Chapter 20
Renal Care
Daniel L. Macken, M.D., James H. Knepshield, M.D., James V. Donadio, Jr., M.D., and Andrew Whelton, M.D.
Section I. The 629th Medical Detachment (Renal)
Daniel L. Macken, M.D., and James H. Knepshield, M.D.
The 629th Medical Detachment (Renal) was a specialized intensive care unit capable of sustaining patients with renal failure by hemodialysis or peritoneal dialysis. The renal unit served as a referral center for all four CTZ`s (Corps Tactical Zones) in the Republic of Vietnam, and provided care to U.S. civilians, Vietnamese civilians and military personnel, and other foreign nationals with ARI (acute renal insufficiency). American military and civilian patients with chronic renal failure underwent dialysis until their conditions stabilized and then were evacuated as rapidly as possible to CONUS (continental United States). If hemodialysis was required en route, it was available at Tachikawa Air Force Base Hospital in Japan, Clark Air Force Base Hospital in the Republic of the Philippines, Tripler General Hospital in Honolulu, and Travis Air Force Base near San Francisco.
ARI has been a significant medical problem in combat zones. During World War II, before the advent of the artificial kidney, the fatality rate among severely wounded ARI patients exceeded 90 percent. The time lapse between in jury and definitive treatment often ranged from 1 to 3 days (MD-S2). By the 1950`s, the artificial kidney had been developed. Shortly after the United States entered the Korean conflict, the WRAIR (Walter Reed Army Institute of Research) Surgical Team, which included Maj. (later Brig. Gen.) William Meroney, MC, Maj. (later Col.) Paul Teschan, MC, Capt. Lloyd H. Smith, MC, Dr. George Schreiner, and many others, established an artificial kidney unit in the field at the 11th Evacuation Hospital. With a great deal of ingenuity, a fuel tank from an aircraft, a cookstove, yards of rubber tubing, and a roller drum artificial kidney of that era, the unit started work.* Mortality from posttraumatic ARI
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*Col. Paul Teschan, MC: Personal communication.
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was reduced to 68 percent when dialysis was required and 30 percent when medical treatment alone was needed (Smith et al. 1955). During this conflict, the delivery of medical care was facilitated by the development of battalion aid stations in forward areas, and helicopters were used to hasten the evacuation of seriously wounded patients to surgical hospitals. The average evacuation time for patients not developing ARI was reduced from days to 3 1/2 hours (Teschan et al. 1955).
The acceleration of U.S. involvement in the Vietnam conflict prompted the decision, in 1965, to establish a renal unit in South Vietnam. The 629th Medical Detachment, formed from WRAIR personnel, arrived in Saigon in April 1966. For a short time before arrival in Vietnam, the renal unit was housed at Camp Zama, Japan, and supported by the 406th Medical Laboratory. This was the beginning of a close association with the laboratory, which provided support for patient care and research in later years.
The initial planning and deployment of the renal unit were directed by Colonel Teschan, then heading the Division of Medicine at WRAIR. Capt. (later Maj.) Ronald Easterling, MC, and Capt. Gary Cordis, MC, were sent from Washington, D.C., to Vietnam. Soon after the unit became functional at the 3d Field Hospital in Saigon, Maj. (later Col.) Craig Canfield, MC, joined it.
Capt. (later Maj.) Andrew Whelton, MC, and Capt. James V. Donadio, Jr., MC, were assigned to the renal unit in 1966 and became the first permanent members. They developed the unit`s ability to manage a large number of seriously wounded ARI patients. They established the unit`s research capabilities with studies on the dialysance of quinine and recorded experiences with posttraumatic ARI and renal failure in association with malaria, typhus, G6PD (glucose-6-phosphate dehydrogenase) deficiency, and phosphorus burns. They attempted to establish communication channels to disseminate information to hospitals countrywide about the prevention and early management of ARI, and they developed a working relationship with the University of Saigon School of Medicine.
