SPECIALIZED CENTERS FOR THE MANAGEMENT OF VASCULAR INJURIES AND DISEASES
Daniel C. Elkin, M. D.*
The arrest of hemorrhage and the preservation of an adequate arterial supply to injured extremities have been the primary concern of military surgeons in all the wars of history. In each successive war the relative number of vascular injuries has steadily become larger because the development of weapons of increasingly higher velocity has magnified the chances of vascular trauma.
During World War II, as a result of widespread use of weapons of such type, multiple wounds were more frequent. Dozens of nonfatal wounds were often observed in the same casualty and as high as two hundred wounds have been recorded. Furthermore, while case fatality and amputation rates were high in injuries of the major arteries, improved methods for the control of hemorrhage, shock, and infection greatly decreased the incidence of death and mutilation and increased the numbers of casualties who lived with possible post-traumatic complications.
The medical records of World War I supplied almost no information about vascular injuries in American military personnel. Early in World War II it became evident that this type of injury was likely to be frequent and would create grave problems. While the principles of vascular surgery had been established for many years, and prior to the outbreak of World War II many significant advances had been made in this field, the fact remained that wounds of this type occurred infrequently in civilian life and that surgeons with extensive experience in this specialty were few.
ESTABLISHMENT OF VASCULAR CENTERS IN THE ZONE OF INTERIOR 1
The problem of supplying competent specialized care by experienced personnel for large numbers of casualties with vascular injuries was solved in World War II by the establishment in the Zone of Interior of vascular centers 2 to which surgeons experienced in vascular surgery were attached and in which
* Whitehead Professor and Chairman of Department of Surgery, Emory University. Brigadier General, MC, USAR (Ret'd.).
1 Unless otherwise specified, all data contained in this chapter are derived from reports prepared for this purpose by J. W. Kahn (formerly Captain, MC, Ashford General Hospital), H. B. Shumacker, Jr. (formerly Lt. Colonel, MC, Mayo General Hospital), and A. H. Storck (formerly Lt. Colonel, MC, DeWitt General Hospital).
2 WD Memo W 40-14-43, 28 May 43.
other surgeons could be trained. To these centers were sent patients with vascular injuries and diseases.
The establishment of these centers made it possible to carry out the necessary treatment of such patients with an economy of equipment, personnel, and effort which would have been impossible had the patients been scattered through a large number of hospitals. It also permitted the observation of patients with vascular injury and disease in numbers far beyond those of any similar previous experience. Careful and detailed records were kept and analysis of data derived therefrom permitted deductions and conclusions which could not be gained from the small series of cases previously observed by surgeons in civilian practice.
The first vascular centers to be activated were located at Ashford General Hospital, White Sulphur Springs, W. Va., and Letterman General Hospital, San Francisco, Calif. These centers were established by a War Department memorandum dated 28 May 1943.3 The former center continued in operation throughout the war and was not deactivated until 30 June 1946.4 The author of this chapter served as chief of the vascular surgical section throughout the period of operation.
The vascular center established at Letterman was active until 23 December 1943 5 and the patients on the vascular ward at the time were transferred to Torney General Hospital, Palm Springs, Calif., which had been officially designated a vascular center 17 December 1943.6 Lt. Col. Russell H. Patterson served as chief of the center during the 7 months period of activity at Letterman. Torney General Hospital continued to house the vascular center until 12 June 1944 when DeWitt General Hospital, Auburn, Calif., was officially designated as a hospital to which patients with vascular disorders should be sent.7 Capt. (later Major) LeRoy J. Kleinsasser served as chief of the vascular surgical section at both Torney and DeWitt General Hospitals.8 He held this position until May 1945 when he was succeeded by Maj. (later Lt. Colonel) Norman E. Freeman who served until the center was deactivated. 9
Early in 1944 the influx of patients with vascular disabilities from the European and Aleutian theaters reached a point where it became necessary to establish another center for patients with vascular disorders. A third vascular center was therefore designated at Percy Jones General Hospital, Battle Creek, Mich., 12 June 1944.10 This center was active only a short time for on 25 August 1944 Mayo General Hospital, Galesburg, Ill., was designated a vascular center and all patients and personnel were transferred from Percy Jones to
3 See footnote 2, p. 1.
4 Final Rpt, 1946, Ashford General Hospital. HD.
5 Annual Rpt, 1943, Letterman General Hospital. HD.
6 Ltr, Gen Somervell to CGs all SvCs and MDW, 17 Dec 43, sub: Hospital designated for specialized treatment. S G : 323.7-5.
7 W D Cir 235, 12 Jun 44.
8 Annual Rpt, 1945, DeWitt General Hospital. HD.
10 See footnote 7 above.
Mayo General Hospital.11 The vascular center at Mayo continued in operation until 17 October 1946 12 when it lost its designation. Lt. Col. Harris B. Shumacker, Jr., served as chief of section in this center during its entire period of operation.
Although the vascular centers were briefly conducted as specialized surgical sections attached to the surgical service of the hospitals in which they were located, they soon became, for all practical purposes, independent units.
