ANNEX C

EVACUATION ASSESSMENT

Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) 

16 December 2003 

Chartered by 

US Army Surgeon General 

This is an annex to the OIF MHAT Report addressing the behavioral health 

evacuation system in OIF (including Kuwait and Iraq). The findings were 

obtained from many sources to include surveys, interviews, DoDsupported databases, and “homegrown” databases. 

This report is redacted to remove unit identifications, unit locations, and personal 

identity information in accordance with Army Regulation 25-55, Department of 

the Army Freedom of Information Act Program, and Army Regulation 340-21,

The Army Privacy Program. Redacted information appears throughout this 

report blacked out, such as below. 

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TABLE OF CONTENTS

ANNEX C: EVACUATION ASSESSMENT .......................................................C-1

Introduction ...................................................................................................C-3

Findings.........................................................................................................C-3

Recommendations ........................................................................................C-8

Future Implementation ................................................................................C-10

Methods ......................................................................................................C-11

Results ........................................................................................................C-16

APPENDIX 1: Sources of Data .......................................................................C-32

APPENDIX 2: Description of Department of Defense-Supported Databases .C-34

APPENDIX 3: LRMC Chart Review Data Points............................................C-36

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ANNEX C to OIF MHAT REPORT

INTRODUCTION

The MHAT Charter and the Behavioral Health Consultants to the OTSG 

sought to answer several questions related to Army OIF evacuations: 1) Was 

there a surge in behavioral health evacuations; 2) If so, why was there a surge in 

behavioral health evacuations; 3) Do minor behavioral health disorders and 

administrative issues account for the surge in behavioral health evacuations; 4) 

How many behavioral health evacuees return to duty in OIF; and 5) Do 

behavioral health evacuees receive follow-up care after returning to home 

station? 

FINDINGS

DATA FINDING #1: There was a surge in all Army OIF evacuations during 

July 2003. This surge was seen in the evacuation rates of the five 

 leading medical-surgical specialties, to include behavioral health. 

In July 2003, the Army OIF evacuation rate per 100K Soldiers increased 1.8 

times (668 evacuees in June to 1225 in July). The top five evacuating medicalsurgical specialties demonstrated a similar rise in evacuation rates during the 

month of July. This surge was not unique to behavioral health. 

Despite this one-month surge, the proportion of behavioral health evacuations to 

all Army OIF evacuations remained relatively stable. Behavioral Health 

accounted for only 7.1% of all OIF Army medical-surgical evacuations, which was 

substantially lower than the evacuation rates of the leading medical-surgical 

specialties. 

Placed into a historical perspective, the Army OIF’s behavioral health rate fell 

within range of previous military operations (see Table 1). 

Table 1: Behavioral Health Evacuation Rates in Previous Military Operations* 

Military Operation 

Behavioral Health 

Evacuations/ All 

Evacuations** 

% 

Gulf War 215/6316 3.4% 

Somalia 22/538 4.1%

OIF 527/7415 7.1%

Afghanistan 10/119 8.4%

Kosovo/Bosnia 60/253 23.7%

* Provided by the AMEDD Center & School, Directorate of Combat 

Development and Doctrine 

** All services represented in these figures (Army, Air Force, Marines and 

Navy) 

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DATA FINDING #2: No single hypothesis adequately explained the surge in 

Army OIF evacuations during July 2003, to include behavioral health. 

Several hypotheses attempted to explain the surge in evacuations, but each 

failed to provide a satisfactory answer. 

Backlog Hypothesis: The “backlog hypothesis” suggested that the surge in 

evacuations was a result of two coinciding developments: 1) after May 2003, 

Soldiers had time to address medical issues put on hold during the combat 

phase of operations; and 2) the availability and efficiency of medical services 

improved as the OIF theater matured. The observed increase in evacuations 

during June and July and return to baseline in subsequent months supported this 

hypothesis. Additionally, this hypothesis passed the “common sense test” 

because treatment can be postponed for many medical conditions. The 

hypothesis failed to explain, however, any delay in surgical treatment for 

accidents and injuries. 

Shrinking Force Hypothesis: The “shrinking force hypothesis” suggested that 

as troop strength decreased in June and July, the remaining force was 

increasingly stressed by ongoing hostilities. Vulnerable Soldiers developed 

medical-surgical illnesses, thereby leading to an increased evacuation rate. This 

hypothesis was supported by the observed evacuation surge in July following the 

decrease in troop strength. It failed to explain, however, the continued decline in 

the evacuation rate in August and September, which also had reductions in the 

overall troop strength. 

Unknown Redeployment Date Hypothesis: The “unknown redeployment date 

hypothesis” explained that the rumors generated in the absence of a firm 

redeployment date resulted in significant emotional stress on Soldiers, resulting 

in increased medical evacuations. This hypothesis was supported by the 

observation that the evacuation rate declined after the official announcement of 

the redeployment policy in August 2003. It failed to explain, however, the 

increases in non-behavioral health evacuations, particularly in surgical 

evacuations. 

Home Front Stress Hypothesis: The “home front stress hypothesis” explained 

that the surge in behavioral health evacuations was the result of improved email 

and telephone communications with family members. Although it was true that 

communication systems became more available in June and July, this hypothesis 

failed to explain the surge in other non-behavioral health evacuations. 

Trivial Evacuation Hypothesis: The “trivial evacuation hypothesis” suggested 

that the surge in behavioral health evacuations was the result of improper 

disposition of minor behavioral health disorders. The LRMC Chart Review did 

not support this hypothesis. Over 80% of all evacuations were diagnosed with 

Adjustment Disorders, Affective Disorders and Anxiety Disorders at LRMC. 

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Compared to all behavioral health charts in this sample, less than 7% of were 

diagnosed with Personality Disorders or V Codes, or given no diagnosis at all. 

Administrative Evacuation Hypothesis: Similar to the “trivial evacuation 

hypothesis,” the “administrative evacuation hypothesis asserted that the surge in 

behavioral health evacuations was the result of command pressure to quickly 

disposition Soldiers through behavioral health, rather than administrative 

channels. The LRMC chart review did not support this hypothesis. In this 

review, MHAT did not identify any evacuations prompted for strictly 

administrative reasons. 

DATA FINDING #3: The percentage of BH patients returned to duty was 

highest among BH units deployed forward, and was lowest among 

units in the rear. 

The high percentage of behavioral health patients returned to duty from DMHS 

and CSC units advocated for the forward deployment of behavioral health units. 

In accordance with Combat Stress Control doctrine (FM 8-51 and 8-55), Division 

Mental Health Sections and Combat Stress Control units were deployed forward 

to provide early assessment and treatment interventions to Soldiers experiencing 

combat stress reactions and neuropsychiatric disorders. The principle of 

“immediacy,” or early identification and treatment, is among the four key 

principles of the military psychiatry (i.e., Proximity, Immediacy, Expectancy, and 

Simplicity). 

As a result of the high return to duty rate, both units and Soldiers benefited. 

Units benefited from continued force sustainment. Soldiers avoided the stigma 

linked to evacuation for a behavioral health illness. 

In contrast with high return to duty rates of behavioral health units in OIF, the 

LRMC chart review revealed that only 10 (3.6%) behavioral health evacuees 

were returned to duty in OIF from LRMC. Ninety-percent (90%) of these 

evacuees were treated as outpatients at LRMC. 