Capt. Rolland F. Regester, MC, and Capt. M. David Cohen, MC, followed in late 1967 and 1968, respectively. At this time use of the renal unit`s services was increasing; during their stay the number of admissions was approximately double that of the preceding year. They were responsible for operation of the unit during the Tet offensive of 1968, which brought a heavy influx of serious casualties. After their departure, the unit was managed by Capt. Frederick Oerther, MC, and Capt. Robin Oxman, MC.
An evaluation of the unit`s operation and goals was undertaken by Colonel Teschan, Col. Samuel Jefferson, MC, and Maj. (later Lt. Col.) James H. Knepshield, MC. Unfortunately, separate parallel command channels had led to administrative uncertainty and misunderstanding; the complete autonomy originally contemplated was not practical in the operational setting of the 3d Field Hospital. After Major Knepshield and Capt. (later Maj.) William Stone, MC, arrived in Vietnam in 1968-69, they recommended that the unit come under the direct command of the hospital commander, Col. Merle Thomas, MC, instead of that of the USARV (U.S. Army, Vietnam) surgeon.
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FIGURE 85. - View of the 629th Medical Detachment (Renal), 3d Field Hospital, 1969.
The unit`s successes in reducing mortality were well documented, but it was apparent that broader expertise in the management of renal failure patients was necessary if treatment was to be more successful. Two more physicians were added to the staff. Maj. (later Lt. Col.) Ronald Fischer, MC, brought experienced judgment in the surgical management of renal failure patients and improved the liaison with the surgical service of the hospital. Capt. (later Lt. Col.) Daniel Macken, MC, broadened the acute care resources of the unit, particularly in the management of cardiopulmonary complications and shock. In addition, the technician and nursing complements were increased and the unit was expanded from 6 beds to 11 (fig. 85). The renal unit accepted more patients in 1969 than in any previous year.
The high mortality among the large surgical population of the unit stimulated the staff to seek methods to prevent or manage such complications of renal failure as sepsis, coagulation defects, stress ulcers, and respiratory, hepatic, and circulatory failure.
A campaign stressing ARI prevention and early management was launched by means of consultant visits to many outlying hospitals, distribution of printed material countrywide, and formal lectures given at in-country medical meetings. This resulted in improved medical care for the renal failure patient at all levels in the chain of medical evacuation.
Greater involvement in the medical education of Vietnamese physicians was initiated through lectures on electrolyte balance and the management of renal failure patients at the University of Saigon School of Medicine, participation in ward rounds at Cong Hoa Military Hospital and Cho Ray Hospital, and efforts to establish hemodialysis capability in the civilian community and at Cong Hoa Military Hospital. Vietnamese physicians began tours involving patient care at the renal unit, and Vietnamese nurses and corpsmen were trained in the
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techniques of intensive care nursing and dialysis. As an outgrowth of this close relationship with the community, a related-donor kidney transplant was performed on a 20-year-old Vietnamese man at a local civilian hospital in a joint effort by Vietnamese and American medical teams (see chapter 23). The favorable publicity surrounding this operation gave impetus to the development of an artificial kidney unit in a Vietnamese hospital.
Later in 1969, Maj. William Miller, MC, arrived in the unit, followed by Maj. David Kessler, MC, and Capt. William Chenitz, MC. During this period, the equipment was augmented and updated. The immunologic behavior of patients with renal insufficiency was explored in an investigation of granulocyte motility. Beginning in 1970, the number of monthly admissions to the unit gradually decreased as American involvement in hostilities declined.
In mid-1970, a new team-Maj. Jay Dennis Morton, MC, and Maj. Paul Balter, MC-arrived. They continued the research protocols and further developed techniques for peritoneal lavage in patients with abdominal wounds, using the Tenckoff catheter. Personnel from Cong Hoa Military Hospital were trained as dialysis technicians (fig. 86); these trainees became proficient in peritoneal dialysis and set up a unit at their own hospital. Later, under the direction of Maj. James D. Flynn, MC, an artificial kidney center was established at Cong Hoa Military Hospital after physicians and technicians were trained in the 629th Medical Detachment. Major Flynn arrived as American involvement in
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FIGURE 87.- The Teflon-Silasti carteriovenous shunt used by the 629thMedical Detachment(Renal).
hostilities was ending, and because of progressively decreasing admissions he deactivated the unit on 1 February 1972. The dialysis equipment was given to the South Vietnamese Medical Corps at Cong Hoa Military Hospital.
