Chapter 3
Full-Scale Operations
Brigadier General Andre J. Ognibene, MC, USA
COMMAND STRUCTURE
As the medical commitment in Vietnam increased, the facilities of the 8th Field Hospital in Nha Trang were strained. On 1 April 1965, the 1st Logistical Command arrived in Vietnam and the 8th Field Hospital was subordinated to it. The requirement for providing the commander of the 1st Logistical Command with advice on all aspects of nondivisional medical support was clearly too large a task for the commander of the 8th Field Hospital. Therefore, the 58th Medical Battalion was assigned to the 1st Logistical Command to perform that mission.
The medical advisory effort at field level increased dramatically with the establishment of USARV (U.S. Army, Vietnam) Headquarters on 20 July 1965. The USARV medical section assumed staff responsibility for the health service of the U.S. Army medical structure in Vietnam. The USARV surgeon was given the task of planning medical service, which would be correlated at USARV Headquarters with troop concentrations and tactical operations. In November 1965, the 43d Medical Group arrived and assumed the medical service mission for the II CTZ (Corps Tactical Zone) while the 58th Medical Battalion continued its mission in III and IV CTZ`s. I CTZ was predominantly under Marine Corps control.
With the continued medical buildup in Vietnam, The Surgeon General activated the 44th Medical Brigade for assignment to Southeast Asia. He had concluded that the medical brigade should be a major subordinate command of USARV Headquarters as were the aviation and military police brigades and the engineer command. However, despite efforts by the USARV surgeon, the brigade was assigned to the 1st Logistical Command and became responsible for medical units not organic to divisions or separate brigades. This involved coordinating activities of incoming units and supervising medical plans, operations, supply, and maintenance and professional medical and dental activities.
The 44th Medical Brigade expanded in proportion to the expansion of the military effort in Vietnam. By early 1967, more than 7,830 medical personnel operated under the unit (Neel 1973, p.17). In the ensuing years, a clearly predict able confusion of command and control, support, and operations occurred between the 44th Medical Brigade and the Professional Services Division of USARV Headquarters. The senior professional consultants were assigned to the Office of the USARV Surgeon. Therefore, their recommendations often were
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made directly to the USARV surgeon but involved units under the control of the 44th Medical Brigade. Medical officers were assigned and transferred by the USARV surgeon`s office, often without the knowledge of the 44th Medical Brigade commander. Had medical and command control activity been placed in an integrated command structure initially, duplication and confusion could have been avoided.
The functions of the Professional Services Division of the Office of the USARV Surgeon expanded rapidly as tactical operations and troop strength increased. By June 1967, the USARV surgeon was the senior medical officer and also controlled the highest level of professional talent in the Professional Services and Plans and Operations Divisions. On 10 August 1967, the 44th Medical Brigade was released from the 1st Logistical Command and assigned directly to USARV Headquarters. This unified the medical service in Vietnam, with the USARV surgeon now also becoming the commanding general of 44th Medical Brigade. He was able, therefore, to exercise full command and control responsibility as the brigade commander while retaining staff responsibilities as USARV surgeon.
The shift of the 44th Medical Brigade to USARV Headquarters did not solve all problems, however. The duplicate functions of the 44th Medical Brigade and the USARV surgeon`s office remained a major deficiency until early in 1970. With the creation of the U.S. Army Medical Command, Vietnam, more efficient medical service, including field-level medical service, could be provided throughout the country, and duplication of effort at all functional areas of command was eliminated (Neel 1973, p. 28-31). It was indeed ironic that only as the war phased down did the medical service achieve a structural organization that was functional, organized vertically, and without duplication. The consultant staff finally had been placed directly in contact with administrative and operations units.
THE CONSULTANT SYSTEM
The consultant staff grew out of a requirement to provide high quality professional advice to the USARV surgeon on all aspects of health-care delivery to the U.S. soldier in Vietnam. Dental, veterinary, preventive medicine, nursing, food service, optometry, and pharmacy consultants were among those assigned to assist in the development of plans and operations. The major professional consultant efforts were in internal medicine, neuropsychiatry, and surgery. The role of the medical consultant expanded rapidly as the number of medical units increased.
To standardize medical care of the soldier, the medical consultant visited all units providing that care. Following visits to treatment facilities, he made policy recommendations to the USARV surgeon. By 1969, medical consultants had taken direct charge of assignment and placement of internists in USARV hospitals and also provided consultant services to all organic medical units of combat organizations. The consultant channel of communications overlapped traditional administrative chains of command and extended from an area
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medical service concept into the traditional field and divisional medical service systems. Because of artificial command boundaries early in the war, the relationship of the medical consultant to internists in Vietnam was sometimes loose and informal and often unofficial. It was always a strong professional relationship, however. Thus, the consultant was able to guide medical practice, establish policy, improve effectiveness in medical care, develop communications channels, and provide information to both divisional and nondivisional units.
The Professional Services Division was headed by the deputy USARV surgeon, who served essentially as the chief of professional services for the Vietnam medical effort. This organizational structure followed traditional hospital or other civilian medical organizational arrangements. Although throughout 1967 and 1968 most consultants were assigned to both the 44th Medical Brigade and the USARV surgeon`s office, permitting command and control authority over medical activities in both jurisdictions, those in the fields of medicine, neuropsychiatry, and surgery were not dually assigned. Despite this command and control deficiency, medical consultants could still exercise a powerful influence over standards in internal medicine. Not until 1970 did the internal medicine consultant carry the weight of the U.S. Army Medical Command into his visits and recommendations. By this time, the war had begun to wind down.