Reasons for a lower percentage of behavioral health patients returned to duty at 

the Combat Support Hospital and Medical Center were not clearly evident from 

this analysis. The following factors may have contributed to the low return to 

duty rates: 

First, patients who continued in the evacuation chain may have required 

hospitalization for severe conditions needing long-term treatment interventions. 

Second, the evacuation policy promoted the evacuation of patients, not their 

return to duty. For many behavioral health patients, even those with transitory 

conditions like Adjustment Disorder, treatment may require more days than 

provided for in the CJTF-7 seven-day evacuation policy. In this light, many 

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hospitals postponed treatment to the next level of care, and invested resources 

to evacuate the patient instead. For example, LRMC Behavioral Health Services 

developed a “rest stop” strategy, particularly for outpatient evacuees. The 

average outpatient behavioral health evacuee stayed at LRMC for only 5 days

(including transportation days) before flying out to the next destination in the 

evacuation chain. Outpatients received a screening behavioral health evaluation, 

but were unlikely to receive any additional behavioral health contact given the 

brevity of the stay. No deployment-specific interventions were developed for 

behavioral health evacuees, and treatment was deferred to the next military 

treatment facility in the evacuation chain. 

Third, while CJTF-7’s evacuation policy directed that evacuations occur “only 

after a good faith effort to address the issue in theater failed,” there were no 

standing operating procedures to guide clinicians how or when to consider 

returning an evacuee to duty in OIF. As a result, many evacuees continued their 

evacuation to the next military treatment facility, even though many showed 

improvement in their condition. 

In fact, several factors indicated improving behavioral health status in the 

evacuee population. First, the number of evacuees with high suicide risks 

precipitously dropped from 89 (32%) in OIF to 22 (7%) at LRMC. Second, there 

was a similar drop in the number of evacuees with elevated homicide risks from

25 (9%) in OIF to 7 (3%) at LRMC. Third, nearly one-third of OIF and LRMC 

evacuees did not require psychotropic medications, suggesting that their 

conditions could be adequately addressed through psychotherapeutic means 

only. 

Of the 4 evacuees who did not have a clinical diagnosis, only half were returned 

to duty in OIF. Of the 2 evacuees diagnosed only with a V Code, none was 

returned to duty in OIF. 

DATA FINDING #4: Over 80% of Army OIF evacuees with behavioral health 

diagnoses redeployed to Ft Stewart received follow-up for their 

conditions—most within one week after arrival. 

Although 41 (84%) of these evacuees received follow-up at WACH, it was 

concerning that 8 (16%) evacuees were lost to follow-up. Failure to closely 

monitor evacuees’ follow-up at home station unnecessarily elevated the risk for a 

bad clinical outcome. 

Adjustment Disorder was most frequently diagnosed in evacuees returned to 

duty after follow-up (33%), and in evacuees who failed to follow-up after return to 

home station (38%). 

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DATA FINDING #5: Clinical charts were inconsistently maintained, and 

documentation did not reliably accompany patients through the 

 evacuation chain. 

Procedures for documenting patient visits varied among the behavioral health 

units. Procedures fluctuated with available resources, environmental conditions, 

operational tempo, type of behavioral health unit (e.g. DMHS, CSC, or CSH), and 

unit policy. Treatment interventions were inconsistently recorded in convenience 

files. Even at LRMC, outpatient evacuee charts were disorganized and stapled, 

contained inconsistent documents, and kept in an accordion file. 

Clinical documentation did not reliably arrive at the receiving facility. Although all 

OIF behavioral health providers claimed to send clinical documentation to the 

receiving facility in the evacuation chain, only 44.8% of LRMC charts actually had 

OIF clinical documentation within the chart. Nearly 38% of reviewed charts had 

neither OIF clinical documentation, nor Patient Movement Request (TRAC2ES) 

information. In some cases, the OIF behavioral health provider relied upon the 

patient to hand-deliver his/her clinical documentation to the next echelon of care. 

Evidence showed that clinical documentation was sent to the next receiving 

facility for 93% of all evacuees leaving LRMC. 

DATA FINDING #6: No Database adequately tracked evacuees or provided 

reliable clinical information 

No DoD-supported or homegrown database system adequately tracked 

evacuations from OIF to CONUS to home station, thereby limiting usefulness in 

medical planning and patient-accountability. 

Although TRAC2ES provided the most useful system for patient tracking, it had 

many limitations. MHAT encountered considerable difficulty using TRAC2ES 

during in OIF because 1) TRAC2ES could only be reached via a SIPRNET 

connection; 2) online TRAC2ES information was “stripped” of evacuee names

and social security numbers; and 3) online TRAC2ES information only extended 

back 60 days. 

In lieu of receiving reliable clinical documentation from OIF, behavioral health 

providers have relied on TRAC2ES to make initial clinical decisions about 

incoming evacuees. For example, LRMC used the TRAC2ES in triage, deciding 

which patients needed immediate evaluation and which patients could wait until 

the next duty day. 

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RECOMMENDATIONS

 Immediate Implementation: 

Clinical Information Between Levels of Care: The flow of clinical 

documentation is essential for continuity of care. Reliance on TRAC2ES is 

insufficient for clinical information given the limitations in its design and purpose. 

As such, MHAT recommends the following processes to ensure proper flow of 

clinical documentation and information between levels of care: 

1) CJTF-7 and CFLCC surgeons should jointly establish a standard clinical 

documentation packet for behavioral health evacuations (see AR 40-66, medical 

record administration and health care documentation, 10 march 2003). 

2) Similarly, CJTF-7 and CFLCC surgeons should jointly establish standard 

procedures for transfer of this clinical documentation packet to the receiving 

military treatment facility (see AR 40-66, medical record administration and 

health care documentation, 10 March 2003). 

3) Behavioral health consultants to the CJTF-7 and CFLCC surgeons should 

develop, promote, and monitor administrative and clinical communication among 

levels of care in the evacuation chain to ensure adequate feedback and 

coordination. At a minimum, the behavioral health consultants in CJTF-7/cflcc 

and BH service/department chiefs should promote communication through the 

following methods: 

Email addresses and telephone numbers for point-of-contacts should be 

developed, maintained, and made accessible to all behavioral health providers in 

the evacuation chain. Points-of-contact should include the deployment cycle 

system (DCS) care managers, located at the final MTF destination.

• Prior the evacuee’s departure for the next level of care, the evacuating 

care provider should notify the Rear Detachment, final MTF disposition, 

and corresponding Deployment Cycle System care manager(s). 

• Receiving BH providers will provide feedback to the sending BH provider 

regarding the value, accuracy, and integrity of transported clinical 

documentation. 

4) CJTF-7 and CFLCC Surgeons should encourage behavioral health providers 

to use sanctioned clinical databases and tracking systems (DNBI, JMeWS, 

TRAC2ES) in favor of homegrown systems. 

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Tracking System: Accurate evacuation data is critical for medical planning, but 

also essential for commanders and family members who are trying to find their 

Soldiers’ whereabouts. Although TRAC2ES provides reliable tracking 

information, it is not designed for clinical information. To improve the 

transmission of clinical data, MHAT recommends the following steps: 

1) At each MTF, PAD/MRO should establish quality improvement review 

procedures to minimize errors in TRAC2ES data entry. 

2) The evacuating provider should indicate the evacuee’s DSM-IV diagnoses (in 

addition to ICD-9) to include in the TRAC2ES narrative for greater clinical clarity. 

3) To encourage utilization of TRAC2ES (and JMeWS), CJTF-7 and CFLCC 

Surgeons should improve behavioral health provider access to the SIPRNET. 