The organization was not precisely the same at all centers though it was always based on the principle that medical and surgical specialists should be in constant consultation with each other and should collaborate in the management of individual patients.
Organization at Ashford General Hospital. At Ashford General Hospital, at Torney, and at DeWitt during most of its period of operation, all patients with vascular disorders were assigned to the vascular surgical section. At these centers, when circumstances permitted, the following organizational setup was considered ideal:
A surgeon in charge of the center with wide experience in the field of vascular surgery. He performed most of the operations, was responsible for all administrative, medical, and surgical policies (in conformity with existing directives), and supervised all medical and surgical treatment.
An assistant surgeon, an experienced general surgeon, with fairly wide experience in vascular surgery. He supervised the center and carried out surgical procedures in the absence of the director.
Two medical officers with a thorough grounding, through training and experience, in the physiologic concepts of vascular diseases and injuries. They supervised or performed special tests, skin temperature and oscillometric studies, and diagnostic spinal punctures and lumbar sympathetic blocks (in collaboration with the chief anesthetist). At least 2 officers were necessary as it proved impossible for a single officer to appraise the vascular status of more than 4 patients per day.
A physiotherapist to give both diagnostic and therapeutic advice.
An officer to supervise reconditioning once definitive treatment was concluded.
A cardiologist to serve as consultant in appropriate cases and to advise on nonsurgical therapy. (While this officer was attached to the medical service, he was available for consultation at all times.)
A neurologist and neurosurgeon to serve as consultants; the former to attend weekly ward walks during which new patients were seen and the latter
11 WD Cir 347, 25 Aug 44.
12 Annual Rpt, 1946, Mayo General Hospital. HD.
to coperate in the performance of sympathectomies. (These officers were attached to the neurologic service, but were available for consultation.)
Organization at Mayo General Hospital. The plan of operation at Mayo General Hospital differed from that at Ashford General Hospital in that the unit was divided into medical and surgical sections. The general understanding at this installation was that patients with vascular conditions requiring surgical treatment should be admitted directly to the surgical section. All other casualties were admitted to the medical section, from which, after the proper workup, they were transferred to the surgical section whenever surgery seemed indicated. Generally speaking, patients were admitted to the medical section if the diagnosis was trenchfoot, frostbite, thrombophlebitis, Raynaud's disease, peripheral edema, or vasospastic and obliterative arterial disease without ulceration. Patients were admitted directly to the surgical section if the diagnosis included arterial aneurysm, arteriovenous fistula, traumatic lesions of the blood vessels, gangrenous and other open lesions of vascular origin, varicose veins, hemangioma, or venous thrombosis. These policies, while carried out with reasonable consistency, were by no means inflexible. Patients with post-traumatic vasospastic disorders, for instance, might be admitted to the surgical section in some instances and to the medical section in others. The decision depended upon the particular clinical manifestations which the patient presented at the time of his admittance.
This plan was adopted at DeWitt General Hospital in May 1945 and was followed until the center was closed. 13
Collaboration Among Services
No matter what the details of organization were in any particular center, the management of patients with vascular lesions was always a combined responsibility. The amount of work prevented collaboration in every case, but whenever it was to their best interests, patients were treated jointly by internists and surgeons. They were never regarded as the sole responsibility of one service or the other.
At all centers, collaboration with the department of roentgenology was excellent. The physical therapy and reconditioning department participated actively in the care of patients. Their personnel supervised corrective exercises and gave the special treatments required by patients with cold injuries and with trauma to the major arterial stems. When personnel of the physical therapy department was in short supply, as it frequently was, corrective gymnastic exercises were developed by the reconditioning section and were used, as far as possible, as substitutes for physical therapy.
In all centers, full use was made of the occupational therapy departments, partly for reconditioning purposes and partly to supply diversion during necessarily prolonged periods of hospitalization. Red Cross workers also
13 See footnote 8, p. 2.
participated in the programs at the vascular centers. At DeWitt General Hospital a special ward was set aside for patients who agreed to discontinue smoking as a phase of the therapy. Special privileges were granted to these patients and Red Cross workers were particularly cooperative in providing recreation.
Time was saved and efficiency increased by the coordinated ward rounds held weekly at each center. They were attended by all members of the medical and surgical staffs and by others concerned with the treatment of patients with vascular lesions. At these rounds new patients with problems of special interest or special difficulty were presented, the management of unusual cases discussed and agreed upon, and general policies were explained. Weekly progress notes on each case were also dictated at this time by the section chief. In addition to the ward walks, dry clinics were held at regular intervals.
Ashford General Hospital
The original allotment of beds for the vascular center at Ashford General Hospital was 50 out of a total bed capacity of 1,875; this was increased as the patient load increased, and at the height of military activity 600 beds were so allotted. Typical of the proportionate distribution of cases was the report made by a representative of the Office of The Surgeon General 14 who inspected the center in September 1944. At that time, of the 241 patients in the vascular section of the hospital, 164 had trenchfoot, 33 had aneurysms or arteriovenous fistulas, 16 thrombophlebitis, 7 thromboangiitis obliterans, 5 Raynaud's disease, 3 frostbite, and 13 miscellaneous vascular conditions.