A critical aspect of personnel assignment was the proper placement and utilization of specialists in internal medicine. Early planners did not realize that the requirement for care in internal medicine in USARV hospitals was equivalent to that in any hospital medical service in the United States. By 1969, control of personnel assignments allowed the medical consultant to place only fully trained B3139 (board certified) or C3139 (board qualified) internists in USARV hospitals. Before this time, D3139 (partially trained) physicians were not distinguished clearly from those fully trained, and assignments to hospitals rather than field units occasionally made a partially trained individual a consultant to one fully certified. The medical consultants maintained this assignment control until the American withdrawal. With frequent visits to hospitals and medical groups, the necessary coordination was continuous, allowing for an effective use of available internists.
The need to attach a fully trained internist to surgical hospitals and MUST (medical unit, self-contained, transportable) units was carefully assessed as the war progressed. While some surgical hospitals, such as the 27th Surgical Hospital, did accept other than wounded patients, most operated strictly in a surgical combat support role. These hospitals did not have the laboratory support to allow much more than a blood count, urinalysis, and necessary X-rays. Consequently, following initial surgery, patients were moved to an evacuation hospital or directly to Japan. Since the internist had been serving as a triage officer or surgical assistant, a position which could be filled adequately by a D3139, removal of fully trained internists from these hospitals began in 1968 and was complete by 1969. This allowed concentration of 52 internists in 13 hospitals with improvement in the quality of care as well as the development of subspecialty expertise in designated centers. These refinements dictated even finer control of assignments by the medical consultant to maintain the center
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designations. The subspecialty designations of internists in 1970, by hospital, were as follows:*
3d Field (Saigon)- hemodialysis; coronary care unit; gastrointestinal endoscopy; hematology; pulmonary function laboratory; dermatology
93d Evacuation (Long Binh)-neurology(EEG);snake bite center; endocrinology 24thEvacuation (Long Binh)-peritoneal dialysis; dermatology
95th Evacuation (Da Nang)-angiography; cardiology; dermatology; snake bite center
8th Field (Nha Trang)-neurology(EEG); gastroenterology
The subspecialty assignments placed expert personnel in a position to use their medical skills for those patients who required them. Unfortunately, despite an obvious need, no one assigned to Vietnam in a patient-care capacity had any background in the subspecialty of infectious disease. It was in this area that the greatest need, and the most serious deficiency in assignment, existed. By 1969, an internist was attached to the 9th Medical Laboratory as a liaison in infectious disease, and a specific effort was made to improve the capability of diagnosing FUO (fever of undertermined origin). While significant research continued, the actual clinical education of the internist in infectious disease was accomplished by self-instruction and the timeless methods of trial and error and experience.
* Lt. Col. T. A. Verdon, Jr., MC, USARV Medical Consultant, Nov. 1969-July 1970: Personal communication.
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The assignment of pediatricians to Vietnam was prompted by the establishment of the CWCP (Civilian War Casualty Program). MACV (Military Assistance Command, Vietnam) Directive Number 40-14 (MACV-66, sec. 3a) stated: "Vietnamese civilians injured by an instrumentality of the Armed Forces of the United States are authorized complete emergency care, including hospitalization when necessary. Care is authorized to be continued until the patient`s condition is stabilized sufficiently to permit discharge or transfer to a civilian hospital, or to a civilian facility for convalescence." The U.S. Army was thus directed to develop a program of care for civilian casualties, estimated at 50,000 yearly (fig. 21) (Neel 1973, p. 166). In 1967, a temporary allocation of 300 beds in USARV hospitals was made for this purpose. Three Army hospitals, with a bed capacity of 1,100, were then designated for the care of Vietnamese civilians.
By 1968, all USARV hospitals accepted Vietnamese civilians on a space-available basis. Pediatricians initially were assigned to these facilities, but pediatric care never developed beyond a small effort for a limited number of patients (fig. 22). Before the assignment of pediatricians to hospitals, care had been provided by an internist-surgeon team and, when available, a general medical officer with some pediatric training. At the peak of assignment in 1969, six pediatricians were assigned to USARV hospitals, as large a complement as the
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dermatology commitment. Their caseload was small and their time was best spent assisting the internist in adult care. Most pediatric care was provided by MEDCAP (Medical Civic Action Program) or through self-help and MACV programs. Most important, Vietnamese families were reluctant to release their children for care in USARV hospitals (fig.23). After 1969, medical consultants urged that pediatricians not be assigned to USARV hospitals. By the end of 1971, the abortive pediatric program in USARV hospitals had ended.
PROBLEMS OF AREA MEDICAL SERVICE
While the development of the practice of internal medicine proceeded rapidly in USARV hospitals, there could be no parallel development in the forward area or in unit-level medical service. The absence of significant laboratory support and the exigencies of missions made the development of that expertise in field units impractical; more important, the ready availability of consultation at fixed-hospital installations made it unnecessary. Some individual physicians were able to establish investigative and therapeutic protocols in some areas of medicine but, for the most part, the advent of the helicopter and rapid air evacuation removed any requirement for sophistication in medical practice in the forward area (fig. 24). A decision as to whether the patient was suffering
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FIGURE 24.- Dustoff arriving at the 24thEvacuation Hospital helipad.
from a self-limited or a progressive disease or required more than symptomatic therapy was sufficient at the unit level. The battalion surgeon`s role thus changed considerably, and in the transition, many difficulties were encountered.
In general, the medical education of the unit surgeon did not prepare him for the myriad skin diseases, diarrheal syndromes, fevers, and other problems. He was hampered by the lack of meaningful publications. No written systematized approach to common problems was available or being developed. He was unable to rely totally on his enlisted support since, although well trained, they too lacked Vietnam experience. If any major lesson is learned from this conflict, it should be that therapeutic methods must be designed for common problems to prevent the disorganization and mismanagement which invariably occur when proper medical background is lacking.