4) Prior to deployment, all behavioral health providers should establish SIPRNET 

accounts. 

5) CJTF-7 and CFLCC Surgeons should establish a procedure with TRAC2ES 

database managers at Scott AFB to allow behavioral health providers access to 

data greater than 60 days old. 

6) Behavioral Health Consultants in CJTF-7/CFLCC and BH Service/Department 

Chiefs should develop, maintain, and monitor feedback among MTFs about the 

quality, accuracy, and value of TRAC2ES information. 

Standards of Care: Evacuees, like all patients, deserve quality medical care. 

Given the transient nature of evacuees, it is particularly challenging for care 

providers to maintain routine standards of care. As such, MHAT recommends 

the establishment of the following procedures: 

1) Quality Improvement 

 Monitor the quality of evacuee charts throughout the evacuation chain 

through locally developed and regulated QI program. 

 Monitor implementation of evacuation policy through locally developed 

and regulated QI program (i.e., do the evacuees satisfy the evacuation 

policy requirements). 

 Jointly develop CJTF-7 and CFLCC policy on escort utilization and 

responsibilities, and monitor through QI program. 

2) Improve RTD by emphasizing treatment for evacuees 

 Implement a BH reconditioning program for CJTF-7 BH evacuees with 

Adjustment Disorder and/or Combat Stress Reactions;

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 Implement treatment initiatives at MTFs for evacuated outpatients, 

particularly for Soldiers with Adjustment Disorder, with the intent to return 

Soldiers to full duty; 

 Develop SOPs for all Medical Centers in the evacuation chain to govern 

behavioral health evacuee evaluation, treatment, disposition, and 

accountability processes. 

3) Promote treatment initiatives by extending the Evacuation Policy for behavioral 

health patients 

 Extend CJTF-7 Evacuation Policy from 7 days to 14 days for Soldiers with 

Adjustment Disorders or Combat Stress Reactions; 

 Consider full use of available days in evacuation policy to treat evacuees 

with Adjustment Disorder or Combat Stress Reactions.

FUTURE IMPLEMENTATION

Tracking Systems: To best oversee the movement of patients throughout the 

evacuation chain and to identify emerging evacuation trends, an automated 

evacuation tracking system must be developed. 

1) MEDCOM should establish a joint process action committee to work on an 

evacuation database system capable of clinical, tracking, and analytical 

functions. It must be readily available, secure and tailored to the needs of line

commanders, medical personnel, medical regulating planners, and medical 

planners. 

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METHODS

To answer these questions, the MHAT examined Department of Defensesupported databases, examined “homegrown” evacuation tracking databases of 

behavioral health units, conducted surveys and interviews of OIF and LRMC 

behavioral health providers, and reviewed OIF Army behavioral health evacuee 

charts at LRMC and Ft. Stewart. In addition, the MHAT examined the command 

and control, communication system, resource support, and policies governing 

behavioral health evacuations from OIF. 

I. Evacuation Tracking Systems

Source of Data: MHAT evaluated four major patient care/evacuation databases 

designed and maintained by DoD agencies: TRAC2ES, PARRTS, JMeWS, and 

the evacuation database used by the OTSG. MHAT chose to rely on the OTSG

Evacuation database, which combined information from other DoD databases: 

TRAC2ES, PARRTS, and MODS. For the purposes of calculating the 

evacuation rate, MHAT did not use “homegrown” databases because they were 

inconsistently maintained and contained errors (e.g., misspelled names, incorrect 

dates, and missing diagnoses). A list of all databases examined can be found in 

Appendix A; further description of all DoD-sponsored databases can be found in 

the Appendix B. 

Inclusion Criteria for OIF Army Evacuations: To prepare the OTSG 

Evacuation database for analysis, MHAT subjected all entries to specific 

inclusion criteria. To be included in the OIF Army Evacuation database, entries 

had to satisfy the following inclusion criteria: 1) must have Army as the branch 

designator; 2) must have Iraq as the operational event designator; and 3) must 

have a date between 1 Mar –30 Sep as the date designator. MHAT used 

PARRTS to fill in blank service branch, operational event, or date entries, and 

eliminated any updated entries that did not satisfy the inclusion criteria. 

Remaining blank entries were assumed to fulfill the inclusion criteria. The final 

database contained all OIF Army Evacuations from 1 March to 30 Sep 2003. 

Inclusion Criteria for Behavioral Health Evacuations: To prepare the OIF 

Army Evacuee database for behavioral health evacuation analysis, MHAT 

subjected all entries to inclusion criteria. To be included in the OIF Army 

Behavioral Health Evacuee database, all entries must have satisfied either of the 

following inclusion criteria: 1) must have Psychiatry as the medical-surgical 

specialty designator; or 2) must have a history highlighting behavioral health 

reasons for evacuation (e.g., intentionally self-inflicted wounds, overdose, or 

psychiatric diagnosis). MHAT team members reviewed the histories of those 

entries without a psychiatry medical-surgical designator for inclusion in the 

database. MHAT reviewed all entries with a Psychiatry designator, and included 

only those with a history consistent with a behavioral health condition. The final 

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database contained all Army OIF Behavioral Health Evacuees between 1 Mar 

and 30 Sep 03. 

Evacuation Rate per 100,000 Soldiers: To determine the evacuation rate per 

100,000 Soldiers, the number of evacuations was divided by the average force 

population in OIF from 1 Mar – 30 Sep 03, and then multiplied by 100,000. 

To determine the evacuation rate per 100,000 Soldiers by month, evacuations

with known dates were sorted by month, divided by the force population during 

that respective month, and then multiplied by 100,000. The total number of 

evacuations with known dates was 82% (the top five evacuating medical-surgical 

specialties ranged from 79-86%). This resulting rate was the unadjusted

evacuation rate per 100,000 Soldiers per month. 

To correct for the missing evacuations, it was assumed that the evacuations with 

unknown dates were proportionally distributed among those with known dates. 

To make the correction, every unadjusted evacuation rate per 100,000 Soldiers

per month was then divided by its corresponding percent value of known dates. 

The resulting higher rate was the evacuation rate per 100,000 Soldiers per 

month. 

Because evacuees were not systematically given a Reserve Component or 

Active Component designation in TRAC2ES, it was not possible to compare the 

rates of these two groups. 

II. Evacuee Chart Review

 

Source of Data: MHAT used TRAC2ES to identify Army behavioral health 

evacuees who were transferred from OIF to LRMC. To that list, MHAT reviewed 

the LRMC Behavioral Health homegrown database, and added other Army OIF 

medical-surgical evacuees who sought behavioral health care at LRMC. All of 

these behavioral health charts, both inpatient and outpatient, were requested by 

the MHAT for review. MHAT personnel reviewed the charts for information 

considered relevant to Army OIF behavioral health evacuations, and entered this 

information into a Microsoft Access file. The list of data points collected in this 

chart review appears in the Appendix C. 

Method of Analysis: Analysis of the LRMC Chart Review database utilized 

tools in Microsoft Access and Excel. Sorting results were compared to the total 

number of database entries for the purpose of generating a ratio or percent 

value. 

III. Workload Tracking Systems 

Source of Data: MHAT reviewed several DoD-supported databases and 

homegrown databases for the purpose of calculating the percentage of 

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behavioral health patients returned to duty. No single workload collection system 

was in place at the beginning of hostilities. Units initially reported workload data 

using either the MEDCOM-supported Disease and Non-Battle Injury (DNBI) 

report, or the experimental Combat/Operational Stress Control Workload and 

Reporting System (COSC-WARS). Many behavioral health units relied on 

“homegrown” databases for closer workload and patient tracking. 

On 10 Jul 03, the CJTF-7 Surgeon ordered that all units use the new JMeWS 

system for reporting workload and patient-specific data. As of Oct 03, however, 

OTSG reported that there is less than 50% participation in JMeWS by OIF units 

due to rapid implementation and minimal user training. As such, MHAT relied on 

other tracking systems for return to duty calculations. 

The DNBI reporting system was widely used by Division Mental Health. Unlike 

the COSC-WARS system, DNBI reports are mandatory, familiar, and well 

integrated into the Army medical system. To improve its value in CJTF-7 medical 

planning, the two behavioral health lines of the DNBI were expanded to nine (see 

Table 2). MHAT utilized the 101st ABN 9-line DNBI reports and evacuation 

records to calculate the percentage of behavioral health patients returned to duty. 

Table 2: 9-Line Disease and Non-Battle Injury Report

Line Description 

1 CSC Casualty, New* 

2 CSC Casualty, Follow-up* 

3 Psychiatry Patient, New* 

4 Psychiatry Patient, Follow-up* 

5 Critical Incident Stress Debriefing 

6 Non-Mission Capable Casualty 

7 Hold Status Casualty

8 Suicidal Patient

9 Homicidal Patient

 * From unmodified DNBI 

The COSC-WARS system was a new workload tracking system specifically 

developed to capture combat stress control interventions on the battlefield. 

Although Combat Stress Control units reported workload information by COSCWARS, implementation proved difficult because users did not receive formal 

training in data entry, and few had access to the 32-page COSC-WARS 

instruction manual. Despite these difficulties, COSC-WARS provided sufficient 

information to calculate the percentage of behavioral health patients returned to 

duty for CJTF-7 Combat Stress Control units. 

To compare with results from DMHS and CSC units, MHAT analyzed the 

homegrown databases of two Combat Support Hospitals: -------- l --------- 

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Kuwait), and ------- ---------, Iraq). Both databases contained patient contact 

information and evacuation records. 

Inclusion Criteria: Prior to calculating the return to duty ratio, the entries of 

each workload database was assessed by the following inclusion criteria: 1) all 

entries were Army, Army National Guard, or Army Reserve components; and 2) 

all entries were diagnosed with or had histories compatible with a behavioral 

health disorder. Entries that had no information regarding component or 

behavioral health condition were assumed to satisfy the inclusion criteria. 

Calculation of the Rate: The rate of behavioral health patients returned to duty 

was calculated by dividing the number of patients returned to duty by the total

number of patients evaluated during the same time period. When the number of 

patients returned to duty was not readily available, it was calculated by 

subtracting the number of patients evacuated from the total number of patients 

evaluated during the same time period. 

III. Behavioral Health Surveys and Interviews

Instrument Development: MHAT developed survey and interview instruments 

to test the hypotheses established in the charter. Questions focused on 

Command and Control of MH units and sections, communication among MH 

units and sections throughout the echelons of care, resources necessary to 

support evacuation of Soldiers, and evacuation polices. 

The following questions appeared in the Behavioral Health Provider Survey: 

 What has been the monthly return to duty rate for Soldiers seen by your 

behavioral health team? 

 Please rank order the most frequent reasons that your patients are 

evacuated to higher levels of care. 

 There has been sufficient holding capability for behavioral health patients 

in my area of operations? 

 Patient transport among levels of care in my area of operations has been 

adequate? 

 Supervision and support from higher levels of care has been adequate? 

 Many of the Soldiers who we evacuated should not have been deployed 

due to prior mental health or other problems? 

The Behavioral Health Provider Interview posed this question: 

 Is your clinical documentation: electronic/paper/none; and is it stored with 

you/stays with Soldier? 

Survey Method: Units selected for the survey were Division Mental Health 

Sections, Combat Support Hospitals, Combat Stress Control Medical 

Detachments and Companies, and Area Medical Support Battalions. Behavioral 

Health Officers, Mental Health NCOs, Mental Health Specialists, and 

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Occupational Therapy Technicians were selected to participate in the survey. 

Surveys required approximately 45 minutes to complete. A non-attributional 

environment was provided for participants. Surveys were collected by MHAT 

personnel and later entered into a database for analysis. No error analysis was 

conducted to assess mistakes made during data entry. 

Interview Method: Units selected for the survey were Division Mental Health 

Sections, Combat Support Hospitals, Combat Stress Control Medical 

Detachments and Companies, and Area Medical Support Battalions. Behavioral 

Health Officers, Mental Health NCOs, Mental Health Specialists, and 

Occupational Therapy Technicians were selected to participate in the interviews. 

Interviews were conducted in small groups, comprised of 3-5 personnel. 

Whenever possible, officers and enlisted groups were interviewed separately. 

Interviews were conducted by 1-2 MHAT personnel, and required approximately 

1 to 11⁄2 hours to complete. A non-attributional environment was provided for the 

interview participants. MHAT personnel took interview notes during the session,

and later entered these notes into a database for analysis. No error analysis was 

conducted for to assess mistakes made during data entry. 

Analysis of Surveys and Interviews: Analysis of the surveys and interview 

database utilized tool in Microsoft Access. Results were compared to the raw 

number of database entries for the purpose of generating a ratio or percent 

value. 

IV. Ft Stewart Behavioral Health Evacuee Follow-up: 

Source of Data: MHAT sought to determine the proportion of Army OIF 

behavioral health evacuees who followed-up for treatment after return to Ft 

Stewart. 

To accomplish this, Army OIF evacuees were identified from two Patient 

Administration Division databases at Winn Army Hospital Center. MHAT entered 

the names of evacuees with behavioral health diagnoses into a Microsoft Access 

database, and then reviewed their clinical appointments in PARRTS. Arrival 

dates at Ft Stewart, diagnoses, and subsequent behavioral health appointment 

dates were added to this Microsoft Access database. For the purpose of this 

analysis, all Substance Abuse, Family Advocacy Program, Social Work, 

Psychology, Psychiatry and Mental Health entries were considered behavioral 

health appointments. MHAT contacted the WACH Behavioral Health Services to 

identify which patients were still in treatment, had completed treatment, and had 

received administrative separations or medical evaluation boards. 

Method of Analysis: Analysis of this database utilized tools in Microsoft Access 

and Excel. Sorting results were compared to the total number of database 

entries for the purpose of generating a ratio or percent value. 

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RESULTS

I. Evacuation Tracking Systems: 

Total Army OIF Evacuations: The Army OIF Evacuee database contained 

entries for 7,415 Soldiers evacuated from OIF from 1 March to 30 Sep 03 (214 

days; 7 months). On the average, 35 evacuees were evacuated per day, and 

1,059 evacuees were evacuated per month. 

Chart 1 shows the number of evacuations by month. The spike in July’s 

evacuations (a 1.6x increase from June) subsided in following months. 

Chart 1

Army OIF Evacuees by Month

N=6053 (known evac dates)

59

603 749

964

1585

1247

846

0

200

400

600

800

1000

1200

1400

1600

1800

March April May June July August September

Behavioral Health Evacuations: Analysis of the Army OIF Evacuee database 

showed that 527 Soldiers were evacuated from OIF for behavioral health reasons 

from 1 March to 30 September 2003. 

