

our service members. Information will be presented on agents such as 

anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic 

fevers. With the release of any biological agent, a diagnostic and treatment 

continuum is of value for medical personnel. The continuum includes: 

1. Clinical Presentation 

2. Diagnosis 

3. Treatment 

4. Infection Control 

5. Long-Term Issues 
Injuries Associated with Biological Warfare Agents 

Key points about biological warfare agents related to the continuum are: 

• Mass exposures are possible in the battlefield 

• Etiology may be known upon admission to VA facilities 

• Primary diagnostic work-up likely not required but initial 

presentation after admission is possible due to longer incubation 

periods of some agents 

• Possibility exists of organisms with altered toxic profile 

Categories of Biological Warfare Agents 

The Center for Disease Control categorizes biological agents into three 

categories, A, B and C (Table 1). This section will focus on only Category “A” 

agents. The Category “A” agents are important because they are easily 

disseminated, easily transmitted, they have a high mortality rate and high 

social disruption potential. The Category “A” agents are: anthrax, botulism, 

plague, smallpox, tularemia, and viral hemorrhagic fever. 

Since these agents have catastrophic potential, it is important that all 

medical personnel understand the need for special preparations related to 

the treatment of the potential victims. Table 1 below presents the categories 

of recognized biological warfare agents. 

BIOL OGIC AL WARFARE A GENTS 

Category A Category B Category C 

Anthrax 

Botulism 

Plague 

Smallpox 

Tularemia 

Viral Hemorrhagic Fever 

Brucellosis 

Foodborne/Waterborne 

(e.g. Salmonella) 

Q Fever 

Staphylococcal Enterotoxin B 

Viral Encephalitis 

Hantavirus 

Multidrug-resistant 

Tuberculosis 

Nipah Virus 

Tickborne Hemorrhagic 

Fever 

Yellow Fever 

Table 1 

48 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

Anthrax 

•	 Bacillus anthracis (B. anthracis): gram-positive spore-forming 

rod, spore and vegetative forms 

• Found in soil or herding animals 

• Industrial exposure (hides, wool handlers) 

• Spores can be long-lived 

• No person-to-person transmission 

Figure 1 is anthrax shown under an electron microscope. Figures 2 and 3 

are light microscopic views of anthrax. 

Figure 1 Figure 2	 Figure 3 

Anthrax is a bacterial infection, which presents in several major forms: 

predominantly skin (cutaneous) and inhalational. The person who is 

infected with cutaneous anthrax will develop a sore that progresses to a 

very classic black eschar (scab). A clinician, who sees a patient with a skin 

wound that has a black eschar, should assume the patient has skin anthrax 

until proven otherwise. 

The more serious form of anthrax is inhalational, that is, it is breathed into 

the lungs. The organism is deposited deep into the lung. The patient may 

present with a fever, but then rapidly progresses to other symptoms associated 

with inhalational anthrax. This patient needs rapid intensive intervention. 

Caring for War Wounded 49 
Injuries Associated with Biological Warfare Agents 

Cutaneous Anthrax 

Cutaneous anthrax infects the body by entering through unintact skin, or 

broken skin. The information listed below outlines some of the 

manifestations of the disease. 

• B. anthracis enters through unintact skin 

• Incubation 1-12 days 

• Small papule forms in 1-2 days that progresses to a vesicle 

• The vesicle progresses to a necrotic ulcer that forms with 

a black eschar 

• The lesion is painless with surrounding edema 

• Fever, headache, malaise, and regional lymphadenopathy 

may be present 

Figures 4-9 illustrate the stages of presentation associated with cutaneous 

anthrax. Figure 4 shows an early cutaneous anthrax lesion at the vesicular 

stage. Figure 5 shows the surrounding edema and early diagnostic black 

eschar. Figures 6 and 7 shows the progression of a lesion on the neck, 

again, note the diagnostic black eschar. Figure 8 shows evidence of regional 

lymphadenopathy. Figure 9 shows the diagnostic black eschar. 

Figure 4 Figure 5 Figure 6 

Figure 7 Figure 8 Figure 9 

50 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

Inhalation Anthrax 

Inhalational anthrax is the most serious form of anthrax. It is a fulminating, 

toxic illness associated with fever, systemic symptoms associate with 

radiologic findings of mediastinal widening, without pneumonia. The 

information below outlines the manifestations of inhalational anthrax. 

Pathogenesis of Inhalation Anthrax 

•	 B. anthracis spores are deposited in terminal 


bronchioles and alveoli
 

• Spores are ingested by macrophages that migrate to 

peribronchia/mediastinal lymph nodes 

• Spores incubate, become vegetative (in approximately 10 d) 

• The vegetative form of B. anthracis produces toxin that 

causes all the damage 

Clinical Findings of Inhalation Anthrax 

• Fever, fatigue, chest pain, non-productive cough 

• Hemorrhagic mediastinitis evident on CXR/CT/MRI after 1-3 days 

• Abrupt onset of severe respiratory distress 

• Septic shock and death 1-3 days later 

• Meningitis and plural effusions are possible findings 

• CXR/CT/MRI Findings (at this stage)
 

°
 Widened mediastinum, pleural effusion
 

°
 Pulmonary infiltrates possible, but maybe not 

According to Inglesby, et al., in the May 1, 2002 edition of JAMA, the 

following are the signs, symptoms, and findings associated with the anthrax 

attacks in the U.S. after September 11, 2001. 

Signs and Symptoms in 10 cases: 

• Fever/chills 10/10 • Fatigue/malaise 10/10 

•	 Nonproductive cough 9/10 • Nausea/vomiting 9/10 

•	 Dyspnea 8/10 • Chest pain 7/10 

•	 Myalgia 6/10 • Headache 5/10 

•	 Abdominal pain 3/10 • Sore throat 2/10 

•	 Rhinorhea 1/10 

Caring for War Wounded 51 
Injuries Associated with Biological Warfare Agents 

Lab and X-ray Findings in 10 cases: 

• WBC normal to slight elevation with left shift frequent 

• Transaminases >40 u/l 9/10 

• CXR 10/10 abnormal
 

°
 Pleural effusions 8/10 


°
 Pulmonary infiltrates/consolidation 7/10
 

°
 Mediastinal widening 7/10 

• CT 8/8 cases abnormal
 

°
 Mediastinal widening 7/8
 

°
 Pleural effusion 8/8 

Anthrax and Biological Warfare Prophylaxis and Treatment 

Anthrax has already been used as a biological terror agent and could be 

used against the troops in “Operation Iraqi Freedom” and the people of the 

United States. 

In the aftermath of the September 11, 2001 terrorist attack, there were 

several actual attacks and many false attacks with anthrax. If there is a 

documented attack using anthrax, many troops might be in the area and 

thus, prophylaxis will be required. Those with documented exposure, but 

without clinical symptoms consistent with the disease of anthrax should 

receive chemoprophylaxis to prevent development of disease. 

Documented Exposure (from proven source or shared environment with 

proven case) 

• Ciprofloxacin or Doxycycline for 60 days 

• Prophylaxis is NOT indicated for those without exposure to 

a documented case or reservoir of B. anthracis. 