Despite the excellent efforts in the field units, many difficulties arose in diagnosis and triage of patients whose illnesses were severe or prolonged. Often patients were held for an inordinate time in outlying units before transfer. Statistics will never reveal the number of days lost when officers and enlisted personnel were first held out of duty for a few days for skin disease, fever, or other causes, and then hospitalized at units or clearing companies for further therapy. Heavily staffed division-level medical services had the space and physicians to hold patients for many days and to institute therapeutic intervention of a very significant nature (fig. 25). The condition of patients evacuated to USARV
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hospitals had often been complicated iatrogenically, and diagnosis was very difficult when antibiotics had been given in the absence of cultures.
Such problems made it clear that in addition to USARV-wide conferences, newsletters, reports, and educational and training programs, a professional channel of communication from hospital to local unit level was urgently needed. The development of the MEDCON (Operation Medical Consultant) concept improved triage capabilities in field units and helped prevent unnecessary therapeutic maneuvers at a unit incapable of proper follow up and treatment of serious disease. Physicians needed to communicate with other physicians directly when patient welfare was concerned.
Field medical service was, in reality, an extension of hospital service in the Vietnam evacuation concept, and the physician caring for the patient along the route of evacuation had to perform at the required level for the job at hand. He was encouraged to seek advice of those qualified to give it, who in turn were directed to extend themselves to provide it. In the absence of this cooperation, medical service deteriorates to isolated enclaves trying to outperform each other, often for unit aggrandizement rather than in the best interest of the patient. The unique superimposition of area medical service upon field medical service in Vietnam offered the opportunity to exploit the best of both systems. Resolution of conflicts or problems had to be decided in favor of the patient, the U.S. soldier. In the spirit of this philosophy, the USARV surgeon in 1969, Brig. Gen. Hal B. Jennings, issued a directive to the commander of the 44th Medical Brigade regarding internal medicine services, from which the following is excerpted.
1. * * * The Chief, Department of Medicine in the 44th Medical Brigade hospitals will develop in conjunction with supported division, group, and separate brigade surgeons a system of liaison visits on a recurring basis, the aid station or unit surgeon visiting the hospital medical service on a monthly basis, and the chief of medicine and his representative visiting the unit surgeon on a quarterly basis; for certain subspecialties such as dermatology, this would be necessary more frequently.
2. It is suggested that standard operating procedures be introduced in the following areas and that these areas be continually under active discussion: (a) selection of patients for evacuation; (b) types of patients requiring consultation; (c) efficiency of consultation systems; (d) methods of patient evacuation; (e) handling of culture materials; (f) improvement of laboratory capability; (g) methods of treatment of medical disease; (h) increasing familiarity with current medical practice; (i) review of specific hospital routines as they affect the unit.
3. This program will require full support by the 44th Medical Brigade in the area of transportation and billeting when necessary. Hospital commanders should give their full measure of support to the chiefs of medicine in this effort.
4. Monitoring will be accomplished through remarks by the chiefs of medicine in the monthly medical reports: aid station/dispensary commanders visiting the hospitals, units visited, personnel contacted, areas of discussion and unresolved problems. The requirement for these remarks in the report will be announced in the Medical Consultant`s Newsletter.
5. The MEDCON concept was presented at the USARV Surgeon`s Conference on 28 March 1969 and was accepted with great enthusiasm by the division surgeons, and the group and separate brigade surgeons. The group was told that this letter would be dispatched to the 44th Medical Brigade and to have their physicians initiate liaison visits to USARV hospitals rendering them support on or about 1 May 1969.
The unified, total-care concept allowed unit surgeons to participate in the
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complete care of their patients. Faced with the exigencies of the situation, these competent physicians had often embarked on therapy in the absence of available diagnostic facilities. For the patient with self-limited disease, this was not a problem, but difficulties clearly arose in the complex case since therapy often clouded diagnosis even further. MEDCON allowed the unit surgeon and the hospital-based internist to view each other`s practice firsthand, recognize individual problems, raise their mutual esteem, coordinate the delivery of health care, and bridge an artificial organizational gap. It brought forward-area medical service into the professional channel of evacuation and control and unified professional care policies in internal medicine throughout the U.S. Army in Vietnam.
EDUCATION AND TRAINING
With the appearance of problem cases of considerable interest at each hospital, medical consultants recognized that individual visits to USARV hospitals could not bring together all the internal medicine activities in Vietnam. Conferences for all chiefs of medical services began in 1968. At these meetings, difficult cases were discussed and policies were reviewed. Under the guidance of the medical consultant, new policies were formulated. One of these was the requirement to enforce 2 days of afebrile status before transfer of falciparum malaria patients to the 6th Convalescent Center. Two patients had died en route in the previous months, one from cerebral malaria and one with splenic rupture. Neither patient had been completely stable or become afebrile before transfer (Ognibene 1969a).
The medical and surgical consultants initiated a combined 2-day conference at the 93d Evacuation Hospital in Long Binh in 1968, and the following list of the subjects discussed on 16 May attests to the breadth of medical interest and expertise represented:
Introduction - Lt. Col. Gene V. Aaby, MC
The American in Asia - Col. Matthew D. Parrish, MC
Fevers of Undetermined Origin - Maj. Fred R. Stark, MC
Clinical Manifestations of Melioidosis - Maj.Neal W. Culp, MC
Malaria - Lt. Col. Nicholas F. Conte, MC
Hepatitis - Col. Robert E. Nitz, MC
Diarrheal Diseases - Lt. Col. Joseph D. Bartley, MC
Rabies - Maj. Lawrence H. Gottlieb, MC
Liver Function Tests - Capt. Ralph G. Oriscello, MC
Renal Failure - 629th Medical Detachment(Renal) physician
Army Psychiatry - Capt. Herbert Block, MC
The first USARV-wide internal medicine conference was held on 31 January 1969 at the 3d Field Hospital in Saigon. Maj. James H. Knepshield, MC, of the 3d Field Hospital, was morning session moderator and Lt. Col. (later Brig. Gen.) Andre J. Ognibene, MC, USARV Medical Consultant, was moderator in the afternoon. Thirty-eight internists from USARV hospitals and 65 unit surgeons attended the intensive 1-day program, which had the following agenda:
Opening remarks - Col. Merle D. Thomas, MC,3d Field Hospital
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Problems in Diagnosis and Treatment of Amebiasis - Capt. Henry B. Head, MC, 3d Field Hospital
Diagnosis and Management of Renal Insufficiency - Capt. William J. Stone, MC, 3d Field Hospital
Management of Cardiac Arrhythmias - Capt. Theodore L. Paletta, MC, 3d Field Hospital Diabetes and Mucormycosis - Capt. Lawrence W. Koch, MC, 93d Evacuation Hospital
Solitary Hyperfunctioning Thyroid Nodules -Maj. Clyde W. Wagner, Jr., MC, 24th Evacuation Hospital
Exercise in Hepatitis - Capt. Lawrence H. Repscher, MC, 6th Convalescent Center
With the conference came the opportunity to discuss standardizing approaches to diseases in Vietnam. Physicians in internal medicine services of the 44th Medical Brigade hospitals and field-unit surgeons from supported units exchanged information which proved fruitful in the ensuing year.
