CHAPTER XI
Disposition of Patients From Orthopedic Services of General Hospitals1
GENERAL PRINCIPLES OF DISPOSITION
An important phase of the management of wounded in any overseas hospital was to determine, as promptly as possible, the expected duration of hospitalization required for each patient before return to duty or some other disposition. Ideally, this determination was made immediately after the patient`s admission to the hospital, on two military principles, (1) that because manpower, resources, and other hospital facilities were limited, they must be conserved and utilized as efficiently as possible; and (2) that a soldier who could not be returned to duty with a reasonable degree of promptness should be evacuated farther to the rear or to the Zone of Interior, in order to leave empty beds and other hospital facilities for casualties arriving from areas farther forward.
In forward hospitals in the Mediterranean theater, holding policies varied with the rate of casualty flow. When casualties were heavy, only those patients expected to return to duty within 48 hours were held. In very quiet periods, on the other hand, the holding time might be extended from 10 to 21 days. The great majority of duty dispositions from forward hospitals, in addition to those for medical conditions, were for minor sprains, bruises, and superficial wounds. Patients with bone and joint injuries obviously had to be sent to the rear, for care in fixed hospitals.
The same plan of prompt estimation of hospitalization time was employed in fixed hospitals, so that soldiers whose military value to the theater was ended could be sent to the Zone of Interior as soon as was feasible. In the Mediterranean theater, soldiers whose return to duty could be expected within 90 days or, at other times, within 120 days, were held for treatment in the theater. All others were evacuated to the Zone of Interior as soon as was compatible with good surgical practice.
In practice, the determination of transportability was always on an individual basis. Not only the risk to life but the possible effect of evacuation on future function and anatomic restoration were considered in the timing. The general plan was to effect the transfer during some lag period of treatment, when no specific therapeutic procedure was required. It was also
1The extensive data on which the material in this chapter is based were collected and tabulated by Lt. Col. George A. Duncan, MC, 45th General Hospital.
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necessary to correlate individual transportability with the availability of transportation facilities.
Civilian standards for discharge from the hospital or return to work were not applicable in military dispositions. A soldier returned to duty had to be ready to perform all his assigned tasks in his special branch of the service. For that reason, hospitalization was necessarily prolonged in comparisons with the period which would be required for a comparable condition in civilian practice.
Dispositions in the Mediterranean theater were as follows:
Category A, to full duty.
Category A2, to a replacement depot for 6 weeks. As a practical matter, most patients discharged from fixed hospitals were sent to these depots. Those who had been classified as category A were returned to duty at once. The others (category A2) underwent reconditioning for 6 weeks. At the end of this time, each soldier appeared before a medical board consisting of a surgeon, an orthopedic surgeon, and an internist, for determination of his final disposition. As a general rule, some 80 percent or more of men classified as category A2 had their classifications raised to A at the end of the reconditioning period. Replacement centers, like the convalescent centers organized in fixed hospitals, were operated in the Mediterranean theater by the Combat Conditioning Command.
Category B, to limited-duty assignment, usually noncombatant.
Category C, to the Zone of Interior.
In the early days of the Mediterranean theater, there was a decided tendency to hold some soldiers with bone and joint injuries in the theater, in the hope that they could be returned to duty. This tendency was strengthened by the pressure brought upon the Medical Corps by combat commanders to return as many men as possible to duty. Orthopedic surgeons fully appreciated the importance of the maintenance of manpower, but many of them felt--and events proved that they were correct--that the pressure exerted in favor of dusty dispositions would result in the return to duty of many soldiers of questionable fitness, who would be unable to carry out the tasks expected of them and who would thus be a liability to their commands.
As experience increased, the fallacy of the original policy as it applied to bone and joint injuries became apparent. The very nature of the injuries which required the admission of the patients to the orthopedic sections of fixed hospitals automatically established many of them as immediate candidates for evacuation to the Zone of Interior as soon as their condition permitted. The best that could be expected for others was disposition to limited assignments, usually noncombatant, within the theater. Only a limited number of casualties with simple fractures and a very much smaller number with major compound fractures or with joint injuries of any severity could be returned to duty within a 120-day holding period, much less a 90-day period. Even wounds of the hands and feet with only moderate bone and joint damage resulted in long periods of disability, and the majority of dispositions in these
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groups had to be to category B or C. The few patients with injuries of the long bones who could be returned to full or limited duty had usually sustained incomplete fractures.
For a large part of the war, it was the practice in many forward hospitals to evacuate to the rear soldiers with chronic, noncombat conditions related to the bones and joints. This was a regrettable expenditure of medical effort and hospital-bed space. Some of these men, it is true, obviously required category C disposition, and their evacuation to the rear was justified. Many of them, in fact, should never have been sent to serve in forward combat units. The others, however, required no additional treatment, and their cases could have been disposed of immediately in forward hospitals by their prompt return to duty. The practice, described elsewhere (p. 272), of screening these men directly behind the battlefront, which was instituted in the late months of the war, was the solution of this particular problem.
The return to duty of patients with injuries to bones and joints from general hospitals overseas was considerably less than might have been expected, even in the light of the nature of most injuries of the bones and joints. A large part of the explanation in such cases was the mental attitude of the soldiers. It was difficult to maintain a proper attitude toward return to duty after long periods of hospitalization, and the experience of the Mediterranean theater paralleled the experience in other theaters, that the farther from the firing line a soldier was removed, the more difficult it was to get him back to full duty, even when his conditions was such that return to full duty was entirely justified.
A SAMPLE HOSPITAL EXPERIENCE
An analysis of the disposition of 4,287 patients with bone and joint injuries and diseases treated on the orthopedic section of the 45th General Hospital during 1944 bears out what has been said earlier in this chapter. This hospital had come into the North African theater early in 1943 and by the beginning of 1944 was thoroughly experienced in the problems of military orthopedic surgery, including the problem of disposition of patients. Its experience may be taken as typical of the experiences of many other general hospitals in the theater.
The 4,287 patients in this series represented approximately 20 percent of the total (medical and surgical) hospital admissions for 1944. More than 60 percent were battle casualties. The cases further represented 5,203 separate orthopedic diagnoses and 1,546 diagnoses of additional injuries not connected with the bones and joints.
Of these 4,287 patients, 24 percent were returned to full duty, either directly from the 45th General Hospital or after the 6-week period of reconditioning just described. Nineteen percent were returned to limited duty in the theater. The remaining 57 percent were evacuated to the Zone of Interior. The predominance of Zone of Interior (category C) dispositions is the more
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impressive when it is recollected that the total figure of 4,287 includes innumerable sprains, many non-combat-connected simple fractures, and many chronic noncombat orthopedic conditions. The patients in these special groups accounted for a large number of the category A dispositions to full duty.
Very few patients with compound fractures of the long bones of the extremity were returned to duty within the theater holding period of 90 or 120 days. Of 374 patients with fractures of the femur of all types, for instance, only 19 were returned to full duty, and 334 were evacuated to the Zone of Interior. The same proportions held for most patients with fractures of the bones of the leg and of the arm and forearm. Even fractures of bones of the hand and foot disqualified a large number of patients for further overseas duty. In 179 compound fractures of the metacarpal bones, for instance, there were 91 dispositions to category C and only 49, well under a third of the total number, to full duty. In 224 compound fractures of the metatarsal bones, there were 150 dispositions to category C and only 43, less than 20 percent of the total number, to full duty.
