Operation Iraqi Freedom AAR “Lessons Learned” LTC David West, Deputy Director,

1. Operation Iraqi Freedom AAR “Lessons Learned” LTC David West, Deputy Director, Proponency Office for Preventive Medicine – San Antonio

2. Agenda 1. Background 2. Center for AMEDD Lessons Learned 3. Preventive Medicine Lessons Learned

3. 1.Background. • Program directed by BG Perugini, CG, AMEDDC&S • Goal: To capture medically related lessons learned during OIF & make them available to leaders. • - Process: Through a series of Rock Drills determine what unit leaders perceived as problems. Provide SMEs to evaluate each problem.

4. Deliverables: • Distill numerous lessons learned to a few key issues, and address “near” issues (OIF2) using existing Integrated Concept Teams. • Publish evaluated and consolidated comments from the AARs on the AMEDDC&S Lessons Learned website, an on-line system to allow convenient archival and retrieval of lessons learned and lessons observed.

5. OIF AAR Timeline • Rock Drills: • 1. 7 – 9 OCT Level 1 & 2 (Div and below) • 2. 15 – 17 OCT Level 3 (Corps) • 3. 20 – 22 OCT Level 4 (CENTCOM, CFLCC, 3d • MEDCOM) • 4. 12 – 14 NOV RC and RMC • AAR: 14 – 19 DEC. Issues identified during the Rock Drills were brought forward to the AMEDD senior leadership

6. Rock Drill Facilitators for 14 Medical Functional Areas: Dental SVCS VET SVCS Hospitalization MED C2 Communications Computers Intelligence Combat Health Log Blood MGT MEDEVAC CBT Stress Control Lab SVCS PVNT MED MED Treatment

7. FIXES TO OBSERVATIONS DOTMLPF Domains: Doctrine Organization Training Materiel Leadership Personnel Facilities

8. 2. Center for AMEDD Lessons Learned • - All OIF observations or lessons learned resulting from the • multiple rock drills held at he AMEDDC&S are available • at: http://lessonslearned.amedd.army.mil/ • - Interactive site; lessons learned, AARs, SOPs, etc from • numerous operations can be retrieved, and new • information can be added

9. Phase I/II/III OIF AAR Issue • ISSUE: Line Command emphasis for PM • DISCUSSION: A number of line units believe field sanitation is a medical responsibility and that PM units/personnel should address these issues. Many units did not deploy with DEET, mosquito nets, and other PM supplies. Many units tried to order the items right before deployment but were unsuccessful. Other units just did not plan on deploying with these items. • LESSON LEARNED: Line Commanders have not completely accepted PM as their responsibility with medical in support. • RECOMMENDATION: Obtain Army leadership support that PM is everyone soldiers’ responsibility, especially that of the Commander. Educate CDRs that if the investment is not made at the front end, the workload in theater to address PM crises will be significant; ounce of preventive is worth a pound of cure. • DOTMLPF IMPLICATIONS: DTL • RESPONSIBLE AGENCY: LEAD:TSG to brief topic at Pre-Command Course and get CSA and G-3 to emphasize at Pre-Command Course also; + other actions; ASSIST:AMEDD C&S, Combatant Command/DIV/BDE Surgeon

10. Phase I/II/III OIF AAR Issue • ISSUE:PM personnel availability • DISCUSSION: PM personnel (enlisted/officers) were not available at the multiple base camps and divisional units which encountered sanitation and hygiene problems. Some units did not have PM support until June 03. Mosquitoes were very bad in Baghdad and flies in other areas. PM doc should not be located at MSB but at the Division Main or Rear where communications to provide PM guidance and oversight is better. • LESSON LEARNED: There was inadequate PM coverage in OIF. • RECOMMENDATION: Locate the PM doc at the Division Main or Rear to better communicate PM guidance to divisional units. Improve communications between the PM assets in theater and the customers. Get sufficient PM assets into theater and push them down to BDE level. • DOTMLPF IMPLICATIONS: DTL • RESPONSIBLE AGENCY: LEAD: Combatant Command/Division/BDE Surgeons; ASSIST: AMEDD C&S

11. Phase I OIF AAR Issue • ISSUE:Units deployed with inadequate PM supplies such as DEET, permethrin, mosquito nets, etc. • DISCUSSION:Units deployed with inadequate PM supplies because they were not stocked at the unit level and orders submitted before deployment were not filled because supplies were not available in the quantities required. • LESSON LEARNED: Units are deploying with inadequate basic PM supplies such as permethrin, mosquito nets, DEET, etc because of inadequate on hand supplies and an inadequate supply system. • RECOMMENDATION: Units need to maintain a basic load of PM supplies, and these supplies should be identified as CTA items. • DOTMLPF IMPLICATIONS: DTML • RESPONSIBLE AGENCY: LEAD: AMEDD C&S, ASSIST: OTSG/MEDCOM