In July 1969, a second internal medicine conference, a 1-day program at the 8th Field Hospital in Nha Trang, was attended by more than 80 Medical Corps officers. The third annual internal medicine conference, held in 1970 at Cam Ranh Bay, was the last USARV-wide conference because of the decline of medical activity in Vietnam.
The feasibility of holding a large-scale medical conference during hostilities was demonstrated by the number of persons able to attend. Because of the difficulty in communication in widely scattered areas and the need for direct dissemination of information and discussion of mutual problems related to improvement in patient care, the requirement to bring physicians together outweighed the risk. The medical consultants hosting these conferences agreed that there was no better way of disseminating valuable information.
The medical consultants issued a monthly medical report and a professional newsletter which, under the MEDCON concept of 1969, were distributed to all field units. These, and the USARV Medical Bulletin which began publication in 1966, were of great value. The bulletin contained many administrative and professional articles and provided an opportunity for expression from both field unit and hospital service. With the talented assemblage of Regular Army and drafted internists in Vietnam, a compendium of guidelines and principles was readily developed for the newly arrived internist. The data collected were assembled in January 1969 and published in the USARV Medical Bulletin in an internal medicine issue. The bulletin was designed to be a means of rapid publication of professional material of consequence emanating from the Vietnam experience. The introduction to the first compendium (USARV-MB 1969) stated its aims as follows:
A number of questions regarding disease trends and basic medical policies have been raised by physicians newly arrived in-country. The purpose of this publication is to provide a concise, up-to-date background on those diseases which are of military importance or of particular medical interest. Secondly, it is designed to provide a ready reference to pertinent USARV Regulations and policy letters, TB Meds and selected articles in the current medical literature. Thirdly, it is designed as a guide book for those entering the practice of internal medicine in Vietnam. Knowledge of these standard operating procedures is necessitated by the need for maintaining continuity of care as the patient progresses through evacuation channels. Familiarity with the variety of illness seen here will also facilitate therapy at a local level and obviate the need, in many cases, for multiple consultations and subsequent loss of duty time.
In January of 1970 and 1971, a revised edition was formulated and
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distributed to each physician arriving in Vietnam. As a medical source book, the compendium was an invaluable aid to the physician unfamiliar with the practice of medicine in Vietnam. For many, it was the only medical guidebook during their first months in the country. The table of contents of the 1971 edition (USARV-MB 1971) indicates the breadth of subject matter covered, which included the following: malaria, hepatitis, shigellosis, amebiasis; nonspecific gastroenteritis, tropical sprue, cholera, parasitic infestations, typhoid fever, plague, melioidosis, tuberculosis, tetanus, gas gangrene, leptospirosis, dengue fever, chikungunya, Japanese encephalitis, scrub typhus, murine typhus, rabies, snake bites, dermatologic problems, venereal diseases, immunization, toxins, allergies and asthma, heat injury, duodenal ulcer, cardiac disease, trauma (early treatment of wounds and injuries), diagnosis and management of acute renal failure, and use of blood and blood products in Vietnam.
In addition to the medical education effort in Vietnam, the medical consultants were responsible for administering the American Board of Internal Medicine examination each year. Despite difficulties in transportation, site selection, air conditioning, security, and communications, each of the examinations was given without loss of records or absence of an assigned participant. The innumerable problems surmounted to achieve this end are recorded only in many anecdotes of frustration, panic, and tears. It remains a tribute to the proctors that management errors were less common in a combat theater than in some centers in the United States. To the internist, the effort meant no loss of time between his eligibility for examination and the time he was able to take it. This had a positive impact on his morale, renewing his faith that the system was responsive and his efforts in patient care were recognized and appreciated.
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HOSPITALIZATION AND EVACUATION
In 1965, the incomplete 8th Field Hospital at Nha Trang, with a 100-bed capacity, was the only U.S. Army hospital in-country, and the 100-bed Navy facility in Saigon was the only other U.S. military hospital. With the buildup of U.S. combat forces in 1965, a large number of hospital units were deployed to Vietnam. Initially, because of limited beds, patients had to be evacuated from the country within 15 days. A small number of special cases were retained for 30 days. By mid-1966, a 30-day holding policy was finally invoked for Vietnam. Those patients who could be treated within this period and returned to duty were held in-country (Neel 1973, p.60).
In early 1966, 1,627 beds were available in Vietnam (Neel 1973, p.60). With the deployment of additional hospitals to the country throughout 1966 and 1967, the number of Army hospital beds rose, by 31 December 1968, to more than 5,000 (AMEDD-AR). At the peak of deployment, hospitals were located in accordance with the division of Vietnam into four Corps Tactical Zones (map 1). As Army strength fell from 331,100 in January 1970 to 119,700 by the end of 1971, the number of available hospital beds in Army facilities decreased proportionately from 3,513 to fewer than 1,000 (MACV-73). By the end of 1972, the medical operations of the U.S. Army in Vietnam had ended.
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MAP 1.- U.S. Army hospitals in South Vietnam, 31 December 1968.
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FIGURE 26.-The 45th Surgical Hospital, Tay Ninh.
Not all USARV hospitals were equipped to handle medical patients. Evacuees at surgical hospitals generally required no internal medicine service. Fully trained internists were not assigned to the 2d Surgical Hospital in Lai Khe, the 45th Surgical Hospital at Tay Ninh (fig. 26), the 3d Surgical Hospital in Dong Tam, the 7th Surgical Hospital at Blackhorse Firebase at Long Giao south of Xuan Loc, the 18th Surgical Hospital at Camp Evans, or the 22d Surgical Hospital at Phu Bai. However, medical services were functional at the 12th, 24th, 29th, 36th, 67th, 71st, 85th, 91st, 93d, and 95th Evacuation Hospitals (fig. 27), the 3d, 8th, and 17th Field Hospitals, and the 6th Convalescent Center. During 1969, the year of peak troop strength, 52 internists were assigned to hospitals and functioned in teams of three and four. As hospital units were deactivated or redeployed, the need for specialists in internal medicine was reduced proportionately.
In general, most internal medicine services in Vietnam had 100 to 200 beds. Since hospitals were built in a wide variety of configurations, a number of unusual wards existed. Throughout the war patients at the 93d Evacuation Hospital were treated in bunk beds. The nurses` station was located at the center of a large cross, and hundreds of patients could be seen from the single nursing station. The initial lack of air conditioning in these wards made it difficult to treat serious problems of fever and fluid and electrolyte balance; air conditioning was at times the only requirement to treat severe miliaria rubra (prickly heat). During 1966 and 1967 the physical plant improved. Through concerted
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FIGURE 28. - Aerial view of the 3d Field Hospital complex.
efforts of contractors, the Corps of Engineers, and self-help medical personnel, most hospitals by the end of 1968 were comparable to many modern hospitals in the United States. In particular, the 3d Field Hospital was considered by many to be the "Walter Reed of the East" (fig. 28).
In addition to the internal medicine activities in evacuation and field hospitals, a major medical effort was centered in the convalescent center at Cam Ranh Bay (fig. 29). Since malaria and hepatitis were significant medical problems, the number of patients who would be evacuated out of country was high. These patients could not be held in evacuation or field hospitals because of lack of bed space. Under the recommendations of Lt. Gen. Leonard D. Heaton, the development of a convalescent center began. On 29 November 1965, the 6th Convalescent Center opened with 1,300 operating beds (Hall and Shafer 1970, p.1) (fig.30). A number of excellent studies on falciparum malaria and infectious hepatitis were performed there and are alluded to in the chapters related to these diseases.
The 6th Convalescent Center provided a controlled physical activity program and integrated this program with special physical therapy classes. Supervised calisthenics were performed in a graduated program of physical reconditioning (fig.31). This allowed patients in the recovery stages of acute infectious diseases to return to duty in top physical condition. Any relapses or physical difficulties occurred at the center under the direct supervision and observation of the medical staff and the physicians in charge. The convalescent center in-
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tegrated physical activity with the early medical and surgical care of patients. Patients evacuated from the country with malaria were reduced from 27 percent of medical evacuees in 1966 to about 10 percent by 1968. Specific figures are not available for hepatitis patients, but most medical consultants believed that hepatitis evacuations had been similarly reduced. In addition, after 1966, evacuation for medical causes never exceeded 20 percent of the total patient evacuation (AMEDD-AR, J).
The convalescent center concept was not new, having been initiated in 1943 and further refined in the Korean war. Patients with hepatitis, for example, had been returned to duty within 20 days during the Korean conflict. Early return to duty was also achieved at the convalescent center during the Vietnam war with a significant savings in combat manpower. The early physical activity concept brought the average theater length of stay to 7 days in forward hospitals and 18 days at the convalescent center, well within the limits of the 30-day evacuation policy (Repsher and Freeburn 1969; Hall and Shafer 1970, p.6). Thus almost all patients with falciparum malaria, hepatitis, and scrub typhus returned to duty in Vietnam (Hall and Shafer 1970) (tables 3 and 4).
Out-of-country evacuation in the early years was generally by plane to Clark Air Force Base in the Philippines and subsequently to CONUS (continental United States). Not until the summer of 1966 did jet aircraft take patients from Vietnam directly to CONUS with one stop in Japan. Following this change in
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FIGURE 30.-Patients arriving for rehabilitation at the 6th Convalescent Center.
evacuation routes, a fixed-bed capability was developed in Japan to care for patients who could be expected to return to duty within 60 days. This significantly reduced the requirements on medical services within the United States and actually maintained at the same level or reduced direct evacuation to CONUS despite the increasing troop strength. Army patient arrivals in CONUS from the Pacific were as follows:
1966 - 4973
1967- 10,671
1968 - 10,800
1969 - 11,415
1970 - 7.364
1971 - 7, 473
1972 - 16,033
A change in policy on drug abuse patients, on 25 June 1971, increased the total number of patients being channeled from Vietnam to the United States. In addition, facilities in Japan were reduced (AEROMED-2) (fig. 32).
On 30 October 1971, the 6th Convalescent Center at Cam Ranh Bay ceased to operate as a convalescent center. Drug treatment centers were established in this facility as well as at Long Binh(MD-IM3). By 20 April 1972, the medical installation at Cam Ranh Bay had closed permanently.
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The relationship of the internal medicine effort in Vietnam to hospitalization and evacuation can best be seen from the data collected by medical consultants during their service in Vietnam. At peak troop strength in 1969, there were generally more than 5,000 monthly medical admissions to USARV hospitals with internal medicine services, or 3 to 4 medical admissions per internist per day (Ognibene 1969b). Approximately 350 required out-of-country evacuation. In the later years of the war, only 10 to 15 percent of evacuees had malaria. Table 5 gives a breakdown of medical and surgical patients evacuated from Vietnam to Japan between 1966 and 1970.