Of this total, 513 Soldiers were designated as psychiatry evacuations (i.e., 

entries with the psychiatry medical-surgical specialty designator). Of the 513 

psychiatry evacuations, 11 were eliminated because their histories were not 

consistent with a behavioral health issue. Review of the history fields from other 

medical-surgical specialty evacuations revealed that 25 entries were related to 

behavioral health issues (see Table 2); these entries were included in the final 

dataset, bringing the total number of entries to 527. 

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Table 2: Behavioral Health Evacuees Given A Non-Psychiatric Designator 

Medical-Surgical 

Specialty

Behavioral Health Issue Number of 

Evacuations 

Intentionally Self-Inflicted 

Gunshot Wound 

5 

General Surgery 

Depressive Disorder 1 

Overdose 4 Internal Medicine Sleepwalking Disorder 1 

Orthopedics Intentionally Self-Inflicted 

Gunshot Wound 

5 

Neurology Various psychiatric disorders 5 

Pulmonary Manic Episode 1

Obstetrics Overdose 1

Gastrointestinal Overdose 1 

Thoracic Intentionally Self-Inflicted 

Gunshot Wound 

1 

Total 25 

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Based on 527 behavioral health evacuations, on the average, 2.5 behavioral 

health evacuees were evacuated per day, and 75 behavioral health evacuees 

were evacuated per month (see Table 3 for all medical-surgical specialty 

evacuations). 

Table 3: All Medical-Surgical Specialty Evacuations

Medical-Surgical 

Specialty

Total 

Evacuees 

Ave. Daily

Evacuations 

Ave. Monthly

Evacuations 

Orthopedic 2,007 9.4 288

General Surgery 1,049 4.9 150 

Psychiatry (Behavioral 

Health)

513 (527) 2.4 (2.5) 73 (75)

Neurology 490 2.3 70

Neurosurgery 346 1.6 49

Gynecology 304 1.4 43

Cardiac 298 1.4 43

Urology 276 1.3 39

Internal Medicine 269 1.3 38 

Pulmonary 252 1.2 36

Gastrointestinal 239 1.1 34

Ear Nose Throat 214 1 31 

Dermatology 191 .89 27

Ophthalmology 171 .80 24

Obstetrics 116 .54 17

Oncology 97 .45 14

Burn Surgery 89 .42 13 

Infectious Disease 69 .32 9 

Metabolic 68 .32 9

Renal 58 .27 8

Endocrine 51 .24 7

Podiatry 44 .21 6

Dental 41 .19 6

Rheumatology 35 .16 5

Audiology 31 .14 4

Oral Surgery 28 .13 4 

Hematology 19 .09 3

Maxofacial Surgery 14 .07 2 

Thoracic 7 .03 1

Vascular Surgery 6 .03 1 

Unknown 23 .1 3

C-18
 

Chart 2 shows a spike in evacuations during July 2003 for the top three 

evacuating medical-surgical specialties. The chart only includes evacuations 

with known evacuation dates (80-83% of entries).

Chart 2

Monthly Evacuations

N=2910 (known dates)

7

42 40

70

136

106

49

16

245

258

238

346

273

233

19

88 98

145

245

156

100

0

50

100

150

200

250

300

350

400

March April May June July August September

Month

Number of Evacuees

Behavioral Health (83% dates known)

Orthopedics (80% of dates known)

General Surgery (81% of dates known)

Relative Evacuations: On average, behavioral health represented 7.1% of all 

Army OIF evacuations. Table 4 shows the average percentages of the top five 

evacuating medical-surgical specialties to all Army OIF evacuations.

Table 4: % of Medical-Surgical Specialty Evacuations/All Evacuations 

Medical-Surgical Specialty % 

Orthopedics 27.1

General Surgery 14.1 

Behavioral Health 7.1 

Neurology 6.7

Neurosurgery 4.3

C-19
 

Chart 3 shows that proportion of behavioral health evacuations to all Army OIF 

evacuations has remained relatively stable. 

Chart 3

Monthly Ratio of Medical-Surgical Specialty Evacuations 

to All Army OIF Evacuations

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

March April May June July August

Month

% of Evacuations/

All Arm

y OIF Evacuations

Orthopedics

General Surgery

Behavioral Health

Evacuation Rates per 100K Soldiers: The Army OIF evacuation rate per 

100,000 Soldiers equaled 4,877 evacuations per 100K Soldiers (7415 

evacuees/152,030 average Soldier number x 100K). Chart 4 shows the Army 

OIF evacuation rate per 100K Soldiers. 

C-20
 

Chart 4

Army OIF Evacuation Rate (Evacuees per 100k)

76

452 506

668

1225

1057

717

0

200

400

600

800

1000

1200

1400

March April May June July August September

Month

Evacuees per 100K Soldiers 

Chart 5 shows the evacuation rates per 100K Soldiers for the top five evacuating 

medical-surgical specialties, and the total Army OIF troop strength from 1 March 

to 30 Sep 2003. 

C-21
 

Chart 5

OIF Troop Strength by Month and Evacuation Rates per 

100K per Month

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

March

April

May

June

July

August

September

Month

Number of Soldiers

0

200

400

600

800

1000

1200

1400

Evacuations per 100K Soldiers

Troop Strength

Army OIF Rate per 100k

Behavioral Health Rate per 100K

Orthopedic Rate per 100K

General Surgery Rate per 100K

Neurology Rate per 100K

Neurosurgery Rate per 100K

II. Evacuee Chart Review

LRMC Chart Review: According to the LRMC Evacuation database, LRMC 

evaluated 661 Army OIF evacuees for behavioral health issues from 1 March to 

30 Sep 03. This total included behavioral health evacuees and other medicalsurgical evacuees, who received behavioral health services during their stay at 

LRMC. 

LRMC provided 279 behavioral health charts for review (42% of all charts; 54 

inpatient; 212 outpatient; and 13 both in- and outpatient charts). Fourteen 

percent (14%) were charts of Soldiers evacuated out of OIF for non-behavioral 

health reasons. MHAT preferentially selected outpatient charts for review given 

that Soldiers evacuated for minor behavioral health conditions were more likely 

maintained as outpatients at LRMC. 

LRMC outpatient charts were maintained by the behavioral health outpatient 

service. Each record was comprised of various administrative and clinical 

documents – stapled together and stored in an accordion file. Chart content was 

inconsistent across the sample. 

C-22
 

Tables 5, 6, 7a, 7b, 8, and 9 summarize the demographic characteristics, 

estimated evacuation rates for Active and Reserve Components, diagnosed 

behavioral health disorders, prescribed medications, and return to duty in OIF 

rates respectively. 

The estimated BH evacuation rates for Active and Reserve Components have a 

1: 2.8 ratio (see Table 6). Data was unavailable to compare AC and RC 

evacuation rates for other medical-surgical specialties. 

Table 5: Demographics 

Category # % 

Enlisted 267 95.7%

Officer 11 3.9%

Warrant Officer 1 .4% 

Male 234 83.9%

Female 45 16.1%

Active 

Component 

161 57.7%

Reserve 

Component 

110 39.4%

Unknown 

Component 

8 2.9%

Table 6: Estimated Evacuation Rates for Active and Reserve Components 

Component 

% Of

LRMC 

Charts 

Estimated # of 

Evacuations 

(% of LRMC 

Charts x 527 BH 

Evacuations)

Average 

Monthly

Force 

Population

Rate per 100K 

Soldiers (Est. # of 

Evacuations/Force 

Population x 100K)

Active 57.7% 304 122,565 248.1

Reserve 39.4% 208 29,465 705.2

AC: RC 

Evac Rate 

Ratio 

1: 2.8 

C-23
 

TABLE 7A: Diagnosed Behavioral Health Disorders 

Category # % 

Adjustment Disorders 110 39.43% 

Affective Disorders 70 25.09% 

Anxiety Disorders 54 19.35% 

Other 14 5.02%

Personality Disorders 13 4.66% 

Psychotic Disorders 5 1.79% 

No Diagnosis 4 1.43% 

Unknown 4 1.43%

Substance Abuse Disorders 3 1.08% 

V Codes 2 0.72% 

Table 7b: Expanded List of Behavioral Health Disorders 

Diagnosis # % 

Adjustment Disorders 110 39.43%

Affective Disorders 70 25.09%

Bipolar Disorder (10) (3.58%) 

Depressive Disorder NOS (20) (7.17%) 

Dysthymic Disorder (5) (1.79%) 

Major Depressive Disorder (34) (12.19%) 

Mood Disorder NOS (1) (0.36%) 

Anxiety Disorders 54 19.35%

Acute Stress Disorder (24) (8.60%) 

Anxiety Disorder NOS (2) (0.72%) 

Generalized Anxiety 

Disorder (4) (1.43%)

OCD (1) (0.36%)

Panic Disorder (6) (2.15%) 

PTSD (17) (6.09%)

Other 14 5.02%

ADHD (2) (0.72%)

Asperger's Disorder (1) (0.36%) 

Conversion Disorder (4) (1.43%) 

Dissociative Disorder (1) (0.36%) 

Intermittent Explosive 

Disorder (2) (0.72%)

Narcolepsy (1) (0.36%)

Post Concussive Disorder (1) (0.36%) 

Presenile Dementia (1) (0.36%) 

Sleep Disorder NOS (1) (0.36%) 

C-24
 

Psychotic Disorder NOS 5 1.79%

No Diagnosis 4 1.43%

Unknown 4 1.43%

Substance Abuse 3 1.08%

V code: partner relational prob. 2 0.72%

Total 279 100.00%

Table 8: Medications Prescribed to Evacuees 

LRMC 

 Yes No Unknown # OIF % OIF

Yes 82 8 19 109 39.07%

OIF No 24 72 5 101 36.20%

Unknown 46 17 6 69 24.73%

# LRMC 152 97 30 279

% LRMC 54.48% 34.77% 10.75%

Table 9: Return to Duty in OIF Rates

Patient Status # RTD % 

Inpatient Only 1 (out of 54) 1.9% 

Outpatient Only 9 (out of 

212) 

4.2% 

Both 0 (out of 13) 0% 

Total 10 (out of 

279) 

3.6% 

Diagnosis # RTD % 

Adjustment 

Disorder 

6 (out of 

110) 

5.5% 

Dysthymic 

Disorder 

1 (out of 5) 20% 

No Diagnosis 2 (out of 4) 50% 

PTSD 1 (out of 17) 5.9% 

Table 10 shows that 31.9% of all Army behavioral health evacuees in the LRMC 

chart sample were evacuated from OIF for concerns related to elevated suicidal 

risk factors. Following evaluation at LRMC, only 7.9% of all evacuees were 

considered at elevated risk. 

Table 11 shows that 9.0% of all Army behavioral health evacuees in the LRMC 

chart sample were evacuated from OIF for concerns related to elevated 

homicidal risk factors. Following evaluation at LRMC, only 2.5% of all evacuees

were considered at elevated risk. 

C-25
 

Table 10: Suicidal Concerns Prompting Evacuation to Next Echelon of Care 

LRMC 

 Yes No Unknown # OIF % OIF

Yes 20 68 1 89 31.9%

OIF No 1 160 0 161 57.7%

Unknown 1 7 21 29 10.4%

# LRMC 22 235 22 279

% LRMC 7.9% 84.2% 7.9%

Table 11: Homicidal Concerns Prompting Evacuation to Next Echelon of Care 

LRMC 

 Yes No Unknown # OIF % OIF

Yes 5 20 0 25 9.0% 

OIF No 2 231 1 234 83.9%

Unknown 0 9 11 20 7.2% 

# LRMC 7 260 12 279

% LRMC 2.5% 93.2% 4.3%

Table 12 shows that only 44.8% of LRMC charts had clinical documentation 

accompany evacuees from OIF. The following documents were considered 

clinical documentation for the purpose of this analysis: AF Form 3899, SF 600, 

DA 3822, SF 539, and memorandum. 

Table 12: Documentation in LRMC Charts 

OIF Clinical Documentation # % 

Yes 125 44.8

No 154 55.2

LRMC Clinical Documentation Forwarded to Next Echelon of Care 

Yes 258 92.5

No 21 7.5

Patient Movement Request (or TRAC2ES)

Yes 109 39.1

No 170 60.9

OIF Clinical Documentation and TRAC2ES

Both present 64 22.9 

Neither present 105 37.6 

Return to Duty: The percentages of behavioral health patients returned to duty 

ranged from 11% to 97%, depending on the type of behavioral health unit. All 

results appear in Table 13. 

C-26
 

Table 13: Return to Duty 

Type of Unit Unit Dates 

# Of 

Patient

s 

# Of 

RTD % RTD

Division Mental 

Health Section 101 ABN 30 Mar – 6 Sep 03 495 479 97

Combat Stress 

Control units

All CJTF-7 

CSC units 

26 Jul – 27 Sep 

03 2008 1919 96

Combat 

Support 

Hospital (Iraq) 

1 Apr – 31 Jul 03 301 209 69 

Combat 

Support 

Hospital

(Kuwait) 

------------- 12 Mar – 1 Sep 

03 229 26 11

Regional 

Medical Center LRMC 1 Mar – 30 Sep 279* 10 3.6 

* # Of charts reviewed 

(b)(2) 

III. Behavioral Health Surveys and Interviews

Evacuation Policy of CFLCC and CJTF7: The CONPLAN for CJTF7 (------- 

CSC to -------- Medical Bde Conplan -------- ) addressed evacuation policy and related 

procedures. 

Battle fatigue casualties triaged as DUTY, were returned to duty to their unit. 

REST cases were sent to rest in their unit CSS unit element. REFER and HOLD 

cases (requiring observation greater than 24 hours), received CSC Restoration 

services as far forward as the tactical environment permitted. First line 

Restoration (1-3 day treatment) for battle-fatigued Soldiers was the FSMC/ASMC 

responsibility, but if workload was high, then Soldiers were to be referred for 

transport to the nearest second-line restoration center. CSC Reconditioning 

extended CSC Restoration up to 14 days of treatment in the Corps area, and 

may require an exception to Corps evacuation policy. The second line 

Reconditioning was provided by a 3rd MEDCOM Field Hospital or CSC Company 

located in the COMMZ. This was the exception as most Soldiers were sent to 

their local CSH and were often evacuated from theater by psychiatry in the CSH. 

The CJTF-7 Evacuation Policy stated that evacuations out of theater were made 

only after a good faith effort to address the issue in theater failed, or if Soldiers 

were unable to adequately contribute to the mission or were dangerous to self or 

others. The Soldier’s Rear Detachment Command was to be made aware of 

their Soldier’s circumstances and was to coordinate mental health follow-up in 

CONUS. 