Anthrax Treatment 

The recommended treatment for documented infection with B. anthracis 

consists of the following: 

• Cutaneous: Oral ciprofloxacin x 60d 

• Inhalation: Early empiric treatment (high index of suspicion, 

clinically compatible scenario) 

° combination antibiotics – then based on in vitro activity using 

IV ciprofloxacin or doxycycline + 1 or 2 additional antibiotics 

(rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, 

imipenem, clindamycin, clarithromycin) 

• Switch to oral ciprofloxacin or doxycycline when appropriate 

52 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

• Total treatment – 60 days 

• Expect need for drainage of pleural effusions 

Infection Control 

Neither cutaneous nor inhalation anthrax are transmitted person-to-person 

so normal hospital infection control procedures are adequate. The 

following is the recommended control procedures: 

• No need for isolation – no person-to-person transmission 

• Standard barrier precautions 

• High-efficiency particulate air filter masks are not indicated 

• No need to prophylax patient contacts (unless they had 

similar exposure as patient) 

Long Term Issues of Anthrax 

• Cutaneous – not much 

• Pulmonic – probable need for long-term recovery period due 

to extensive tissue damage by toxins and systemic disease 

• Difficult decontamination of source areas – thus, potential for 

prolonged exposure 

Botulinum Toxin 

Botulism is an intoxication by botulinum toxin, a highly lethal toxin that 

can be put in food, liquids, or aerosolized. It causes an acute afebrile illness 

(i.e., the patient is sick, but without a fever). Intoxication with botulinum 

toxin starts with cranial nerve palsies and can progress to respiratory 

muscle paralysis where a patient may need artificial ventilation for a period 

of weeks to months. It is a very intensive process. 

General Information on Botulinum Toxin: 

• Easy to produce or acquire in large quantities 

• Highly lethal via aerosol or food 

• Incubation of clinical manifestations: 

° 2 hrs – 8 days (foodborne)
 

° 12 – 80 hrs (inhalation – experimental)
 

• Action: Blocks cholinergic synapses 

Caring for War Wounded 53 
Injuries Associated with Biological Warfare Agents 

Clinical Information 

• Acute, afebrile, symmetric, descending flaccid paralysis 

• Multiple cranial nerve palsies (ptosis, diplopia, blurred vision, 

enlarged/sluggish pupils, dysarthria, dysphonia, dysphagia) 

• Dry mouth/injected pharynx 

• Progressive loss of gag reflex and respiratory muscle activity 

• Artificial ventilatory support may be required for long periods 

Botulinum Intoxication – Primarily a Clinical Diagnosis 

• Toxin assay (reference lab) 

Treatment 

• Mostly supportive
 

°
 Ventilator support (weeks to months may be required) 

° Botulinum antitoxin – equine, as early as possible to 

retard or arrest progression 

Prophylaxis 

• None until symptoms develop 

Infection control for patients with exposure to botulinum toxin requires no 

special requirements or isolation. Standard precautions need to be provided 

as a routine since this is a biological infection. Human-to-human 

transmission is not of concern; decontamination is accomplished by removal 

of exposed materials or clothes and washing. 

54 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

Plague 

Yersinia pestis (Y. pestis) is the organism that causes plague. Plague can 

present in two main ways: bubonic plague - where a person gets bitten by 

an infected insect, is exposed to Y. pestis, and presents with regional 

infection manifested by a large swollen lymph node, called a bubo (Figure 

10). However, the more serious form is pneumonic plague, where an 

individual breathes in the organisms (Figure 11 – micrograph of Y. pestis 

organisms) and presents with a nonspecific febrile illness that progresses 

rapidly to pneumonia, septic shock, disseminated intravascular coagulation 

(DIC), and death. The pneumonic plague is a highly contagious condition 

in the hospital setting. 

Figure 10	 Figure 11 

Bubonic Plague 

•	 vector-borne
 

°
 adenopathy (bubo) 

Pneumonic Plague - most likely form of attack. Clinical Presentation: 

• Chills, fever, weakness, head ache, malaise, cough, 

nausea/vomiting 

• Fulminant pneumonia, bloody sputum 

• Septic shock, DIC, purpura, gangrene 

• Rapid progression – exposure to death 2-6 d 

• High mortality, but may respond to early treatment 

Plague Treatment 

• Rapid initiation of antibiotic treatment is required: 

° Streptomycin IM or Gentamicin IV/IM or 

° Doxycycline, ciprofloxacin, chloramphenicol (all IV) 

° Change to PO when indicated 

Caring for War Wounded 55 
Injuries Associated with Biological Warfare Agents 

• In Mass Casualty Settings: 

° Doxycycline, ciprofloxacin, chloramphenicol PO

• All therapy continued for 10 days 

Prophylaxis 

• When exposure is confirmed: 

IV antibiotics for anyone with T >38.5C or cough 

° 

° 

PO antibiotics for symptoms after mass exposure 

° For asymptomatic exposures or close contacts of proven cases: 

• Doxycycline, ciprofloxacin, chloramphenicol x 7 days PO 

Infection Control 

Plague infection control issues are very important because this organism is 

transmitted via respiratory droplets. Standard respiratory droplet 

precautions are required of hospital workers using surgical masks, gowns, 

gloves, and eye protection. Patients should be isolated for up to 48 hours 

after antibiotics are administered for this infection. Inpatients who have 

been diagnosed with plague who are in the hospital and are being 

transferred around the hospital should also wear surgical masks to prevent 

infection of other hospital workers. 

In addition, mortuary workers and other hospital personnel should be 

advised of the diagnosis of plague. It is important to emphasize for those in 

whom exposure to aerosolized Y. pestis has been confirmed, prophylaxis 

should be instituted as soon as possible. Anyone who has been exposed, 

who has a fever or cough should be treated as if they have plague and get 

appropriate IV antibiotics and clinical monitoring. In addition, for close 

contacts of cases, they can also receive oral antibiotics for seven days. 

• Transmission via respiratory droplets 

• Standard respiratory droplet precautions (surgical masks, 

gowns, gloves, eye protection) 

• Patient isolation 48 hrs after initiation of antibiotics 

• Patients in transit should wear surgical masks 

• Mortuary workers should be advised about diagnosis in 

order to take appropriate precautions 

• No spore formation – thus, no unusual environmental 

decontamination needed 

56 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

Plague Complications 

Patients are also likely to need treatment for complications such as: 

• Gram-negative sepsis 

• ARDS 

• DIC 

• Shock 

• Multi-organ failure 

Smallpox 

Smallpox is a disease that is easily transmissible person-to-person. It 

presents as a nonspecific viral syndrome with fever, headache, fatigue, and 

malaise that progresses to a characteristic rash. It is a very highly contagious 

disease, particularly in the rash stage (Figures 12, 13, and 14). 

Figure 12 Figure 13 

Figure 14 

The clinical manifestations of 

smallpox (variola) have some 

similarities and important 

differences with chickenpox 

(varicella). The similarities 

and differences are 

summarized in Table 2 (top 

of next page). 