TABLE 5.- U.S. Army medical and surgical patient evacuations from Vietnam to Japan, 1966-70
Figures for 1971 and 1972 include many patients evacuated under the drug abuse program and are reviewed in Volume III of the Internal Medicine in Vietnam series (forthcoming). It is apparent from table 5 that the percentage of medical evacuations from Vietnam fell significantly in relation to the changes in evacuation policy, troop strength, and the opening of the 6th Convalescent Center. The reduction of the percentage of evacuations for malaria from 27 percent of medical evacuations to a stable figure of approximately 10 percent was a significant accomplishment in the maintenance of combat strength. Unfortunately, overall figures are not available for the percentage of hepatitis patients evacuated from country. However, these patients generally constituted, from medical consultants` figures, a consistently larger proportion than those with malaria. The records of the medical consultant in 1969 (Ognibene 1969b) indicate the following breakdown of the 338 average monthly evacuations to Japan:
Hepatitis (over 30 days) - 106
Chest disease (asthma, bronchitis, etc.) - 37
Falciparum malaria (complicated) - 27
Skin diseases (unresponsive to treatment) -26
Heart disease - 20
G6PD deficiency (with hemolysis) - 15
Various arthritides (mainly Reiter`s syndrome) - 13
Amebiasis (for liver scan) - 12
Hypertension
Peptic ulcer (with complication)- 10
Diabetes - 8
Anemia (unclassified) - 3
Infectious mononucleosis (persistent fatigue)- 3
Tuberculosis - 3
Melioidosis - 3
Vivax malaria - 1
Venereal disease - 0
Miscellaneous disorders - 40
In the absence of a specific administrative evacuation requirement or drug abuse program, hepatitis was apparently the major cause for evacuating medical patients from Vietnam to Japan. Most of these patients were able to return to duty in Vietnam because of the 60-day evacuation policy in Japan. With con-
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tinued interest at the 6th Convalescent Center in the early rehabilitation of hepatitis patients, the number requiring out-of-country evacuation was held to a minimum. The average time lost from duty because of infectious hepatitis early in the war was greater than 50 days; by 1969 this had been reduced to approximately 20 days. In addition, the aggressive development of treatment programs and new skills in the management of infectious diseases in Vietnam reduced hospitalization for Plasmodium falciparum malaria from 35 days in 1966 to 18 days in 1969 and for Plasmodium vivax infection from 21 days in 1966 to 5 days in 1969. This eliminated any need for transporting patients with vivax malaria to a convalescent center (Ognibene 1969a). With continued physician education and a reasonably flexible evacuation policy, the number of out-of-country evacuations for medical reasons remained significantly below the surgical evacuation figure despite the fact that medical admissions outnumbered surgical casualty admissions by 5 to 1 as is seen in chart 1.
In addition to out-of-country evacuation, a flexible in-country medical evacuation system was required. Helicopters capable of transporting six to nine patients at a time were the backbone of the aeromedical evacuation system (fig.33). With the development of this type of in-country transportation, significant traffic in outpatient consultation began in 1968, reaching its peak in the later years of the war. Unfortunately, neither evacuation hospitals nor field hospitals were constructed or staffed to render significant care to outpatients.
During the height of the buildup, in January 1969, the 24th Evacuation Hospital in Long Binh reported more than 1,300 internal medicine outpatient consultations by the three internists staffing the large ward service of the hospital. Outpatient services, with limited enlisted support, were made available in a small Quonset but (EH-24) (fig.34). As outpatient consultations increased, the pressure on internists to maintain an active inpatient service was overwhelming in view of the limited staffing. Severe stress was also placed on the air evacuation system since helicopters ferried patients back and forth from field units to hospitals for their consultations.
Many consultations could have been handled by doctor-to-doctor communication between hospital units and the field medical units they supported had it been available. Such communication must be established early to prevent an excessive consultation load and the loss of combat man-days which it entails. Lieutenant Colonel Ognibene (1969b), the medical consultant, wrote in his monthly report of July 1969:
A month-to-month increase in consultation requests is reaching a point where the patient load cannot be adequately handled by the medical staff at fixed hospitals. Unit surgeons are asked to review their consultation practices critically with a view toward handling everything possible at the unit or dispensary level. A patient referred to a hospital should mean that admission is being considered. As a general rule, young men with abdominal distress, nausea, or complaints of "gas" do not need barium studies of their intestinal tract. X-ray services of fixed hospitals are primarily engaged in casualty care and in-hospital X-ray and are not designed for outpatient loads. Outpatient care must of necessity be minimized. Action by unit surgeons at all levels to minimize requests on hospital facilities is immediately necessary [fig. 35].
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Patients must have access to specialized care through their unit medical service; however, policies and guidelines must be established early to insure proper use of available facilities so as to conserve the fighting strength. Proper triage technique is critical for effective care. The initiation of medical consultant visits under the MEDCON program reduced outpatient consultations at hospitals through education and actual onsite consultations. These visits were most successful in the area of dermatology, where they reduced the need for rear echelon consultation and evacuation of patients with skin diseases.
SCOPE OF DISEASE
Maj. W. S. King, U.S. Army surgeon and medical director, commented after the first Battle of Bull Run that "diseases destroy more soldiers than do powder and the sword" (Woodward and Otis 1870, p. 1). During conflict, attention is focused on combat casualties, surgical requirements, evacuation, and combat support. When the glamor fades and the mists of war have cleared, the keen eye of history again affirms the huge impact of disease on the success or failure of military campaigns. The Vietnam conflict was no exception to this rule. Disease was listed as the cause of 56 to 74 percent of admissions to hospitals in Vietnam, 1965-70 (PAD) (table 6).