C-27
 

Each behavioral health activity was directed to report their workload via the 

Combat and Operational Stress Control Workload Activity Report System to the 

----- Medical Bde who then consolidated and submitted the results to the V Corps 

Surgeon’s cell in the CREAR HQ. A part of this report provided evacuation 

statistics from each behavioral health activity. 

MHAT requested but did not receive CFLCC written reference to review their 

evacuation policy, but verbal confirmation by CFLCC staff did indicate CFLCC 

was following theater evacuation policy that was 72 hours at level II, and 7 days 

at level III. 

To initiate the medical evacuation process, the patients’ medical information was 

entered into TRAC2ES to reserve space for travel and provide the Air Force with 

the necessary information needed to transport the patient safely. Earlier in the 

deployment, some patients used commercial air, thereby bypassing the 

TRAC2ES system and making patient tracking difficult. At the time of the MHAT

visit, all patients were medically evacuated from LRMC to CONUS via the Air 

Force evacuation system. 

LRMC Evacuation Procedures: Patients arrived through the Air Force medical 

evacuation system to Ramstein AFB. They were shuttled immediately to the

Deployed Warrior Medical Management Center (DWMMC) located at LRMC 

during duty hours or to the LRMC emergency room after duty hours for medical 

screening. 

DWMMC was an operation cell established to help OIF/OEF Soldiers navigate 

through the medical system at LRMC. DWMMC staff was comprised of 

physicians, triage nurses, case managers, and patient administrators who follow 

each patient until they depart LRMC. DWMMC staff members provided physical 

exams and medical screening, assess medical needs and schedule same-day 

appointments (or next workday appointments if the patient arrived at night or on 

the weekend). DWMMC staff members were ultimately responsible for tracking 

evacuees throughout their stay at LRMC. 

Patients with psychiatric diagnoses, as identified in TRAC2ES’ narrative history, 

were screened in the psychiatry outpatient clinic during the duty day, or in the ER 

by the psychiatry staff on call during evenings and weekends. 

During the initial screening, psychiatry staff assessed the patient’s safety risks 

(i.e., suicidal and homicidal risks) and determined whether the patient would be 

maintained as an inpatient or outpatient. No standing operating procedures were 

developed. LRMC behavioral health staff reported that admission criteria for OIF 

evacuees did not differ from routine admissions. 

C-28
 

Originally outpatients were originally housed on a minimal care wing in LRMC, 

but were billeted at Klaber Caserne at the time of the MHAT visit. Outpatients 

are monitored and supervised by a DWMMC’s First Sergeant. Daily roll call and 

check-in visits at DWMMC provided evacuee accountability. Shuttle service was 

provided to and from LRMC. LRMC discouraged alcohol use by evacuees, but it 

was readily available in the local economy. 

Diagnostic and therapeutic interventions for inpatients included: a psychiatric 

evaluation, medication management, one-on-one contact with ward staff, and an 

occupational therapy evaluation. Occupational therapy provided a conditioning 

group and life skills group for inpatients each day. A psychologist, social worker 

and chaplain provided daily group therapy. Typical length of stay for inpatients 

was 5-7 days. 

Outpatient services included: a psychiatric evaluation, medication management, 

and one or two clinical visits prior to departure to CONUS. Because the typical 

length of stay for outpatients was 5 days, LRMC did not emphasize outpatient 

treatment services for evacuees. No SOPs outline criteria for determining which 

evacuees remained at LRMC for treatment, which evacuees returned to duty in

OIF, and which evacuees went to the next level of care. 

LRMC behavioral health staff members characterized their role in the evacuation 

process as analogous to a “rest stop in the desert.” Staff members believed that 

treatment and final disposition responsibilities fell to military treatment facilities at 

the major hubs or home station. No medical boards or administrative boards 

were initiated for OIF/OEF evacuees stationed in CONUS. 

Beginning in July 03, each evacuee was given a behavioral health POC with 

phone number at the next level of care. Active duty Soldiers went back to their 

home station and received their medical care at their local MTF. National Guard 

and reservists were evacuated to the medical center “hubs” (WRAMC, EAMC, 

BAMC and MAMC), which was nearest to their original mobilization site. Once 

returned to their home station, there was no system to track NG and RC evacuee 

participation in behavioral health care. 

Given logistical restraints, LRMC did not alert home units about further 

evacuation to CONUS. Instead, this notification was left to the next echelon of 

care at the home station or the MTF hub. 

Once the patient completed all medical appointments and was cleared by the 

case manager, a Air Force Form 3899 was completed by the case manager and 

was sent to the Air Evacuation clerk, who manifested the patient for a MEDEVAC 

flight to the next level of care in CONUS. The patient departed to Ramstein AFB 

for the flight via military shuttle. A psychiatric technician escort accompanied 

high-risk patients to CONUS. 

 

C-29
 

IV. Ft Stewart Behavioral Health Evacuee Follow-up 

The Winn Army Medical Center databases identified 49 Army OIF evacuees with 

behavioral health diagnoses, who were returned to Ft Stewart from 19 Mar to 8 

Oct 03. Of those evacuees, 43 (88%) were behavioral health evacuees, and 6 

(12%) were medical-surgical evacuees who had secondary behavioral health 

diagnoses. 

Of the 49 evacuees, 41 (84%) followed up with behavioral health services at 

WACH. Of the 41 evacuees, 19 (46%) were evaluated on the same day they 

arrived at WACH; 34 (83%) were seen within one week. Twenty-two percent of 

all these evacuees received only one follow-up visit; and 31 (75%) received six or 

fewer follow-up visits (range 1-25 visits; median 4). 

Table 14 shows the WACH behavioral health evacuees’ treatment status as of 1 

Nov 03. Of the 8 evacuees who failed to follow-up, 3 were diagnosed with 

Adjustment Disorder; 3 were diagnosed with Depressive Disorder Not Otherwise 

Specified; and 2 were diagnosed with Acute Stress Disorder. WACH Behavioral 

Health Services was unable to provide the current treatment status of 12 (24%) 

of the evacuees. 

Table 14: WACH BH Evacuees’ Treatment Status 

Treatment Status # % 

Chart Closed 18 37%

 RTD 9 18% 

 MEB 2 4% 

 Admin. Separation 5 10% 

 Other 2 4% 

Ongoing Treatment 11 22%

Unknown 12 24%

No Follow-up 8 16%

TOTAL 49 100%

Table 15 shows the percent of evacuees returned to duty by diagnosis and by 

follow-up at WACH. WACH records showed 9 evacuees were returned to duty 

after follow-up, and 8 failed to follow-up. For the purposes of this analysis, 

evacuees who failed to follow-up were considered “returned to duty” by default. 

Of all diagnoses, Adjustment Disorder accounted for 35% of all behavioral health 

evacuees who returned to duty with or without follow-up (6 out of 17 evacuees). 

Adjustment Disorder was diagnosed most frequently among evacuees returned 

C-30
 

to duty after follow-up (33%, 3 out of 9 evacuees), and among evacuees who 

failed to follow-up after return to home station (38%, 3 out of 8 evacuees). 