Caring for War Wounded 57 
Injuries Associated with Biological Warfare Agents 

Smallpox vs. Chickenpox 

Variola (Smallpox) Varicella (Chickenpox) 

Incubation 

Prodrome 

Distribution* 

Progression* 

Scab formation 

Scab separation 

7-17 days 

2-4 days 

Centrifugal 

Synchronous 

10-14 d p rash 

14-28 d p rash 

14-21 days 

Minimal/none 

Centripetal 

Asynchronous 

4-7 d rash 

<14 d rash 

* denotes important differences Table 2 

Smallpox presents in the following manner: 

• Incubation ~ 12 days (7-17) 

• Early symptoms are nonspecific: fever, headache, backache, 


vomiting, malaise, aches for 2-4 days
 

• Rash appears 2-3 days later 

centrifugal pattern
 

°
 

° 

synchronous emergence and progression from 


maculopapules to vesicles to pustules
 

°
 scabs over in 1-2 weeks 

• Mortality ~ 30% - due to toxemia 

• Laboratory diagnosis not required after index cases are 


confirmed (BL-4 Lab required)
 

Smallpox Treatment 

There is no known treatment for smallpox. Medical personnel will need 

to provide supportive measures, and isolate the patient to prevent further 

infections. This is important, because transmission occurs primarily after 

rash appears. As part of this treatment, consider isolation at non-hospital 

facilities. Antivirals are under investigation as a treatment, and antibiotic 

prescriptions may be used for secondary bacterial infections. 

Infection Control 

Infection control for smallpox has to take immediate priority once it has 

been determined that there is a patient with smallpox. Infection control 

involves appropriate isolation and vaccination of contacts. The smallpox 

58 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

vaccine is likely effective in preventing appearance of smallpox if given within 

3-4 days of exposure. The following procedures make up this response: 

• ACTIVATE FACILITY SMALLPOX HEALTH CARE RESPONSE TEAM 

• Initiate smallpox vaccination of all hospital workers (include 

housekeeping, mortuary workers, etc) 

Vaccinate all close contacts of index case(s) ° 

• Patients should be kept in respiratory isolation: aerosols and 

pustules are infectious 

• Keep isolated for 7-10 days after onset of rash 

• Bedding & equipment – autoclave, destroy, or launder with 

hot water/bleach 

Tularemia 

Tularemia is a bacterial infection caused by Francisella tularensis (F. 

tularensis) that presents as a febrile illness with a wide array of clinical 

manifestations depending on where the bacteria enters the body. Tularemia 

can present as a systemic infection, as an oral or mouth or throat infection, 

a skin infection, or pulmonary infection, and can be slower to present than 

plague or anthrax. The clinical presentation of tularemia is similar to Q 

Fever (caused by Coxiella burnetti) and distinguishing between the two 

may be difficult without laboratory confirmation. 

Tularemia Infection Features 

•	 F. tularensis: small, non-motile, aerobic, gram-negative 

coccobacillus 

• One of the most infectious pathogens known – inhalation of as 

few as 10 organisms can cause disease 

• Occurs widely, recovered from soil/water and vegetation 

• Vectors mostly small mammals (moles, mice, rats, rabbits) 

• Humans become infected naturally by bites from flees/ticks, from 

infected animals or exposure to animal tissue, fluids, or aerosols 

• Between 1985-1992, 1409 cases reported in U.S. with 20 deaths 

• No person-to-person transmission 

Caring for War Wounded 59 
Injuries Associated with Biological Warfare Agents 

Tularemia Clinical Presentation 

• Sudden onset of non-specific febrile illness 

• Forms: Ulceroglandular, glandular, oculoglandular, 


oropharyngeal, pneumonic, typhoidal, and septic
 

In pneumonic tularemia, pharyngitis, bronchiolitis, 

pneumonitis, pleuritis, hilar lymphadenitits are common 

° 

° 

Pulse/temperature dissociation is common 

Tularemia - Diagnosis 

• Rapid diagnostic testing is not available 

• Gram stain or DFA are used on secretions, or biopsy specimens 

• Definitive Diagnosis: Growth of F. tularensis from culture 

of pharyngeal washings/sputum or other infected fluids 

confirms diagnosis 

Treatment 

• Streptomycin IM or gentamicin IM or IV or ciprofloxacin IV (10d), 

doxycycline, chloramphenicol IV (14-21 d) 

• In mass casualty setting and in prophylaxis: 

Doxycycline PO 100mg BID x 14 days
 

°
 

° 

Ciprofloxacin PO 500 mg BID x 14 days 

• Vaccination: a live attenuated vaccine is under review by FDA 

Infection Control 

• No person-to-person transmission 

• Standard precautions for hospital, labs, linens, housekeeping, 

and mortuary workers 

• Standard precautions for environmental decontamination 

and protection 

Viral Hemorrhagic Fevers (VHF) 

Viral hemorrhagic fevers (VHF) are actually a collection of several viruses 

(Ebola, Lassa, Marburg, Rift Valley Fever (Rift VF), New World CongoCrimean Hemorrhagic Fever virus, and New World Arenaviridae (NWA)), all 

of which present as a severe febrile illness, where coagulation problems are 

the predominate clinical sequelae. Because of frequent bleeding, the viral 

60 Caring for War Wounded 
Injuries Associated with Biological Warfare Agents 

Figure 15 

hemorrhagic fever viruses are also very contagious in the hospital setting. 

Thus, strict blood and body fluid precautions are needed to maximize 

infection control. VHF’s have an incubation period of 4-21 days, with a 

mortality rate that varies from 10-90%. 

Figure 15 is an example of a VHF 

(ebola virus). 

VHF Diagnostic Criteria: Diagnosis 

requires high index of suspicion and 

viral isolation at CDC or USAMRIID. 

• 	Temperature >38.3C of <3 wks 

• 	Severe illness 

• 	2 symptoms: epistaxis, 

hemorrhagic rash, hematemesis, 

hemoptysis, bloody stool 

• 	No predisposition for 

hemorrhagic disease 

Treatment 

• Primarily supportive 

• Ribavirin x 10 d (only for Lassa, NWA, Rift VF) 

• Prophylaxis: None proven effective 

• If symptoms in exposed individual develop 


(T >38.3C) within 21 days – treat as active case
 

Infection Control 

Infection control procedures for patients with the viral hemorrhagic fevers 

are important. There are numerous infection control procedures that MUST 

be adhered to. The quality of the infection control program will keep the 

infection level low, or non-existent. 

• VHFs are highly infectious via blood/bodily secretions 

• Isolation and barrier precautions required: 

Strict hand hygiene, double gloves
 

°
 

° 

Impermeable gowns, coverings
 

°
 N-95 masks or PAPRs
 

°
 Face shields/goggles 

• Required for health care workers and housekeeping, 

mortuary staff, etc 

• Patients in isolation rooms 

Caring for War Wounded 61 
Injuries Associated with Biological Warfare Agents 

• Negative air pressure rooms thru HEPA filter 

• Restricted access by non-essential staff/visitors 

• Patients with same diagnosis can be roomed together 

• Patients with Ebola, Marburg, Lassa, NWA – no sexual activity for 

90 days after recovery 

Long-Term Issues Associated With the Use of Biological Warfare Agents 

The long-term sequelae of the use of biological warfare agents must also be 

considered. They include: 

• Psychological Impact & PTSD – HUGE long term issue 

(Hyams, et al., 2002) 

• Long Term Health Impact of Those Exposed 

• Worried Well Phenomenon 

• Public Communications 

The Department of Veterans Affairs Employee Education System, with the 

Office of Public Health and Environmental Hazards has produced a Veterans 

Health Initiative “Endemic Infectious Diseases of Southwest Asia” that is 

comprehensive in nature, and is a valuable resource to support the 

information contained in this section. The VHI can be accessed at: 

http://www.va.gov/vhi. 

62 Caring for War Wounded 
Warfare Warfare

Injuries Associated with 

Radiological 

Injuries Associated with 

Radiological 

Caring for War Wounded 63

Objectives 

Describe a scenario in which troops might be exposed to 

radiological material; 

Explain the key points regarding radiological exposure; 

Define the special situations that might involve VAMC staff 

when working with battlefield casualties; and 

List the dangers of radioactivity related to depleted uranium. 

Introduction 

The intelligence on whether Iraq has nuclear weapons is uncertain, but that 

does not rule out the possible use of a radiological dispersant device or 

“dirty bomb”. The scenario for use of one of these dirty bombs is uncertain, 

however the possibility exists that this could happen. 

The radiological dispersant device or “dirty bomb” is comprised of 

radioactive material, and a conventional bomb. The “dirty” term is derived 

from exploding the bomb, and spreading the contaminating radioactive 

material around the surrounding area. Even though the possibility is low 

that Iraq has a nuclear weapon, it should be kept in mind as a potential 

source of radioactivity as well. 

An important concept to understand is the difference between exposure 

and contamination. A soldier who encounters a piece of radioactive material 

in the desert will experience exposure. The soldier will be irradiated and 

receive irradiation. A soldier who is contaminated would have radioactive 

material in or on his/her body. If the service personnel was involved in an 

explosion where radioactive material enters the body, (e.g., ingested, 

inhaled, or by wound contamination), they would be contaminated. 

The exposure level is hard to determine if dosemetry device is not worn. 

When a person is exposed, they are NOT radioactive, they are just exposed. 
Injuries Associated with Radiological Warfare 

Exposure to Radiation 

The injuries experienced from exposure to radiation vary from burns to 

death. Figure 1 shows the hands of an individual who was exposed to a high 

level of radioactivity. This is a radiation burn. 

There is no way to tell 

the difference between 

a radiation burn and a 

thermal burn, other 

than NOT being 

exposed to something 

that is hot or a flame. 

Therefore, health care 

providers need to 

consider a history 

when symptoms 

present as shown in 

Figure 1. 

Individuals may experience different types of radiological exposure 

such as irradiation (Figure 2), external contamination (Figure 3), and 

internal contamination (Figure 4). The levels and type of exposure will 

determine the decontamination and treatment required for the victim. 

Figure 1 

Figure 2 Figure 3 Figure 4 

64 Caring for War Wounded 
It is important to learn the phases of acute radiation syndrome, and what 

they do to the victim. Figure 5 depicts the levels of exposure, and the potential 

damage to the victim. Figure 6 lists the Units of Measurement for radiation. 

Figure 5 

Injuries Associated with Radiological Warfare 

Figure 6 

For example, if somebody receives 200 or 300 rads (2 to 3 grays) of 

radiation, they would suffer the hematological phase of radiation syndrome, 

which means 30 days after the exposure, the white cells would fall to very 

dangerous levels. They would then experience infection, and could have 

bleeding disorders. Also, all of the radiation symptoms might manifest 

themselves at the time these military personnel are at a VA hospital. 

The victim may be internally or externally contaminated. To decontaminate 

an individual who has external contamination, remove the clothing and 

thoroughly wash the body; this will remove 95% of the contamination. 

Internal contamination has three different ways to enter the body: 

inhalation, ingestion, and direct exposure with entry through a wound. 

Regardless of entry point, treatment may be necessary. The treatment is 

discussed in the next portion of this section. 

Special Situations for VAMC Staff 

Since many of the individuals the VA will receive have been away from the 

battlefield for a while, the medical personnel need to be aware of the 

process that the individual has already been through. He/she has been 

treated for all of the acute injuries, and any kind of radiological injury. 

However, the important thing is to take care of the surgical emergency first. 

As a health care provider, if you are worried about the radiation and the 

patient’s bleeding to death, you are not going to help him or her. 

However, if the victim comes back to the VA and still has small amounts of 

embedded material inside a surgical wound, which is now being dressed or 

closed, the patient has to be taken back to the operating room. A surgeon, a 

nuclear medical physician, and a health physicist (who will be there with a 

meter to measure the radioactivity as the surgeon is debriding the wound), 

will determine if the radioactivity has been removed. This scenario is a 

possibility at one of the VAMCs. 

Caring for War Wounded 65 
Injuries Associated with Radiological Warfare 

Another special situation might be if an individual ingests or inhales cesium. 

If still in the body, there are a number of methods to remove the 

radioactivity. A publication called NCRP Report Number 65, has information 

on all the various isotopes and how to treat the victim. Two examples; 

cesium that is ingested can be treated with Prussian Blue, an oral 

medication. Prussian Blue is not commercially available without calling Oak 

Ridge React/TS Facility in Oak Ridge, Tennessee. In addition, iodine, also an 

oral medication, is used to block the thyroid with stable iodine isotope to 

prevent uptake of the radioactive iodine. This particular blocking must be 

done at or shortly after the time of exposure. The victim cannot wait to be 

transported. However, something like the Prussian Blue treatment and all 

the other treatments described in NCRP Report may be done after the fact. 

Depleted Uranium 

Depleted uranium is used in many different warfare weapons. Depleted 

uranium is radioactive, but only slightly. It has very weak alpha emissions. It 

is not very dangerous as a radioactive agent, it is however, more dangerous 

as a heavy metal. In addition, the danger to a returning soldier who is 

contaminated with depleted uranium is the danger of heavy metal. It is 

important to remove as much of the depleted uranium from the body as 

feasible, not from a radiological point of view, but a chemical point of view. 

The most important thing clinicians should know about radioactive 

weapons, is that they are easier to deal with, than chemical or biological 

weapons. Every hospital has a radiation detector. The ability to measure 

radioactive contamination in a returning combatant is possible, and the 

VAMC’s have the staff that can remove the contamination if necessary. 

There are fears, with “radiation”, but it is the easiest to deal with. 

The VA has produced a comprehensive VHI on Radiation. This VHI has 

information on depleted uranium. The VHI may be accessed at: 

http://www.va.gov/vhi. 

66 Caring for War Wounded 
Combat Effects on Mental Health ombat Effects on Mental Health 

Caring for War Wounded 67

Objectives 

Describe the lessons learned on how combat effects 

mental health; 

Define Post Traumatic Stress Disorder (PTSD); 

Define Acute Stress Disorder (ASD); 

Define Combat and Operational Stress Reaction (COSR); 

Explain the treatment of Combat and Operational Stress 

Reaction; 

List the health care disciplines within VA that treat mental 

health issues; and 

Describe the model VA uses to treat mental health issues 

in combat veterans. 

Introduction 

The Department of Veterans Affairs has been working at regional and 

national levels to define and roll out its mental health response to receiving 

acute war casualties. 

The VA is a world leader in treating traumatic stress. That skill and 

experience will serve the VA well in the days ahead. 

It is very important that each VAMC/CBOC bring together the full range 

of partners in the mental health response. These include (but are not 

limited too): 

• Psychiatrists 

• Psychologists 

• Mental Health Nurses 

• Social Workers (mental health settings, and other settings as well) 

• Chaplains (many VA chaplains have experience in working with 

trauma survivors) 

• Administrators 
Combat Effects on Mental Health 

• Vet Center Staff 

• Volunteers 

What have we learned about traumatic stress? 

The VA has learned that traumatic stress can present differently in different 

people and in different conflicts, AND that, given enough stress, anyone 

can break. 

• One out of 5 casualties of WWII was psychiatric 

• There seemed to be relatively few acute mental health problems 

during the Vietnam War, but follow up showed that one third of 

all combat veterans went on to develop PTSD at some time after 

the war 

° Half of those Vietnam veterans still had PTSD in the late 1980s 

• The best available data show that 10% of combat veterans of 

Gulf War I have PTSD 

What is Post Traumatic Stress Disorder (PTSD)? 