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Fortunately, the Vietnam conflict was characterized by an intensive effort to return patients with medical illness to duty rapidly and to hold at a minimum those patients evacuated from the country. Because of this effort, days lost from duty were reduced and the potentially disastrous impact of disease on combat effectiveness was diminished. The total days lost from disease after 1967 never exceeded those lost from battle injury (PAD) (table 7).
It is essential to understand that internal medicine in Vietnam involved not only such "hallmarks" as tropical illnesses, esoteric disorders, and unusual infections but also the usual comprehensive lists of diseases afflicting military populations of the size found in South Vietnam. The continuous presence of common
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medical diseases in large troop populations is often forgotten but, nonetheless, is a constant challenge to hospital medical services and the evacuation system. The ensuing chapters detail the effort in specific areas of importance and provide the basis for understanding the magnitude of the medical effort.
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A conclusive statistical picture of the scope and character of patients admitted to internal medicine services in Vietnam is difficult to obtain. Most reporting forms did not specify types of internal medicine admissions. Registrar reports carried only gross figures in broad categories. However, some statistics were kept by chiefs of departments of medicine in relation to their own services. These generally reflect the broad variety of diseases facing the internist supporting a combat operation.
A statistical breakdown kept at the busy 85th Evacuation Hospital in 1967* supports the observation that medical admissions exceeded surgical admissions and combat casualties in almost every month of the year. However, the staffing of the internal medicine services was significantly less than that of any of the surgical departments. The breakdown of the 1,631 medical admissions and other selected cases for May, June, and July 1967 was as follows:
?
Malaria:
Falciparum - Cardiovascular :276
Vivax - 211 Hypertension - 24
Mixed - 18 Myocardial infarction - 2
Malariae - 2 Cardiac arrhythmia - 3
Fever of Undetermined Origin - 318 Rheumatic heart disease - 2
Acute pericaritis - 1
Central Nervous System: Myocarditis - 1
Syncope - 19 Acute thrombophlebitis - 6
Headache - 20 Chronic venous insufficiency - 5
Convulsive disorder - 16
Viral Meningitis- 13 Respiratory:
Cerebrovascular accident - 1 Upper respiratory infection - 120
Brain tumor - 1 Tuberculosis - 8
Bells`s palsy - 1 Chronic obstructive lung disease - 5
Peripheral neuropathy - 1
Renal:
Renal calculus - 4
*Maj. Robert E. Blount, MC, Chief of Medicine, 85th Evacuation Hospital, 1966-67: Personal communication.
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Acute glomerulonephritis - 1 Dermatologic:
Chronic nephritis- 2 Pyodermas, cellulitis - 74
Prostatitis - 13 Stevens-Johnson syndrome - 1
Lymphogranuloma - 3 Erythema multiforme - 2
?
Chancroid- 1 Herpes Zoster - 2<>
Penicillin-resistant" gonococcal urethritis- 2
Rheumatologic
Gastrointestinal: Gout - 5
Gastroenteritis (unclassified) - 175 Reiter`s syndrome - 2
Infectious hepatitis - 99 Post traumatic arthritis - 3
Peptic ulcer disease - 29 Ostroarthritis - 2
Shigellosis-1 Other - 5
Salmonella typhosa -1
Amebiasis -16 Hemotologic:
Hookworm - 6 Infectious mononucleosis - 19
Strongyloidiasis - 5 Hemolytic anemia and G6PD deficiency - 9
Giardiasis - 1 Idiopathis thrombocytopenia purpura - 1
Ascariasis - 1
Schistosomiasis (mansoni) - 1 Endocrinologic:
Hiatus hernia - 1 Throtoxicosis - 1
Cholecystitis -1 Diabetes - 8
Pancreatitis-1 Hypoglycemia - 1
Ulcerative colitis - 1
Hemorrhoids - 8 Miscellaneous:
Acute diverticulitis - 1 Dubin-Johnson syndrome - 1
Mumps orchitis - 1
Allergic: Renal glycosuria - 1
Asthma - 22 Clotting abnormality (unclassified) - 1
Serum sickness - 3 Carcinoma of the bowel - 1
Urticaria - 8 Snake bite - 1
Penicillin allergy - 2 Scorpion bite -
Drug overdose - 2 Ethanolism, acute -4
The average of 18 daily admissions at the 85th Evacuation Hospital, imposed on three or four physicians devoting an extended working day to direct patient care, was above the USARV hospital average of four admissions per internist per day (Ognibene 1969b). Little time was left for outpatient care. However, because the workday was prolonged, one physician could often accomplish the work of two. Unlike surgical admissions, medical admissions were constant and did not parallel combat activity. Breaks in the patient flow were rare and coverage could be planned with some certainty. The mass casualty situations which all too often faced the surgical staff were not characteristic of internal medicine practice in Vietnam.
At the peak of troop strength, 13 medical services, each with three to five internists, provided care to the 5,000 patients admitted per month (Ognibene 1969b). The diagnostic and therapeutic efforts directed at these patients in USARV hospitals were responsible for preventing a disastrous repeat of the French experience. A major requirement for diagnosis and treatment of such a challenging array of patients was laboratory support of medical facilities. Because certain conditions, especially those seen by the internist, must be diagnosed before any decision to treat or evacuate the patient can be made, a fully staffed and equipped laboratory must be functional with the opening of any
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hospital in a combat-support activity (fig. 36). The importance of the availability of blood chemistries and bacteriologic and hematologic support cannot be overemphasized, as it relates directly to reduction in combat-days lost.
In addition to effective laboratory support, a formulary must be available to assist in the provision of efficient drug support for the treatment of complex medical diseases. In 1969, such a formulary (USARV-TF) was developed for Vietnam by the consultant staff in conjunction with the Medical Materiel Division. The number of drugs available and the unlimited and uncontrolled distribution to all units, however, hampered an efficient delivery system (fig. 37). Unsupervised procedures resulted in significant overordering. The USARV pharmacy consultant, the director of logistics, and the USARV medical consultant combined efforts to reduce both the number of line items and the distribution of drugs so that only the necessary medications would be delivered to each location, in consonance with the level of patient care. In addition to the improvement in health care that resulted, the cost savings of this program were significant. Curtailing requests for unlimited drugs provided the resources to streamline delivery of authorized drugs to physicians and patients who required them.
Designed to correspond with up-to-date formularies in CONUS, the formulary retained for use in large hospital centers those drugs which were required for patient care in medical centers and did not release these drugs for field use. This also facilitated delivery of drugs to physicians in the field as well as in fixed hospitals.
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The formulary was produced in pocket size and issued to all physicians in September 1969. A representative page demonstrates the characteristic breakdown by drug class and issue restrictions as follows (stock number is also included):
PART B
Penicillins
Oral Dosage Forms
NOMENCLATURE FSN ISSUE RESTRICTIONS
Ampicillin, Cap, 250 mg, 24s 6505-783-0223 None
(Polycillin, Penbritin)
Ampicillin, Cap, 250 mg, 100s 6505-770-8343 Hospital use only
(Polycillin, Penbritin)
Authorized Substitution 6505-935-1148 1 for 5
Ampicillin, Cap, 250 mg, 500s 6505-935-1148 Hospital use only
(Polycillin,Penbritin)
Authorized Substituion 6505-770-8343 5 for 1
Ampicillin, Oral Susp, 125 mg. per 5cc, 5oz, 6505-926-8924 None
(Polycillin, Penbritol)
Potassium Phenoxymethyl Penicillin, Tab, 6505-656-1612 None
400,000 units, 100s
Potassium Phenoxymethyl Penicillin, Tab, 6505-935-5856 None
800,000 units, 100s
Potassium Phenoxymethal Penicillin, Oral susp, 6505-226-1367 None
200,000 units per 5 cc, 5 oz
Sodium Oxacillin, Cap, 250 mg, 6505-226-1202 Hospital Use only
48s (Prostaphlin)
Sodium Oxacillin, Oral Susp, 6505-C99-0866 Hospital Use only
250 mg per 5cc, 100 cc (Prostaphlin)
With established laboratory support and a maturing drug delivery system, medical care in Vietnam for the U.S. soldier was rapidly achieving the therapeutic sophistication of Army hospitals in the United States by 1970. The chapters which follow attest to this accomplishment and provide the basis for future reference in combat situations in a tropical setting.
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REFERENCES
AEROMED-2- 2d Aeromedical Casualty Staging Flight. Aeromedical evacuation, 1966-72. Report, undated.
AMEDD-AR- Commander, U.S. Army Medical Command, Vietnam. Army Medical Department Activities Report to The Surgeon General, 1969. On file at U.S. Army Center of Military History.
AMEDD-AR,J- Commander, U.S. Army Medical Command, Japan. Army Medical Department Activities Reports to The Surgeon General, 1966-70. On file at U.S. Army Center of Military History.
Army Medical Department Activities Report, Japan. See AMEDD-AR,J.
Army Medical Department Activities Report, Vietnam. See AMEDD-AR.
Drug abuse, Internal Medicine in Vietnam. See MD-IM3.
EH-24-24th Evacuation Hospital, LongBinh.1969. Monthly report USARV medical consultant, Jan. 69.
Hall, A. P., and Shafer, J. A. 1970. The mission of the Sixth Convalescent Center. Paper, dated 9 Apr. 70, unpublished.
Individual Medical Records, Patient Administration Division. See PAD.
MACV-66- Military Assistance Command, Vietnam. 1966. Medical service medical care for Vietnamese nationals at U.S. medical facilities. Directive 40-14, 14 Nov. 66. On file at U.S. Army Center of Military History.
MACV-73- Military Assistance Command, Vietnam. 1973. U.S. military personnel in South Vietnam, by month, by service. Report, 7 Dec. 73. On file at U.S. Army Center of Military History. MD-IM3-Medical Department, U.S. Army. Drug abuse. Internal Medicine in Vietnam, vol. III. Washington: Government Printing Office, forthcoming.
Medical service medical care for Vietnamese nationals at U.S. medical facilities. See MACV-66.
Neel, S. 1973. Medical support of the U.S. Army in Vietnam, 1965-1970. Vietnam Studies. Washington: Government Printing Office.
Ognibene, Lt. Col. Andre J., MC, USARV Medical Consultant. 1969a. End of tour report to USARV surgeon, 28 Oct. 69.
________1969b. Monthly reports to USARV surgeon, Jan.-Oct. 69.
PAD- Patient Administration Division, Health Services Command, Department of the Army. Individual Medical Records (IMR), 1965-70.
Repsher, L. H., and Freeburn, R. K.1969.Effects of early and vigorous exercise on recovery from infectious hepatitis. New England J. Med. 281: 1393-96.
2d Aeromedical Staging Flight. See AEROMED-2.
Therapeutic formulary. See USARV-TF.
24th Evacuation Hospital. See EH-24.
USARV-MB 1969-USARVM. Bull (USARV Pam 40-13), Jan.-Feb. 1969. Copy in Joint Medical Library, Office of the Surgeons General.
USARV-MB 1971- USARV M. Bull (USARV Pam 40-25), Jan-Feb 1971. Copy in Joint Medical Library, Office of the Surgeons General.
USARV Medical Bulletin. See USARV-MB 1969 and1971.
USARV-TF-USARV Therapeutic Formulary. Dated 1Sept. 1969.
U.S. military personnel in South Vietnam, by month, by service. See MACV-73.
Woodward, J. J., and Otis, G. A., eds.1870.The medical and surgical history of the War of the Rebellion. Appendix to part I. Washington: Government Printing Office.