12. Phase I/II/III OIF AAR Issue • ISSUE:PM supplies (i.e., DEET, Permethrin, lip balm, sunscreen, water test kit, fly bait, disinfectants, doxycycline, vaccines, etc) were not being resupplied to units • DISCUSSION:Units were not getting resupply of PM supplies despite requisition submission. Doxycycline resupply arrival cut too close to where only days of stockage remained. • LESSON LEARNED:Resupply system is broken. • RECOMMENDATION:Preposition of such supplies as well as push packages. MEDLOG needs to identify the problem areas of the resupply system and fix it. They need to be more responsive to customers. Need to identify cold chain for vaccine storage. • DOTMLPF IMPLICATIONS:DOTMLF • RESPONSIBLE AGENCY:LEAD: AMEDD C&S, ASSIST: OTSG/MEDCOM

13. Phase I/II/III OIF AAR Issue • ISSUE:PM Policies and Practices • DISCUSSION:PM policies were often confusing & contradictory; e.g. the use of doxycycline issued for malarial prophylaxis was unclear (one tablet/day was the instruction whereas the bottle instructions said two tablets/day & also stated that it should not be taken for more than 4 months). Some units took methoquine, while others took primaquine. Soldiers were issued Ciprofloxacin for anthrax prophylaxis and took it instead of doxycyline for malarial prophylaxis. • LESSON LEARNED:PM and other medical policies impacting the soldier must be clear (KISS) and minimize impact on soldier mission focus. • RECOMMENDATION:Determine the medical countermeasures absolutely required for soldiers to deal with disease threats and develop easily understood policies using risk communication and good marketing techniques. Obtain support of Surgeons. • DOTMLPF IMPLICATIONS:DTML • RESPONSIBLE AGENCY:LEAD: OTSG, AMEDD C&S, ASSIST: MEDCOM

14. Phase I/II/III OIF AAR Issue • ISSUE:Theater malarial chemoprophylaxis policy • DISCUSSION: There were conflicting guides for malarial chemoprophylaxis as to the use of doxycycline, mefloquine, or other medications. One division surgeon initiated a different chemoprophylaxis regimen compared to other units. Selection of the chemoprophylactic agent was made so close to deployment of units that it did not allow time for medical logistics to procure, pack in unit dose and field to units efficiently. There was uncertainty on the approp chemopro for aviators. • LESSON LEARNED: There was confusion in terms of the theater malarial chemoprophylaxis policy. Decision on the chemoprophylactic agent was made late burdening the medical logistics system to respond effectively. • RECOMMENDATION:Issue one clear policy for malarial chemoprophylaxis for all theater units to follow. Decision on the malarial chemoprophylactic agent(s) needs to be made early on to permit medical logistics to procure, repack and distribute efficiently. • DOTMLPF IMPLICATIONS: DTML • RESPONSIBLE AGENCY: LEAD: OTSG, ASSIST: MEDCOM

15. Phase I/II/III OIF AAR Issue • ISSUE: Wild Dogs/Animals and Rabies • DISCUSSION: Units encountered problems with wild dogs/packs, bats, and cats and the potential for soldiers to get rabies. One unit reported that one soldier with bat bite, had to send soldier to Kuwait for the vaccination series resulting in lost to unit for 4 weeks. Some soldiers feed the dogs and kept them as pets which should not be allowed. • LESSON LEARNED: The large numbers of wild dogs and other animals are potential source for rabies. • RECOMMENDATION: Remove or neutralize wild dogs and other animals which are potential rabies threat to soldiers. Don’t feed the animals and do not make pets out of them. • DOTMLPF IMPLICATIONS: DTL • RESPONSIBLE AGENCY: LEAD: AMEDD C&S, ASSIST: OTSG/MEDCOM

