C. Gulf War Practice

Forms were inconsistent; not every unit used the same forms. There was little storage, and no consistency as to who kept the records. She rarely saw an individual medical record. Sometimes she had abbreviated or abstracted parts of individual medical records…. she would have liked information on allergies, medications, past medical and surgical histories, current complaints, and vital signs.  -interview with a MASH nurse[41]

Medical recordkeeping during the Gulf War was accomplished during a rapid, large-scale, and diverse deployment, which incorporated policy being tested for the first time or modified to meet unique situations. Major recordkeeping issues included: the adequacy of medical records during pre-deployment screening; the deployment of abbreviated medical records; the documentation of immunizations; the transfer of deployment medical information to individual health records; and access to medical records following the separation of the servicemember.

The unit had no medical records with them. Had to write everything down on a standard form, in place of medical records. The information was given to the unit’s records people….  -interview with a clearing company physician[42]

Content of the record: Lessons-learned and after-action reports confirmed that personnel were mobilized and deployed with significant medical problems. Some reports cited insufficient time for medical personnel to thoroughly screen records as one possible cause, while others commented on the lax physical profiling procedures and the poorly documented medical records that made it difficult for physicians to decide about the "deployability" of reserve servicemembers during the initial screen.[43] The absence of permanent or temporary profiles and missing or outdated physical examinations were specifically noted, raising issues about the connection between the military medical and personnel systems.[44] Dental care documentation—particularly disqualifying dental conditions for recalled reservists—was sometimes missing;[45] documentation of HIV testing was also scarce.[46] A Marine reserve battalion reported on pre-deployment delays caused by time needed to obtain and update the unit’s medical records with information on physical and dental examinations and immunizations.[47]

I’m not sure, but I think the original records were kept stateside, and partial copies were available at the point of care.  -interview with a medical company first sergeant[48]

At least one Air Force unit reported confusion over the policy on individual health records accompanying deployed personnel. (In January 1991 the policy was changed so that an AF 1480, Summary of Care, would accompany the servicemember and the medical record would remain at the permanent duty station.) Confusion arose in this unit because message traffic initially reported a change in policy, then indicated a decision would be forthcoming, then announced the final policy change.[49]

… there were no standard forms available for patient administration. All the records that were used were usually a single piece of blank paper with handwritten notes. Whatever remained of these temporary/informal records were boxed up in Saudi Arabia prior to her return. She has no idea what happened to them.   -interview with a MASH patient administrator[50]

There also appeared to be some confusion about the location and use of the abbreviated health records. Staff from the Office of the Special Assistant contacted medical personnel with Gulf War experience (including healthcare providers and support personnel, largely from the Army and the Air Force) regarding a variety of issues. Approximately 80 individuals of the nearly 200 contacted were able to provide some useful information about medical recordkeeping during this deployment. Medical personnel recalled that full individual health records often accompanied deployed servicemembers. In the absence of full records, abbreviated records were sometimes available. At other times neither full individual medical records nor abbreviated records were available. Medical personnel commented that they would have liked to have essential information—about allergies, medications, and medical problems—at the time of examination and treatment.

To his knowledge, no records ever had any documentation about PB or Cipro.  -related by a hospital corpsman[51]

Documentation of anthrax and botulinum toxoid immunizations was irregular, perhaps owing to the need for operational security in the administration of both vaccines, and to the uncertain guidance regarding the documentation of the investigational vaccine (botulinum toxoid). For pyridostigmine bromide (PB), also an investigational product, the problem was magnified by the wide-scale distribution of this self-administered drug. Of the estimated 250,000 servicemembers who took PB,[52] there appear to be few examples of documentation in either individual health records or unit records, making it difficult to assess any potential contribution of this drug to the currently unexplained post-conflict illnesses.[53]

There was a tendency not to record minor problems, but major sicknesses were documented fully. No abbreviated or abstracted parts [of medical records] were available, but since all of her patients were conscious, it was not a problem.  -interview with an evacuation hospital nurse[54]

Consolidation of the record: The Presidential Advisory Committee on Gulf War Veterans’ Illnesses (PAC) noted that interactions between deployed forces and medical care providers were recorded (in a paper-based system), but that much of this information was not incorporated in servicemembers' permanent health records. The PAC further commented that this breakdown was particularly common for the recording of immunizations.[55] The General Accounting Office echoed the PAC’s concerns about problems with medical recordkeeping,[56] while a study by the Institute of Medicine cited the lack of uniform and retrievable medical information as greatly inhibiting systematic analysis of the health effects of Gulf War mobilization.[57]

He got a physical at the end of second Saudi tour. But it is not in his medical record. The results are supposed to be in some repository somewhere.  -related by a Fox vehicle commander [58]

An experience by staff from the Office of the Special Assistant reflects some of the above concerns. During a June 1998 visit to the VA Records Management Center in St. Louis, Missouri, staff members had the opportunity to review a small number of permanent health records of servicemembers who (according to service-generated listings) were hospitalized in deployed medical facilities during the Gulf War. Of the 28 individual health records reviewed from all services, 16 contained no reference to, or documentation of, the inpatient care received in deployed medical facilities. If this sampling is indicative, veterans could have difficulty proving they sought and received care for health problems while serving in the Gulf, and supporting their eligibility for VA benefits.

… is concerned about an immunization he received in November ’90…. He refused to take the booster because he was told that the shots he was given would not be documented in their shot records.  -related by an air search and rescue member[59]

Additional information on medical record consolidation issues came from calls by Gulf War veterans to the Office of the Special Assistant. Staff from this office searched a database of some 2100 phone calls from Gulf War veterans and found approximately 100 that mentioned some difficulty with medical records. These veterans typically voiced concerns that immunizations and other health care received during deployment had not been documented in their permanent health records. Medical personnel with Gulf War experience (See Content of the record above.) recalled that when care was documented, individual forms or blank paper were sometimes used and given directly to the servicemembers. Medical personnel could rarely provide information about when and how newly-generated medical information was joined to the abbreviated or permanent individual health records. 

These calls by veterans and conversations with medical personnel reflect the experiences and impressions of individuals and small groups, and therefore should not be generalized. Yet they do indicate some problems with the availability of medical record abstracts created specifically for use during deployments, and with the transfer of medical information—and especially immunization information—to the individual health record. Such problems may indicate confusion over policy on whether the medical record itself or an abbreviated form was to accompany deployed personnel, and on how, where, and even whether to document immunizations. Figure 4 illustrates the multiple places in which immunizations might have been recorded.

Figure 4.  Records containing immunization information (Gulf War)

There were no medical records available at the front line. Everything was started there and when the patient left, the record left with him/her.  -interview with a holding company physician[60]

Custody of the record: Transfer and storage of medical records are of interest because of subsequent difficulties arising from lost or misplaced records. In one instance, Air Force reserve personnel reported confusion over where to maintain the health records of individual mobilization augmentees (IMAs). After initially being advised to retain IMA medical and dental records at the Air Reserve Personnel Center (ARPC), the policy was changed to send the records to the medical treatment facilities at the bases where the reservists were to be mobilized. A number of these individuals, however, had their reporting bases changed en route or shortly after arrival, making it difficult to determine where the records actually ended up. Well into the demobilization process it was reported that substantial numbers of IMA health records had not been returned to the ARPC.[61]

Information was given to the individual [patient]…. it became confusing as to whether the information actually made it to the medical record.  -interview with an evacuation hospital physician[62]

Some of the Gulf War veterans who called the Office of the Special Assistant and mentioned difficulties with their medical records were concerned that documentation of health care had been altered or removed from their medical records; others were concerned that the records themselves had been lost. Without broader and deeper research that is beyond the scope of this paper, it is difficult to draw meaningful conclusions about specific incidents or estimate the magnitude of these problems.

Before leaving the Gulf, [he] recommended to his superiors that all such [admission/disposition] logs be collected at a central location in case they were needed for reference. He was told to "forget it, we want to go home."  -interview with a medical unit commander[63]

An initiative to identify and improve veterans’ access to their Gulf War inpatient records was undertaken by staff from the Office of the Special Assistant in conjunction with the National Personnel Records Center (NPRC). (See section III.E. Post-Gulf War Practice.) This initiative pointed out some of the difficulties in locating inpatient records from Gulf War deployed hospitals. For example, not all Gulf War hospitals are listed in the NPRC holdings, suggesting several possible explanations: the hospitals did not send their records to the NPRC; the records were sent to the NPRC but not identified as coming from the Gulf; the hospitals forwarded these records with patients to other (non-Gulf) medical facilities for further treatment; or perhaps the medical records were somehow combined and stored with other types of Gulf War records.

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