PTSD is defined as: 

• Intrusive memories, mental images, nightmares, and 

flashbacks of the stressor; 

• Avoidance of reminders and of feelings related to the event; 

• This sometimes culminates in severe social and 


emotional withdrawal;
 

• Marked trouble falling or staying asleep, a tendency to startle 

easily, and feelings of panic; and 

• By definition, PTSD cannot be diagnosed until 4 weeks 

after trauma. 

What is Acute Stress Disorder (ASD)? 

ASD is defined as: 

• Involving many of the same intrusive, avoidant, 


and hyperarousal symptoms associated with PTSD
 

• At least three of the following dissociative symptoms: 

° A subjective sense of numbing or detachment 

° Absence of emotional responsiveness
 

°
 Dissociative amnesia 

• The disturbance lasts for at least 2 days and does not persist 

beyond 4 weeks after the traumatic stressor 

68 Caring for War Wounded 
 

Combat Effects on Mental Health 

Many in VA are used to dealing with PTSD and ASD, but few have 

experience with Combat and Operational Stress Reaction (COSR), which 

may include any of a number of symptoms found in PTSD or ASD, but 

which may also be limited to: 

• dissociation (amnesia, acute confusional states, trance) 

• conversion (partial or complete paralysis, blindness, 

mutism, tremor, etc) 

• mixed anxiety states, especially panic attacks 

These were once called War Neuroses. They have been a part of every war, 

and are most often seen at or near the front. War neuroses rarely present in 

VA settings. The symptoms present differently in different individuals. 

NOTE: Because of the way that casualties from the front may 

now be sent to VAMCs, medical personnel may, indeed see 

some people with these acute combat responses. 

To get an appreciation of COSR, view “Let There Be Light”, an Army training 

film that depicts the real-life treatment of these disorders at the end of 

WWII. The film features real patients and real doctors. It can be obtained 

from your VA library. 

It would be beneficial to identify staff members who are knowledgeable 

about the management of dissociation and conversion reactions. Hypnosis 

and sodium amytal treatment have a long record of success in such cases, 

but these procedures need to be done by experienced people. We have no 

way of knowing if the problems faced now would be the same as those 

faced during WWII, but it is safe to say that, while much has changed since 

the 1940s, people have not. 

The mental health effects of combat can present in different phases that 

may or may not be progressive. A combat veteran can present with acute 

mutism or hysterical blindness, but not go on to develop ASD or PTSD. 

Another combat veteran will not show any acute signs of psychological 

trauma, but will develop delayed onset PTSD months or years after the 

event. Other veterans will develop: 

• Depression 

• Substance Abuse 

• Mood Disorders 

• Schizophrenia 

This may be a new disorder for that person or an exacerbation of a 

pre-existing illness. 

Caring for War Wounded 69 
Combat Effects on Mental Health 

One of the most important questions is “Can we prevent chronic illness by 

acting effectively at the outset?” 

Research shows that those who develop peritraumatic dissociation or ASD 

are more likely to go on to develop PTSD. There is less evidence that early 

intervention can prevent chronic mental health problems, but it makes good 

clinical sense to try. 

The National Center for PTSD is a valuable source of information for those 

treating veterans with PTSD. Also, the VA is in the late stages of developing 

PTSD Clinical Practice Guidelines. These guidelines can be previewed at 

http://www.guideonline.info/REVIEW/GOL_PTSD/PTSD_TOC.htm. 

Additional information on PTSD can be found in the DSM-IV, or in a 

comprehensive Veterans Health Initiative on PTSD which the VA produced 

in 2002. The PTSD VHI can be accessed at: http://www.va.gov/vhi. 

Mental Health Treatment Model 

Keeping in mind that different VAMCs will likely face different demands; a 

model has been developed that describes the continuum of treatment VA 

has in place to serve the veterans and their families. 

70 Caring for War Wounded 
Combat Effects on Mental Health 

Mental Health Treatment Model - Debriefing 

Outcome evaluation studies advise against the use of Critical Incident Stress 

Debriefing (CISD or, sometimes called CISM), otherwise known as the 

Mitchell Model. Many people have been trained in CISD and are enthusiastic 

about using these skills. However, the literature shows that CISD does not 

prevent PTSD and that being re-exposed to traumatic memories before they 

are ready may harm some people. This may be especially problematic when 

applied as single session interventions. 

The approach for care should be based on support, normalization of acute 

responses to trauma, education, identification of appropriate resources, and 

appropriate triage. Many of these same elements are found in CISD. The 

important difference is that clinicians should try to avoid re-traumatization 

by inappropriately re-exposing people to their memories and feelings. 

Interventions should emphasize good follow up to allow a patient to deal 

with his or her situation at his or her own rate, and within the context of a 

reliable therapeutic relationship. 

Mental Health Treatment Model - Inpatient Issues 

Staff should keep track daily of those patients who could be discharged or 

transferred out in the event of the need to accept casualties. Beds are 

tracked nationally. 

In some cases, medical center leaders may chose to close entire inpatient 

psychiatry units and convert them to medical or surgical units. Mental 

health leaders should be involved in any such planning and should advise 

top leadership about best options. 

One important factor in any such decision is to determine what capacity of 

beds will be needed to maintain the usual population, or if expecting MH 

casualties to begin arriving in the future. Regional planning needs to 

consider the possibility of terrorist attacks at home and the need to 

maintain capacity for dealing with them. 

Many psychiatric wards are neither piped nor wired for even basic medical 

treatment (oxygen, vacuum, emergency backup power at each bed). 

Finally, if the patients are sent to another facility, will a part of the staff need 

to accompany them to the new facility? 

Mental Health Treatment Model - Outpatient Issues 

VA clinicians will notice an increase in contacts with existing patients, which 

will result from the patients viewing the events on the news. This is a basic 

component of PTSD, but exacerbation under stress can occur in veterans 

with depression, substance abuse, schizophrenia, and other disorders; 

especially if that patient is a combat veteran, or perhaps the parent of 

someone currently in the military. 

Caring for War Wounded 71 
Combat Effects on Mental Health 

One measure that proved useful in the immediate aftermath of September 

11, 2001, and the 1995 Oklahoma City bombing was to send a letter to the 

veterans who were enrolled in MH or Vet Center programs. This letter is 

intended to reassure veterans that the VA is standing by them and is 

available through the current crisis. Such a letter could be generated by 

computer and mailed to all veterans with a diagnosis of PTSD, or to all 

veterans with future MHC appointments. 

Letter to Veterans 

Dear....., 

Veterans have a special understanding of war and, often, a 

special sensitivity to news about war. We, the staff of the 

Mental Health Clinic of your VA Medical Center, are aware 

that this may be a particularly stressful time for you and 

your family. We want you to know that we are available to 

you and that we are standing by to be of help should you 

need us. Your next scheduled appointment is on [ ] but 

you can reach us at [ ] if you would like to talk with us 

sooner. If we can help, please don’t hesitate to call. 

Sincerely, 

Director, Mental Health Clinic 

72 Caring for War Wounded 
Combat Effects on Mental Health 

Mental Health Treatment Model - Med/Surg Patients 

Many, perhaps even most, combat veterans who go on to develop PTSD, 

had not been identified as needing mental health intervention in the acute 

aftermath of combat. It is possible that relatively few returning casualties 

will be identified as needing acute mental health intervention and that most 

will be triaged to medical or surgical services. Based on experience in past 

wars, it would be important to provide basic support and conduct mental 

health triage on all med/surg casualties. 

In doing this, it would be important to emphasize that all clinicians, provide 

support, answer basic questions, provide education about normal responses 

to trauma (changes in sleep, dreams, jumpiness, irritability, social 

withdrawal, etc). Make it clear that these are the normal responses of 

people living through abnormal events, and identify resources that 

casualties and their families may find useful now or in the future. 

The National Center for PTSD is producing a packet of written materials for 

patients, families, and staff. One pamphlet will contain basic information 

about stress responses, warning signs of trouble, and places in the 

community where people may go to seek more information and help as 

needed. This information will be posted on VA Web sites as templates into 

which local VAMC’s and Vet Centers can insert appropriate local information. 

The staff that does these informal interventions (referred to as “therapy by 

walking around”) might be social workers, nurses, chaplains, or Vet Center 

staff members. Med/Surg unit nurses and nurse managers are invaluable 

allies in this process since they know which patients are having trouble 

sleeping, acting out their dreams, isolating themselves, or are having 

trouble during or after family visits. All unit staff should be cultivated as 

partners in this process. 

Mental Health Treatment Model - Families 

It is not uncommon to see family members in hospital lobbies, lounges, and 

hallways. However, should large numbers of casualties be brought to VA, it 

is likely that these members will be younger and that they will have small 

children with them. They may present in larger numbers than usual and are 

more likely to be from out of town and have little support in the area. It is 

important that VAMC staff develop ways of welcoming and engaging these 

family members. 

It might be useful to identify “family rooms” and to provide reading 

materials (including resource information materials) as well as age 

appropriate books and toys for children. VA library staff can play a role in 

selecting and maintaining these materials. Volunteer Services can be of help 

in finding toys and providing needed day care so that husbands, wives, 

parents, and older children can have time to visit with casualties without 

small children in tow. 

Caring for War Wounded 73 
Combat Effects on Mental Health 

Among the materials could be informational handouts developed by the 

National Center for PTSD. These handouts provide basic information about 

normal psychological responses to combat as well as ways of telling when to 

consider seeking help from a mental health professional. The literature 

shows that one of the factors that determines if a patient will develop PTSD 

is the amount of family support he/she receives. It is reasonable to assume 

that, by increasing the information that families have about normal 

responses and helping them know when to ask for help, the VA will be able 

to improve the level of family support available to the veteran. 

Family educational groups should be offered that promote the sharing of 

information and coping strategies between families. This valuable 

intervention should be offered at different times of the day. 

Mental Health Treatment Model - Small Children and Drop in Centers 

VA staff may not be used to making interventions with young children and 

few child specialists are on staff at VA. There are, however, good resources 

in many communities who can meet with VA staff and help them develop 

age appropriate interventions for small children. It would be helpful to 

identify a play area for children and some volunteer baby-sitting that would 

allow the parents to deal with other issues. 

One useful intervention is a coloring book exercise that brings a parent and 

child together in a structured activity that allows a child to begin to share 

responses with that parent. The University of North Carolina at Chapel Hill 

Department of Psychiatry developed a coloring book for children dealing 

with war issues. It can be accessed at: 

http://www.psychiatry.unc.edu/Coloring%20Book%20Project/childtrauma.htm. 

While this coloring book may need to be modified for children of casualties, 

it is a good example of materials that can be offered to children and parents 

at such times. 

VAMCs may be able to open “Drop In” areas where visiting family members 

can always find someone to talk with. They could be staffed by chaplains, 

nurses, or other staff who would provide informal support, but who would 

also be ready to triage to other services as appropriate. 

Additional Services 

Vet Centers - Vet Center staff have a tremendous amount of experience with 

combat veterans and their families. They may be able to partner with VAMC 

staff in a variety of ways. At a minimum, VAMC mental health staff should 

touch base with local Vet Center team leaders to discuss their respective 

programs for dealing with the current situation and to consider useful 

collaborations. 

74 Caring for War Wounded 
Combat Effects on Mental Health 

Local Community Medical Centers - VAMCs should be aware of which 

local medical centers may also be receiving casualties (under the provisions 

of the National Disaster Medical System). Non-VA medical center staff may 

not have experience or confidence in dealing with combat veterans and it 

may be helpful to provide basic education and support to colleagues in 

these other programs. It might be beneficial to agree on how they would 

seek VA consultation on patients and their families who might need help in 

dealing with responses to psychological trauma. 

American Red Cross - The American Red Cross (ARC) is present in every 

community across America. VA staff should touch base with local ARC 

leadership to be sure that information being given out to families of active 

duty personnel, casualties, and veterans is helpful and consistent with VA 

communications. 

Staff Issues 

Help for Staff - One of the most important lessons learned in previous 

disaster responses is that staff members need support too. At times, 

dedicated staff members overextend themselves in caring for trauma 

survivors. They are also sometimes deeply disturbed by the events their 

patients describe and by their wounds. Each medical center should identify 

staff members (mental health staff, social workers, chaplains, and/or 

experienced administrators) who will spend time touching base with 

caregivers during this operation in order to provide support. Encourage the 

staff to get reasonable rest and self-care, and help identify appropriate 

resources should further intervention be advisable. Employee Assistance 

Programs can be an invaluable help in this. 

Dealing With the Media - At times of national crisis, public information is a 

vital public health intervention. On the other hand, those who provide 

information to the media can also do great harm if they are not well 

informed and if they do not understand how to work with the media or 

how to communicate with those in their audience. Medical Center Public 

Affairs Officers should approve all media contacts. Those who work with the 

media may find it helpful to refer to Web sites on psychological trauma such 

as those operated by the National Center for PTSD (http://www.ncptsd.org) 

or the International Society for Traumatic Stress Studies 

(http://www.istss.org). 

Educational Outreach to Local Military Bases 

The casualties the VA will be treating and their families are part of a larger 

military community. Because of this, it makes sense for VA to integrate its 

efforts and resources with those of the military community. 

VA and Vet Center facilities near military bases that have deployed major 

units should establish or strengthen existing relationships with military 

Caring for War Wounded 75 
Combat Effects on Mental Health 

family support programs, chaplaincy programs, and with the mental health 

component of the base hospital. It is essential to reach out to unit chaplains 

as well as hospital chaplains. Many units will have a divisional surgeon 

and/or a divisional psychiatrist who is not part of the military hospital team 

and who could be a valuable partner. 

It is critically important to establish a positive relationship with unit 

command. Without their support, it will be difficult to have any positive 

impact. 

It is also important to create an outreach to local National Guard and 

Reserve units. Their needs and those of their families may be very different 

from those of active duty men and women. 

Military units are often associated with a Unit Association. These military 

retirees and their families have the potential to serve as peer counselors and 

strong community resources to returning casualties and their families, in 

particular because there is a strong identification through the unit and its 

mission. They remain an untapped resource with great promise. 

VA/DoD Clinical Practice Guidelines for the 

Management of Traumatic Stress 

A combined team of VA and DoD staff are close to completing clinical 

practice guidelines for the management of combat stress response (also 

called acute stress response), Acute Stress Disorder, and Acute and Chronic 

PTSD. Work is underway to provide draft copies of these guidelines as an 

aid to clinicians dealing with casualties. These evidence-based guidelines 

offer treatment algorithms with full annotations designed to be effective in 

both Primary Care and Mental Health settings. These CPGs can be previewed 

at http://www.guideonline.info/REVIEW/GOL_PTSD/PTSD_TOC.htm. 

Conclusion 

As it readies itself to meet the challenge of returning casualties from Iraq, VA 

can rely on its expertise and resources. Mental health can only play its full 

part if it acts in coordination with other VA components. VA should also 

coordinate with local military and medical communities. Even if this crisis 

should pass us by, mental health needs to learn from this experience so that 

they can be prepared for new conflicts and new challenges. 

76 Caring for War Wounded 
Combat Effects on Mental Health 

Frequently Asked Questions 

FAQ 1: Are there lessons from VA’s experiences after September 11, 2001, 

that will serve well now? 

A: Yes. Know your partners. Practice “therapy by walking around.” 

Be aware of the needs of families and communities. Realize that 

sharing information can be good therapy, whether it is sitting down 

with a patient or a family member, or speaking to the public through 

the media. Finally, take good care of your colleagues and yourself. 

You are no good to your patient if you work yourself into the 

ground. 

FAQ 2: Does every military unit have a designated mental health program? 

A: No. Despite ongoing efforts in DoD, many active duty military 

personnel worry that talking about mental health responses to 

combat experiences could impair their unit’s mission or even 

endanger their careers. Yet, without access to appropriate 

interventions, military men and women may be at greater risk for 

long term mental health problems. VA mental health experts may be 

a resource in helping DoD units develop a broader mental health 

infrastructure. The spectrum could span from educational outreach 

and peer counseling services to defining access to mental health 

programs. 

FAQ 3: What is the National Center for PTSD? 

A: A program developed within VA Mental Health to provide clinical 

expertise, education, and research about PTSD. The National Center 

for PTSD’s Web site (http://www.ncptsd.org) is an authoritative 

source of information that includes model disaster plans, 

educational materials on-line, and the world’s largest bibliographic 

database on traumatic stress studies. They are a tremendous resource 

available to all VA staff. 

Caring for War Wounded 77 
78
 
Family Support Programs for 

Veterans and Their Families

Family Support Programs for 

Veterans and Their Families 

Caring for War Wounded 79

Objectives 

Explain the need for family support services; 

List the VA support services from Gulf War I for the families 

and the combat wounded veteran; 

List the types of support services VHA offers; 

Describe the eligibility requirements for services for 

returning veterans; and 

Explain what VA clinicians need to do to get ready to 

provide support services for combat wounded veterans and 

their families. 

Introduction 

The Department of Veterans Affairs is concerned about the physical and 

mental well-being of the troops in combat; however that concern does not 

stop with just the troops. The VA is also concerned about the impact of 

combat on the people the veteran has left behind, the families. Because 

the family is key to the success of a wounded veteran’s care, VA social 

workers provide counseling, educational, and referral services for family 

members of veterans. 

The VA Social Work Department exists to ensure that the veterans and their 

families receive the best care available. 

MISSION: The mission of VA Social Work is to eliminate psychosocial 

complications as significant barriers to healthcare interventions for veterans 

and families. This is accomplished by developing and maintaining 

integrated, quality programs in patient care, research, education and 

prevention. 

VISION: In return for the investment of veterans’ trust and institutional 

support, VA Social Work will provide the foremost leadership in the 

psychosocial care of veterans and their families. 

VALUES: VA social workers are committed to the psychosocial welfare of 

veterans and their families. We offer social work staff as our greatest resource. 
Family Support Programs for Veterans and Their Families 

Our commitment 

1. To place at the center of our concern the dignity and worth 

of the individual. 

2. To incorporate into practice an understanding of the veteran 

within his or her family and sociocultural environment. 

3. To value and respect the distinctive role and expertise of each 

member of the multidisciplinary team. 

4. To identify gaps in services/resources and to advocate for systems 

changes that are responsive to veterans’ changing needs. 

5. To create within the discipline a learning environment that 

fosters new knowledge, enhances clinical social work practice 

and promotes administrative excellence. 

6. To be ethical in fulfilling our responsibilities. 

7. To be conscientious stewards of institutional and community 

resources essential to our mission. 

Valuable information on the Social Work services can be found at: 

http://www.va.gov/socialwork 

Why Family Support Services are Needed 

• Many of the military personnel serving in Gulf War II have never 

seen combat before and their families are perhaps less prepared 

• Large numbers of National Guard members and Reservists have 

been called to active duty 

° they were quickly mobilized and deployed, giving families 

little time to prepare 

° many have decreased income, which may lead to financial 

problems for families left behind 

° some family members have to take on new roles within 

the family 

° many family members may not be familiar with or have 

ready access to military installations for counseling and 

support services 

• More military personnel come from diverse ethnic backgrounds. 

Their family members may not speak English as a first language 

• More women have been deployed, sometimes leaving behind 

young children 

The information provided supports the need for the family support 

programs developed by the VA. 

80 Caring for War Wounded 
Family Support Programs for Veterans and Their Families 

What VA Provided During Gulf War I 

• Persian Gulf Family Support Program outreached to more than 

20,000 Gulf War I veterans and offered marital and family 

counseling services to over 1500 of them 

• Partnerships with the Department of Defense and the 

American Red Cross 

° outreach and dissemination of information 

° providing services within and outside VA 

Types of Services VHA Can Offer 

• Social services
 

°
 referrals for legal, housing, transportation, and financial needs 

° help arranging child care
 

°
 family education re: community services and VA 

benefits available 

° support groups
 

°
 community support networks
 

°
 coordination of services and case management 

• Counseling services
 

°
 marital and family counseling
 

°
 issues of loss
 

°
 psychosocial difficulties associated with injuries 

° psychosocial difficulties associated with rapid mobilization 

and deployment 

° psychosocial difficulties associated with return home 

Eligibility 

• Without new federal legislation 

for two years, VA can provide free medical care to veterans 

newly-returned from a combat zone 

° 

° 

services can be provided to the family members of these new 

veterans in conjunction with care provided to the veterans 

(family counseling) 

° bereavement counseling to families of veterans 

• The legislative authority to offer the Persian Gulf Family Support 

Program has expired. 

To offer the program, VA would need new federal legislation. Under current 

law, VA staff can offer marital and family counseling to veterans discharged 

from active duty and their family members for up to two years following the 

veteran’s return from a combat zone. The Department of Defense can offer 

counseling services to active duty military personnel and their families. 

Caring for War Wounded 81 
Family Support Programs for Veterans and Their Families 

How to Get Ready 

• VA clinicians need to: 

° become familiar with the military experience, including 

military ranks and the differences for National Guard 

and Reservists 

° clearly understand what services and programs can be 

offered by VA and to whom 

° become familiar with resources available from DoD, 

including Tricare services 

° become familiar with resources available in the community 

° develop partnerships with 

• staff at nearby DoD installation 

• American Red Cross contacts 

• staff at community agencies 

• develop a plan for provision of services 

• develop a plan for outreach, in collaboration with the 

DoD installation and community partners 

Frequently Asked Questions 

FAQ 1:	 Why are family support services needed? 

A: Many of the military personnel serving in Gulf War II have 

never seen combat before, and their families are probably less 

prepared than the service members themselves. 

FAQ 2:	 What services did VA provide during Gulf War I? 

A: The VA provided marital and family counseling services. 

FAQ 3:	 How can social workers help the families of Gulf War veterans? 

A: Through the partnerships they have developed with the 

Department of Defense and the American Red Cross, and by 

disseminating information to the families about the services 

VA provides. 

FAQ 4:	 What services can VA social workers provide? 

A: Psychosocial services, including counseling, to eligible veterans 

and their families. 

FAQ 5:	 What are some of the psychosocial difficulties social workers 

might expect to encounter with family members and 

returning veterans? 

A: The main difficulty will be the reintegration of the veteran into 

the family upon their return. 

82 Caring for War Wounded 
Family Support Programs for Veterans and Their Families 

FAQ 6: Are Gulf War II veterans eligible for VA health care benefits? 

A: Yes. Current legislation provides for a benefit period that is up 

to 2 years upon return from the combat zone. 

FAQ 7: What can VA staff do now to prepare? 

A: The two most important things the VA staff can do to prepare for 

the returning military member is to become familiar with the 

military experience, and to learn about the programs that the VA 

offers for the veterans. 

Caring for War Wounded 83 
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Pesticide Registration http://www.epa.gov/pesticides/citizens/registration.htm. 

84 Caring for War Wounded 
CME EXAM CME EXAM

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1 The Fourth Mission of the Veterans Health Administration “Contingency 

Support” is also known as: 

a. Education 

b. Emergency Management 

c. Medical Care 

d. Research 

2. The Federal Response Plan was established by: 

a. Executive Order 12656 

b. Public Law 93-288 

c. Public Law 97-174 

d. Presidential Decision Directive 67 

3. Which of the following is NOT a responsibility of the Federal 

Coordinating Centers? 

a. Coordination with local/state authorities 

b. Enrollment of non-federal local hospitals into NDMS 

c. Management and stockpiling of pharmaceutical caches 

d. Solicitation and organization of local, private sector hospitals, 

and community support services 

4. Which of the following is NOT one of the three distinct levels 

of proximity? 

a. Advanced 

b. General 

c. Immediate 

d. Internal 
CME EXAM
 

5.	 Chemicals like chlorine, phosgene, and nitric oxide are examples of: 

a. Very soluble chemicals 

b. Soluble chemicals 

c. Relatively not soluble chemicals 

d. Less soluble chemicals 

6.	 A Fit and Healthy Force; Prevention of Disease and Injury; and 

Treatment and Care for Ill and Injured Individuals are part of the: 

a. Force Health Protection Program 

b. Health and War Health Program 

c. Pre-Deployment Medical Program 

d. Prevention Training and Deployment Program 

7.	 If a military member has a disqualifying medical condition they may: 

a. Stay on active duty and NOT deploy 

b. Stay on active duty and deploy 

c. Deploy, but not enter the combat zone 

d. Be discharged from active duty 

8.	 The Millennium Study is an example of a ______ long-term health 

status study between DoD & VA. 

a. Blind 

b. Independent 

c. Joint 

d. Pharmaceutical 

9.	 The VA’s Vet Center Program started after which war? 

a. Bosnia-Herzegovina 

b. Gulf War I 

c. Gulf War II 

d. Vietnam War 

86 Caring for War Wounded 
CME EXAM
 

10. Which of the following are the locations for the War Related Illness 

and Injury Study Centers (WRIISCs)? 

a. VAMC Birmingham, AL and VAMC Washington, DC 

b. VAMC East Orange, NJ and VAMC Washington, DC 

c. VAMC Cleveland, OH and VAMC Long Beach, CA 

d. VAMC East Orange, NJ and VAMC Nashville, TN 

11. The purpose of the Post-Deployment Health Clinical Practice 

Guidelines is to help: 

a. The families of veterans cope with the veterans deployment 

b. The health care provider with the treatment of the veterans family 

c. The health care provider and veteran with health concerns 

related to their deployment 

d. The veteran cope with concerns that affect their family related to 

their deployment 

12. Booby traps were prevalent in which theater of operation? 

a. Afghanistan 

b. Bosnia–Herzegovina 

c. Iraq 

d. Somalia 

13. The VA receives patients that have had what type of treatment 

associated with amputation? 

a. Tendon repair 

b. Orthodox circular amputation 

c. Nerve repair 

d. Flaps 

14. Many health care providers in the VA have: 

a. Experience with combat related injuries 

b. No experience with combat related injuries 

c. Seen gunshot wounds, but not from high-velocity weapons 

d. Never seen gunshot wounds 

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CME EXAM
 

15. Which of the following chemical agents were found at the Khamisiyah 

ammunition depot? 

a. Sarin and Mustard agent 

b. Sarin and Soman 

c. Soman and VX 

d. Sarin, Cyclosarin, and Mustard agent 

16. Which of the following agents is likely carcinogenic? 

a. Cyclosarin 

b. Mustard agent 

c. Soman 

d. VX 

17. Which of the following is NOT considered to be a life-threatening 

symptom of chemical agents? 

a. Abdominal cramps 

b. Diarrhea 

c. Miosis 

d. Vomiting 

18. Which of the following pesticides was removed by the EPA for home use 

in June 2000 because of acute toxicity concerns? 

a. Baygon® (Propoxur) 

b. Cutters® (DEET) 

c. Dursban® (Chlorpyrifos) 

d. Vapona® (Dichlorvos) 

19. Which pesticide in excreted from the body relatively more slowly? 

a. DEET 

b. Lindane 

c. OFF® 

d. Permethrin 

88 Caring for War Wounded 
CME EXAM
 

20. Which pesticide type causes reversible inhibition of the enzyme AChE? 

a. Methyl Carbamate 

b. Organochlorine 

c. Organophosphorus 

d. Pyrethroids 

21. Which Biological Warfare Agent category has agents that have 

catastrophic potential? 

a. Category A 

b. Category B 

c. Category C 

d. Category D 

22. Which Biological Warfare Agent was used in the attacks in the 

U.S. after 9/11/01? 

a. Botulism 

b. Cutaneous Anthrax 

c. Inhalational Anthrax 

d. Smallpox 

23. How many days after an individual received 200-300 rads (2-3 grays) of 

radiation will it take to drop their white cells to a very dangerous level? 

a. 10 days 

b. 20 days 

c. 30 days 

d. 40 days 

24. What type of radioactive emissions does depleted uranium emit? 

a. Very weak Alpha 

b. Weak Alpha 

c. Strong Alpha 

d. Very strong Alpha 

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CME EXAM
 

25. A medical care provider can diagnose PTSD within ____ weeks after 

the traumatic event. 

a. 2 weeks 

b. 4 weeks 

c. 6 weeks 

d. 8 weeks 

26. Amnesia, acute confusional states, and trance are symptoms 

consistent with: 

a. Panic attacks 

b. Mixed anxiety state 

c. Dissociation 

d. Conversion 

27. What is the percentage of Gulf War I veterans who have been 

diagnosed with PTSD? 

a. 5% 

b. 10% 

c. 15% 

d. 20% 

28. Which department within the VA was created to meet the concerns of 

the veteran and their family? 

a. Community Outreach Department 

b. Mental Health Department 

c. Social Work Department 

d. Vet Center Department 

29. Without new federal legislation, eligibility for medical care will 

expire ___ year(s) after a veteran returns from a combat zone. 

a. 1 year 

b. 2 years 

c. 3 years 

d. 4 years 

90 Caring for War Wounded 
CME EXAM
 

30. Approximately how many Gulf War I veterans were serviced through the 

Persian Gulf Family Support Program? 

a. 20,000 

b. 40,000 

c. 60,000 

d. 80,000 

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