16. Phase I/II/III OIF AAR Issue • ISSUE:PM units have too few truck sprayer system to deal with disease vector threat • DISCUSSION:Mosquito, sand fly, and filth fly infestations were often problems. Under MRI the Ento and Sani units were combined. The OIF TPFDD requested “PM Det”. The units deployed were either Sani or MRI units which fell in on MF2K PM (Sani) APS. This resulted in insufficient numbers of truck mounted sprayers and vehicles. The issue was further compounded by a low Operational Readiness Rate for the sprayers. • LESSON LEARNED:Inadequate disease vector control during OIF in terms of truck mounted sprayers. • RECOMMENDATION:Ensure adequate truck sprayer systems are deployed to theaters with significant disease vector threats. Re-examine the medical TOE PM structure for large area ULV sprayers. Recommend 3/division supported plus 3/corps supported. May need to be part of corps responsibility. Ensure adequate vehicles are allocated for area PM support. • DOTMLPFIMPLICATIONS: DOTML • RESPONSIBLE AGENCY: LEAD: AMEDD C&S, ASSIST: OTSG/MEDCOM

17. Phase I/II/III OIF AAR Issue • ISSUE: CIF issued uniforms are not permethrin treated. • DISCUSSION:CIF issued uniforms are not permethrin treated by the manufacturer. Permethrin kits for soldier use were not universally available to all soldiers in the theater. • LESSON LEARNED: CIF issued uniforms are not permethrin treated by the manufacturer. Permethrin IDA kits are not universally available. • RECOMMENDATION:CIF issued uniforms should be permethrin treated. Permethrin IDA kits should be made readily available through the resupply system. • DOTMLPF IMPLICATIONS:DTML • RESPONSIBLE AGENCY: LEAD: AMC, Quartermaster School, ASSIST: AMEDD C&S, OTSG/MEDCOM

18. Pre-Phase I OIF AAR Issue • ISSUE:Policy on Blood Draw before using primaquine as a chemoprophylactic agent • DISCUSSION: Soldiers are not given a blood draw to identify individual with G6PD deficiency and who should not take primaquine. There were units who were directed to take primaquine as their chemoprophylactic agent. • LESSON LEARNED: Soldiers are not given a blood draw to identify individual with G6PD deficiency and who should not take primaquine. • RECOMMENDATION: Re-examine the policy on blood draw to identify individuals with G6PD deficiency and who should not take primaquine. • DOTMLPF IMPLICATIONS:DTML • RESPONSIBLE AGENCY: LEAD: OTSG, AMEDD C&S, ASSIST: MEDCOM

19. Phase I/II/III OIF AAR Issue • ISSUE:There is no central theater management of FHP assets (EAD/EAC) to effectively address theater requirements. • DISCUSSION: There were numerous PM/occupational/environmental health issues in OEF and OIF that required surveillance and mitigation. These issues were not adequately addressed at the MEDCOM level. There were many PM assets in the theater but were not under one command and control for efficient operations. Must have a Combatant Command process for addressing FHP/PM issues in theater. • LESSON LEARNED: FHP/PM effort is fragmented and not integrated to better serve the theater. • RECOMMENDATION: Develop an 06 Force Health Protection Command integrating PM and other assets to ensure FHP/PM issues in “Discussion” are addressed in a seamless, proactive manner on an area support basis; One-Stop-Shop. This is the Combatant Command process for addressing theater FHP/PM issues. • DOTMLPF IMPLICATIONS: DOTMLP • RESPONSIBLE AGENCY: LEAD: AMEDD C&S, ASSIST: MEDCOM, OTSG, POPM, CHPPM

20. Questions? Please submit all questions in triplicate through the first GO in your chain of command. All questions will be cheerfully ignored in the order received.

21. 21 Oct 03 ROCK DRILL PREVENTIVE MEDICINE OBSERVATIONS (OIF) LEVEL 4 and 5 Areas of Interest (Examples): CENTCOM, CFLCC, 3rd MEDCOM, V Corps policies affecting the following areas of PM interest and also developing standardized/uniform policies for all services. Line Command Emphasis for PM Use of DEET and Permethrin Treated Uniforms Disposal of Human Waste and Garbage Above Items Class III (…fly bait/disinfectants) Hygiene (Hand Washing) Sun Tan Lotion & Lip Balm Water Sources Availability of PM Supplies Drinking Water Discipline Soldiers Trained in PM Measures/Practices Availability of PM Personnel ChemoProphylaxis (anti-malarials/vaccinations…) Source of PM Information PM Communications Policies on PM Practices Data Base for Reporting DNBI Joint and Coalition Force PM Issues Wild Dogs and Rabies Predeployment and Post-deployment Questionnaires & DU Exposure Questionnaire Food Sources Occupational & Environmental Health Surveillance NBC Medical (Patient Decon, CP DEPMEDS, CBPS, field expedient shelter protection, protection of materiel, medical evacuation/regulating, etc) (Optional) NAME________________________ UNIT____________________________ CONTACT INFORMATION___________________________________________________ List your Preventive Medicine observations, potential fixes, and successes for OIF, Level 4/5: