APPENDIX II
Method of Handling Neuropsychiatric Casualties in Theaters of Operation (Proposed 1949)
1. The basic principles for treatment of combat psychiatric casualties in a theater of operation are as follows:
a. Treatment as far forward as possible. The farther forward such neuropsychiatric patients are treated the greater are the chances for returning them successfully to combat.
b. Centralization of screening, treatment and evacuation. In combat there is a powerful tendency toward indiscriminate evacuation, particularly of neuropsychiatric casualties. Manpower is thus needlessly wasted, and the morale of those who remain is adversely affected. Centralization of neuropsychiatric screening, treatment, and evacuation facilities is essential in order to control this tendency.
c. Avoidance of hospital atmosphere. Although neuropsychiatric disorders represent genuine sickness and require professional care by specialized medical personnel, the majority of patients do not require typical hospital facilities and actually may be harmed psychologically by a hospital atmosphere.
2. Evacuation of neuropsychiatric casualties will ordinarily be accomplished by the channels shown in figure 1. See page 34.
3. Return to duty of recovered neuropsychiatric patients ordinarily will be accomplished by the channels shown in figure 18.
4. Units specialized for neuropsychiatric patients and general medical organizations ordinarily will be used as follows:
a. At the divisional level:
(1) Battalion aid stations. Neuropsychiatric patients will be first evacuated to the battalion aid station. Experience has shown that a large proportion of the neuropsychiatric casualties resulting from combat can be returned to duty from this level. Such patients should be returned to duty either directly or, when conditions permit, after mild sedation and a 24 hour rest in the company or regimental kitchen areas. Patients requiring further treatment will be evacuated. One of the major functions of the division psychiatrist is to supervise the diagnosis, treatment, and evacuation of neuropsychiatric patients by the battalion surgeons.
(2) Regimental collecting stations where no treatment will begiven neuropsychiatric patients, except for such sedation as may be necessary for further evacuation. In its screening procedure, however, the collecting station performs an important function in picking up patients who have not been officially evacuated by their own battalion surgeons.
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Figure 18. Channels for return to duty of neuropsychiatric cases in a theater of operations.
(3) Clearing stations where all neuropsychiatric patients are sorted and classified as follows:
(a) Those requiring prolonged care and who are to be evacuated to establishments farther to the rear.
(b) Those who are probably returnable to duty within a few days and who will be held at the clearing stations. The number of days that any casualty will be kept at the clearing station depends on the tactical situation and the necessity of keeping the station free for movement. If conditions permit, short term patients should be held within the division area. Such patients will be returned to their units through the replacement company of the division. This ensures further observation and combat indoctrination prior to their return to combat.
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During combat, the division psychiatrist will spend his time at the clearing station, taking an active part in the diagnosis, treatment, and disposition of patients. He will act only in the capacity of a consultant. The responsibility for treating neuropsychiatric patients resides in the personnel of the clearing company, which will be sufficiently well trained to discharge this responsibility under the supervision and the assistance of the division psychiatrist. The clearing company of the infantry division has one psychiatrist, MOS D-3129, who functions as assistant division neuropsychiatrist, and three neuropsychiatric technicians with each of the 3 platoons of the company. Up to 40 percent of the neuropsychiatric patients can usually be returned to full combat duty at this level, either directly or through the replacement company.
(4) Division replacement company. Neuropsychiatric patients who can be returned to duty from the clearing station but who require further combat indoctrination or training before rejoining their units in combat will be sent to the replacement company. This company is usually established in the vicinity of the division headquarters and receives all replacements for the division, including those from the clearing station. They are carefully processed and indoctrinated before being sent to combat units. The division psychiatrist will maintain a close liaison with this unit.