Section II. Renal Center Operation in a Combat Zone
James V. Donadio, Jr., M.D., and Andrew Whelton, M.D.
Hemodialysis for clinical treatment of ARI (acute renal insufficiency) was first used during the late 1940`s. The development of dialysis and the progress in the management of ARI patients since that time represent two of the great milestones in the history of medicine. Much of our present-day knowledge of posttraumatic ARI stems from the original experience gained during the Korean war (Meroney and Herndon 1954; Teschan et al. 1955; Smith et al. 1955). Therefore, it is not surprising that in the conflict in Vietnam much interest focused on the problem of renal failure.
LOCATION
The physical plant of the renal unit included a six-bed ward containing a dialysis area; laboratory space and equipment for performing basic blood and
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This section is a revised version of the following article by the authors (1968): Operation of a renal center in a combat zone. Mil Med 133:833-37.
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urinary examinations were also located in the unit. Two Kolff twin-coil artificial kidney units were used for hemodialysis, as were Teflon-Silastic arteriovenous shunts (fig. 87). Peritoneal dialysis was carried out using commercially prepared dialysis fluid and administration sets and straight polyethylene peritoneal catheters.
However, merely having the requisite equipment and personnel was not sufficient; an appropriate location was also important. Requirements included: an adjacent aircraft landing strip and heliport; laboratory support on a 24-hour basis for serum electrolyte, creatinine, and urea nitrogen determinations; adequate and reliable electrical power; availability of preheated processed water at all times (100 gallons per hemodialysis); and adequate medical maintenance facilities. The location in Saigon fulfilled all these requirements.
The significance of the in-country location of the renal unit deserves discussion here. Air evacuation of most types of patients from Vietnam to other hospitals in the Pacific area or to the continental United States was well established and was a remarkable achievement. However, transferring a patient from the referring hospital to an air facility and, in turn, from the air facility to the eventual receiving hospital, required as much as 24 hours. Thus, precious time was lost in the early critical phase of illness in patients with ARI. Hyperkalemia and unrecognized extracellular fluid volume excess with pulmonary edema were likely to occur in many of these patients (Teschan et al. 1955).
Those unavoidable delays in patient evacuation from the combat zone were reduced by the strategic location of the renal unit. The 3d Field Hospital was located adjacent to the large U.S. Air Force Base at Tan Son Nhut, Saigon, a hub of in-country air traffic, and patients were rapidly transported by fixed-wing aircraft and helicopter to this base. With prior notification by telephone of patient referral, no time was lost in coordinating and continuing intensive medical or surgical care and initiating dialysis when necessary. Accompaniment of patients by an attending physician from the referring hospital was recommended, to maintain continuity of patient care.
Laboratory support is an integral part of any renal unit, and laboratory personnel must be constantly ready to provide prompt and reliable service. The renal unit received excellent support from the 406th Mobile Laboratory, 3d Field Hospital. All routine hematologic and chemical tests, including blood gas determinations, were rapidly available. The more esoteric chemical or serologic study specimens were shipped by air freight to U.S Army research laboratories in Japan or the United States. Electrical power failures during hemodialysis procedures were, fortunately, infrequent, and the use of twin-coil artificial kidneys with roller-pump mechanisms allowed the pump mechanism to be cranked by hand when necessary. However, when finger-pump mechanisms (Sigma-motor) were used, dialysis had to be discontinued during power failures. Spare parts for artificial kidneys were not readily available in the combat zone; therefore, a supply of additional parts was maintained locally. Servicing and upkeep of renal unit equipment were carried out by the medical maintenance personnel of the 3d Field Hospital.
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PERSONNEL
Dialysis is but one element in the medical and surgical management of ARI patients. The renal center in Vietnam provided total care to its intensive care and dialysis patients, avoiding the too narrow concept of a "dialysis service." Patients with ARI are better managed when total primary care is under the direction of one team of physicians and nurses.
Experience in 1967 showed that two physicians were adequate to staff the unit. However, a third physician with renal training was added to the 3d Field Hospital general medical staff and provided backup assistance when necessary. Two nurses were insufficient to staff the unit, since this required that they work 12-hour shifts, 7 days a week. Nursing support was augmented with personnel of the 3d Field Hospital.
Although peritoneal dialysis and hemodialysis are now considered standard treatment techniques, it is mandatory that physicians with renal and dialysis training supervise and conduct these procedures; such physicians must obviously staff the renal unit. Unfortunately an MOS (military occupational specialty) identifying nephrologists was not established until after the war`s end (AR-chg). The number and MOS breakdown of corpsmen assigned to the renal unit were adequate for proper patient care and the operation of dialysis equipment. At the time of the unit`s initiation, there was no primary or secondary MOS for enlisted personnel to indicate prior training or experience in renal dialysis work. Later, recognition of this specialized training by an appropriate MOS designation ensured assignment to a renal unit. Meanwhile, recommendations had to be made to the USARV surgeon to assign trained dialysis technicians to the unit so that their specialized training could be used for a full tour of duty in Vietnam.
CLINICAL RESULTS
Fifty-seven patients with ARI were referred to the unit during the first 16 months of operation. The authors` experience included 45 cases treated during a 12-month period (September 1966-September 1967). Thirty-one of these pa tients with established renal failure required prolonged dialysis treatment, using either hemodialysis or peritoneal dialysis (table 91).
The spectrum of contributing etiologies was quite varied. There were three main categories: medical causes, posttraumatic renal failure, and miscellaneous causes (table 92). Among the medical causes, tropical illnesses played a prominent role. Although malaria, leptospirosis, amebiasis, and rickettsial infections were observed with some degree of frequency among U.S. personnel in Vietnam, the development of ARI offered additional challenge in diagnosis and management. Peritoneal dialysis, a simple, safe, and effective procedure, was particularly favored in the nontraumatic cases.
Twenty-four cases of posttraumatic renal failure were referred to the unit. Many factors led to the development of ARI in these patients. The majority received multiple organ and extremity wounds with hemorrhage, oligemic shock,
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TABLE 91.- Dialysis procedures, 629th Medical Detachment (Renal),September 1966-September 1967
bowel trauma, and infection. Intravascular hemolysis following incompatible whole blood transfusion was observed in four patients, with ABO reactions occurring in three patients and apparent Rh (rhesus factor) incompatibility in the other. Extensive injury, hemorrhagic diathesis, and intractable hypotension, despite volume replacement and vasopressor administration, precluded hemodialysis in six patients; these six were moribund on admission and died within the first several hours of hospitalization in the renal unit. Hemodialysis was used in the management of 15 patients. One patient with ARI following a hemolytic transfusion reaction received peritoneal dialysis and two patients were managed without dialysis. Of the 18 patients in this "treatable" group, 12 (67 percent) died.
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It is interesting to contrast this group of posttraumatic renal failure patients with those observed in Korea (Meroney and Herndon 1954; Teschan et al. 1955; Smith et al. 1955). Overall mortality among patients referred to the renal insufficiency center in Korea was 53 percent. Comparing this figure with that of the current group is not entirely valid, however, since patient selection was substantially different. During the Korean conflict, delay in evacuation of seriously wounded patients from battlefield to hospital (mean time = 4.6 hours), prolonged hypotension, and use of blood drawn some 2 weeks ahead of time were major factors in the occurrence of renal failure. Many extensively wounded soldiers did not survive to develop renal failure. In Vietnam, seriously wounded individuals were evacuated from the battlefield by helicopter and arrived within a mean time of 35 to 40 minutes at a hospital, where rapid resuscitation and definitive surgery were provided (Hardaway 1967).`` Renal failure in this type of patient did not occur immediately after injury but followed multiple postoperative complications, many of which were associated with gastrointestinal injury and peritonitis.