Table 15: Evacuees Returned to Duty at Ft Stewart 

Diagnosis # F/U # No F/U % RTD

Adjustment DO 3 3 35.3 

Acute Stress DO 1 1 11.8 

Depressive DO NOS 0 2 11.8 

Major Depressive DO 2 0 11.8 

PTSD 1 1 11.8

Malingering 1 0 5.9

Primary Insomnia 1 0 5.9 

V Code: Partner 

Relational Problem 0 1 5.9

TOTAL 9 8 100 

C-31
 

APPENDIX 1 (Sources of Data) to ANNEX C to OIF MHAT REPORT 

The following sources of information were utilized in this assessment: 

1. DoD-Recognized Patient Care/Evacuation Database 

a. TRAC2ES 

b. PARRTS 

c. JMeWS 

2. Force Population Numbers 

a. CJTF-7 C1 

b. CFLCC C1

3. Homegrown Patient Care/Evacuation Databases 

a. Landstuhl Regional Army Medical Center Evacuation Database 

b. Landstuhl Regional Army Medical Center Outpatient Evacuee 

Database 

c. ----- CSH Evacuation Database 

d. ----- Med Bde Evacuation Database 

e. ----- CSH (B) Evacuation Database 

f. ----- CSC Med Det Evacuation Database 

g. WACH PAD databases 

(b)(2)

4. Other Patient Care/Evacuation Data Sources 

a. ------- CSC Med Det COSC-WARS evacuation roll-up 

5. Patient Records 

a. Landstuhl Regional Army Medical Center In-Patient and Outpatient 

Records 

6. Historical and Scholarly References 

a. FM 8-51 

b. AMEDD Journal 

c. DSM-IV 

d. ICD-9 

e. Behavioral health evacuation rates in other military operations 

(Directorate of Combat Development and Doctrine) 

7. CJTF-7 Interviews 

a. Theater Surgeon 

b. Med Bde behavioral health Clinical Ops (G3) 

c. CSC Med Det behavioral health personnel 

d. CSC Co behavioral health personnel 

e. CSC Med Det behavioral health personnel 

f. CSH behavioral health personnel 

g. ) CSH behavioral health personnel 

(b)(2

(b)(2) 

C-32
 

h. 101st AA DMHS behavioral health personnel 

i. 4 ID DMHS behavioral health personnel 

j. 1 AD DMHS behavioral health personnel 

k. MRO ------- Med Bde 

l. C1 

8. CFLCC Interviews 

a. Theater Surgeon 

b. Clinical Ops (G3) 

c. ------- CSH behavioral health personnel 

d. ------- ASMB behavioral health personnel 

e. ------- 

f. ------- CSH behavioral health personnel 

9. Landstuhl Regional Medical Center 

a. Behavioral health personnel 

b. PAD 

c. DWMMC Case Managers 

10. The following resources were requested, but were not available at the time 

this document was written: 

a. CJTF-7 Casualty Estimates 

b. CFLCC Casualty Estimates 

c. Deployed Warriors Medical Management Center (DWMMC) SOPs

d. Landstuhl Regional Army Mental Center SOPs 

e. Landstuhl Regional Army Medical Center In-patient records 

C-33
 

APPENDIX 2 (Description of Department of Defense-Supported Databases) 

to ANNEX C to OIF MHAT REPORT 

JOINT MEDICAL WORKSTATION (JMeWS) 

The Joint Medical Workstation (JMeWS) is one of the latest technological 

advances employed during Operation Iraqi Freedom (OIF). It allows 

commanders and medical planners to monitor the physical well being of their 

service members and medical treatment facilities (MTF) capabilities. The 

information collected can also be used to look for health trends and data 

analysis. Several organizations in conjunction with the Deployment Health 

Support Directorate, worked together and created JMeWS to meet the need of a 

system that could compute and analyze information from the military service’s 

medical surveillance tools already in place. JMeWS provides a real-time medical 

snapshot of what is going on in a specific theater or operation down to the unit or 

joint task force level. Data analysis tools then use the data derived from the 

patients records and disease and non-battle injury reports to determine and alert 

for spikes in specific areas. The Web-Based workstation has been functional 

since January 2003 and is currently being used by the United States Central 

Command (CENTCOM). 

Transportation Command Regulating Command and Control Evacuation 

System (TRAC2ES) 

Transportation Command Regulating Command and Control Evacuation System 

(TRAC2ES) IS A Web tool that tracks and manages casualty evacuations and 

patient movement. The present system was deployed nearly two years ago to 

monitor the movement of causalities out of a combat zone. The Transportation 

Command took over the responsibility for TRAC2Es IN 1993, the casualtyevacuation management software was developed in response to widespread 

complaints following the 1991 Persian Gulf War that it was difficult to track and 

locate wounded service members being treated at military care centers and 

hospitals. Typical scenarios for the applicability for TRAC2ES, commanders on 

the ground determine that causalities need to be evacuated and transported to a 

medical facility. The command will contact the so-called “patient movement 

requirement center,” a facility set up to support a specific conflict. The center in 

turn will request the aircraft and crews to transport those patients. 

C-34
 

Patient Accounting & Reporting Real-time Tracking Data Record (PARRTS) 

The purpose of the Patient Accounting & Reporting Realtime Tracking Data 

Record (PARRTS) is to report special interest patients as required by MEDCOM 

Regulation 40-7, Reporting of Special Interest Personnel. It is an interactive 

web-based data entry system used by Army Medical Treatment Facilities and 

deployed medical assets. Manually data inputted via the PASBA Restricted Wed 

Site. Users of the PARRTS are senior staff members of the OTSG and 

MEDCOM, patient administration personnel at MTF’s, and PASBA Input Sections 

are PARRTS clients. 

Medical Occupational Data System (MODS) 

Medical Occupational Data System (MODS) is a database that helps personnel 

managers, special pay clerks, PROFIS managers; manpower managers and 

medical readiness managers make operational data simpler. MODS provide 

AMEDD human resource and SRP site managers with a responsive and reliable 

information management data system for all categories of military and DA civilian 

medical support personnel. The data that is the basis for MODS is pulled from 

18 different major Army and Department of Defense databases. 

C-35
 

C-36 

APPENDIX 3 (LRMC Chart Review Data Points) to ANNEX C to OIF MHAT 

REPORT 

MHAT reviewed LRMC behavioral health charts for the following data. MHAT 

team members entered this information into a Microsoft Access database. No 

data entry error analysis was performed. The following list contains the specific 

data points in this review: 

 

1. Name 

2. Social Security Number 

3. Inpatient and/or outpatient status at LRMC 

4. Number of non-behavioral health OIF Army evacuees who were referred 

to Behavioral Health while at LRMC 

5. Presence or absence of clinical documentation (originating in OIF) in 

LRMC chart 

6. Type of form used for clinical documentation (originating in OIF) on the 

LRMC chart 

7. Presence or absence of TRAC2ES documentation on LRMC chart 

8. Presence or absence of suicidal concerns in OIF 

9. Presence or absence of suicidal concerns in LRMC 

10. Presence or absence of homicidal concerns in OIF 

11. Presence or absence of homicidal concerns at LRMC 

12. MEBs initiated by LRMC BH 

13. Administrative Separations initiated by LRMC BH 

14. Discharge diagnosis at LRMC 

15. Presence or absence of post-discharge treatment plan 

16. Disposition (e.g., evacuation to another MTF, Return to Duty in CONUS, 

or Return to Duty in OIF) 

Evacuation rates were derived from the Total Army OIF Evacuee and Total Army 

OIF Behavioral Health Evacuee databases. The average monthly rate equaled 

the number of database entries divided by the number of months (covered by the 

database). The average daily rates equaled the number of entries divided by 

number of days (214 days in the database). The evacuee per deployed force 

rate equaled the number of entries divided by the average number of deployed 

Soldiers. The relative behavioral health to total medical evacuation rate equaled 

the Total Army OIF Behavioral Health Evacuees by the Total Army OIF 

Evacuees.