(5) The division psychiatrist is on the staff of the division surgeon. It is his duty, through the surgeon, to advise the division commander on policies, procedures, and situations which affect the mental health of army personnel. Heal so acts as a consultant and supervises the treatment and disposition of neuropsychiatric patients at the division clearing station and at the regimental and battalion aid stations.
b. At the army level:
(1) A neuropsychiatric treatment center will be placed in operation by the army surgeon when indicated. Such a specialized center may be formed by the use of army clearing companies augmented by a neuropsychiatric team. Thisunit will operate under army control immediately behind each corps of the field army. Three neuropsychiatric treatment teams will be provided to each army, one to serve each corps by augmenting clearing companies to form treatment centers. These three centers represent the chief centers for screening and treatment of
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neuropsychiatric patients at the army level. Patients will be received primarily from the division, but also from all other army installations. No neuropsychiatric patient will be evacuated from the army who has not been through one of these centers, unless concomitant surgical or medical conditions make this necessary. Patients will be held normally not to exceed 5 to 8 days, but the length of time that they may be held will always depend on the tactical situation and the necessity for keeping the center free for movement. Those considered salvageable for any duty in the army area should not be evacuated beyond this echelon. More serious cases will be evacuated immediately to the communications zone.
In addition to the 40 percent who may be returned to combat at the level of the division clearing station, at least another 20 percent of all neuropsychiatric casualties can probably be returned to duty from the army neuropsychiatric treatment center. The centers have the important function of providing reserve support for the divisions. When the patient-load in forward echelons makes it impossible to hold neuropsychiatric patients for treatment at the division level, they will be evacuated to the army treatment centers which can absorb these peaks by holding only those patients expected to return to combat. In this way, about 60 percent of the patients can still be returned to combat with a minimum of specialized personnel and equipment, and without risking the adverse effects on morale and operation which indiscriminate evacuation of neuropsychiatric patients always causes.
(2) Evacuation hospitals. No recognized neuropsychiatric patients will be sent to an evacuation hospital except when necessary on medical or surgical grounds. The psychiatrist in each evacuation hospital will have the duty of detecting psychiatric patients not previously recognized as such, and preventing leaks in evacuation screening by insuring their transfer to army neuropsychiatric treatment centers. He also will provide necessary consultation for medical and surgical patients.
(3) Convalescent hospitals. Neuropsychiatric patients considered salvageable for combat or noncombat duty within the army area, and who require more prolonged treatment than it is feasible to give at the army neuro psychiatric treatment centers, will be sent from such centers to a convalescent hospital. One of the new type army convalescent hospitals will be in support of each corps. It is the chief center for the sorting and treatment of neuropsychiatric casualties on those occasions when special treatment centers have not been established.
(4) Army consultant in neuropsychiatry. The army neuropsychiatric consultant serves on the staff of the army surgeon. It is his responsibility, through the surgeon, to advise the army commander
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on policies, procedures, and situations that promote or adversely affect the mental health of army personnel. He also supervises treatment, screening, and evacuation of neuropsychiatric patients within the army.
c. Communications zone level:
(1) Station hospitals (Specialized neuropsychiatric). All neuropsychiatric patients evacuated from an army who are considered salvageable for duty will be sent to a hospital specializing in neuropsychiatric casualties. This unit will operate close to the army area and constitute the chief hospital for the treatment and screening of combat-incurred psychiatric cases at the communications zone level. Ordinarily, it will not treat patients expected to return to combat, since these will be treated in more forward echelons. Also, it will not treat psychotics and other seriously ill patients who will be treated in a general hospital. This unit will ordinarily require a patient capacity of 500 and a staff augmented by one or two neuropsychiatric teams. Equipment is that of a tent hospital, similar to an evacuation hospital. This is so as to provide the mobility necessary to keep the hospital close to the army area, and to avoid a hospital atmosphere. The patients wear fatigue clothing rather than pajamas and sleep on cots rather than hospital beds. Neither of these objectives can be accomplished nor can the necessary centralization of screening treatment and evacuation be maintained by the conventional use of station and general hospitals or other existing facilities.
(2) General hospitals. Psychotics and other seriously ill neuropsychiatric patients evacuated from army areas will be sent to specialized general hospitals if possible. The majority will be evacuated to the zone of interior.
(3) Station hospitals. Neuropsychiatric cases arising in the communications zone will be treated in local station hospitals.