In addition to patients with acute and chronic renal failure, other individuals were referred to the unit for evaluation and treatment. These included patients with hypertension, proteinuria, and various fluid and electrolyte disturbances.
Because of the uncommon etiologies of ARI encountered, a number of clinical research projects were undertaken by members of the renal team in the early period to further elucidate them. The subjects of these studies included: establishment of quinine dosage schedules in patients with ARI complicating acute falciparum malaria (Donadio, Whelton, and Kazyak 1968); the hazard of glucose-6-phosphate dehydrogenase-deficient individuals developing ARI in response to infection from a tropical disease (Whelton, Donadio, and Elisberg 1968); the role of dialysis and long term followup of patients developing renal failure with leptospirosis; the role of iatrogenic copper poisoning in the treatment of phosphorus-burned patients; and the role of antibiotic lavage in posttraumatic renal failure complicated by gastrointestinal injury (Whelton and Donadio 1969).
SUMMARY
Posttraumatic renal failure developed in the setting of multiple postoperative complications, many of which were associated with gastrointestinal injury and peritonitis.
Review of clinical results of 45 cases at the renal unit during 12 months (September 1966-September 1967) revealed a mortality rate of 8 percent among patients with medical causes of renal failure and 67 percent among those with posttraumatic renal failure.
Although an awareness of the principles of ARI prevention existed among
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*`This estimate is also based on the personal observations of the authors in Vietnam.
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the military physicians in Vietnam, renal failure continued to occur in varied circumstances. When renal failure was established, the immediate availability of either hemodialysis or peritoneal dialysis was crucial for managing these patients.
REFERENCES
AR-chg-Department of the Army. 1974. Change 35, 15 June 74, to Army Regulation No. 611-101, 2 June 1980.
Army Regulation. See AR-chg.
Donadio, J. V., Jr., and Whelton,A.1968.Operation of a renal center in a combat zone. Mil.Med133: 833-37.
Donadio, J. V., Jr.; Whelton, A.; andKazyak,L.1968. Quinine therapy and peritoneal dialysis in acute renal failure complicating malarial haemoglobinuria. Lancet1: 375-79.
General surgery, Surgery in World WarII. See MD-S2.
Hardaway, R. M., III. 1967. Surgical research in Vietnam. Mil. Med 132: 873-87.
MD-S2-Medical Department, U.S. Army. 1955. General surgery. Surgery in World War II, vol. II. Washington: Government Printing Office.
Meroney, W. H., and Herndon, R. F.1954. The management of acute renal insufficiency. JA.M.A. 155:877-83.
Smith, L. H., Jr.; Post, R. S.;Teschan, P.E.; Abernathy, R. S.; Davis, J. H.; Gray, D. M.; Howard, J. M.; Johnson, K. E.; Klopp, E.; Mundy, R. L.; O`Meara, M. P.;and Rush, B. F., Jr.1955. Posttraumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis. Am. J. Med 18: 187-98.
Teschan, P. E.; Post, R. S.; Smith, L.H., Jr.; Abernathy, R. S.; Davis, J. H.; Gray, D. M.; Howard, J. M.; Johnson, K. E.; Klopp, E.; Mundy, R. L.; O`Meara, M. P.; and Rush, B. F., Jr.1955. Posttraumatic renal insufficiency in military casualties. I. Clinical characteristics. Am. J. Med 18: 172-86.
Whelton, A., and Donadio, J. V., Jr.1969.Post-traumatic acute renal failure in Vietnam. A comparison with the Korean war experience. Johns Hopkins M.J.124: 95-105.
Whelton, A.; Donadio, J.V., Jr.; and Elisberg, B. L. 1968. Acute renal failure complicating rickettsial infections in glucose-6-phosphate dehydrogenase-deficient individuals. Ann. Int. Med 69:323-28 .