The heavy patient load carried by the Ashford General Hospital Vascular Center during 1944 and 1945 (Table 1), and the number of operations performed there during those years (Table 2), clearly indicate the wisdom and expediency of concentrating patients with vascular injuries in centers where they can receive highly specialized treatment. The statistics also provided evidence that concentration in these centers of the few available specialists is an economical use of personnel, for under any other setup their particular skills would be dissipated.
Percy Jones--Mayo General Hospitals
Because of the physical limitations of Percy Jones General Hospital, only 28 patients were admitted directly to its vascular section. Another 23 were transferred from other sections of the hospital; 78 were seen in consultation but not transferred. Thirty-eight operations were performed, including 23 sympathectomies and 4 excisions of arteriovenous fistulas.
14 Memo, Lt Col M. E. DeBakey, Chief Gen Surg Br, Surg Consultants Div for SG, 13 Sep 44, sub: Report of visit to Ashford General Hospital. HD: 730 (Ashford Gen Hosp).
When this vascular center was transferred from Percy Jones General Hospital to Mayo General Hospital in September 1944, it was allotted 305 beds on the medical service and 195 beds on the surgical service. The allotment was increased or decreased according to the patient load but was in the neighborhood of 500 beds for the first 3 months the center was in operation. Bed capacity was increased to 724 on 6 January 1945, and to 800 on 26 January. Early in May 1945 the patient load decreased chiefly because of the diminution in the number of trenchfoot casualties, and on 20 May the bed capacity was again set at 500.
Between 15 September 1944 and 1 October 1945, 500 patients were admitted directly to the vascular surgical section at Mayo General Hospital, 365 operative procedures were carried out, and 540 patients from other parts of the
hospital were seen in consultation. The patient load on the medical vascular section was 68 in September 1944, 247 in December, and over 500 in January 1945. It remained at about this level until April. By the end of this month the medical service patient load had fallen to about 400, by the end of May it was about 250, and by the end of July only 125 were occupying beds. After this, the patient load was never over 100 on the medical service. In October orders were received that no more patients would be sent to the center and those remaining were gradually dispositioned, the center closing early in 1946.
Letterman--Torney--DeWitt General Hospitals
Thirty patients with vascular disorders requiring surgery were admitted to the vascular section of Letterman General Hospital during its period of operation. Of particular note were 221 patients with trenchfoot admitted to this center from Attu.15 While facilities were adequate at Letterman to handle the expected increase in patients with vascular disorders, the hospital was designated a debarkation hospital and directives were issued arresting the flow of patients requiring specialized care in order to make beds available for expected evacuees from overseas.16 At the time of deactivation, 23 December 1944, patients with vascular disorders were dispositioned to Torney General Hospital which had been designated a vascular center 17 December 1943.17
A 33-bed ward which constituted the facilities of the vascular center established at Torney General Hospital was almost completely filled from the day of its opening. The rapid increase in patient load made it imperative to secure further facilities and plans were made for more ward space as well as for an examining room, a constant-temperature room, and an office in one of the hospital cottages. Before they could be carried out, however, the center was transferred to DeWitt General Hospital, a newly constructed hospital where bed space was available to handle the great numbers of patients expected who would require this type of specialized care.
At DeWitt General Hospital the original allotment of the vascular center was 350 beds.18 Additional beds were assigned as the patient load increased and during the height of the trenchfoot load the allotment reached 500.19
When the vascular centers were first planned it was realized that their success would depend to a great extent on the capabilities of the medical personnel selected to staff them. Two factors were considered of primary importance: (1) assignment to the centers of the limited number of medical and surgical specialists of wide experience in the field of vascular injuries and
15 Annual Rpt, 1943, Letterman General Hospital.HD.
16 Smith, Clarence McK.: Hospitalization and Evacuation in the Zone of Interior. (Manuscript for an administration volume in this series.) <>
17 See footnote 6, p. 2.
18 Annual Rpt, 1944, DeWitt General Hospital. HD.
19 See footnote 8, p. 2.
diseases, and (2) retention of such selected personnel despite rotation policies. The latter consideration was adjudged of particular importance in a field as highly specialized as vascular surgery. It affected not only the medical officers but also the nurses, reconditioning personnel, physical therapists, medical detachment enlisted men, civilian ward attendants, technicians trained in the management of the constant-temperature rooms, and the WAC personnel. In spite of endeavors to prevent them, rotation and changes in personnel were frequent, and training programs to overcome the difficulties caused by this situation were steadily in operation.
When the vascular centers were first established, shortages in medical personnel were especially pronounced and especially serious. In an effort to overcome this shortage an attempt was made at DeWitt to utilize the services of ambulatory officer patients of the Medical Corps, but for a variety of reasons the policy was not satisfactory. Some of the patients were physically and emotionally exhausted from their combat experiences and were really unfit for anything but rest. Others felt that their stay in the hospital was limited and therefore had little interest in undertaking serious work. Still others were expecting separation from the service. Whatever the reason, the quality of work done by officer patients was frankly inferior and frequently had to be done over by the regular staff. The plan thus resulted in a loss of time and effort rather than a saving. It was quickly abandoned at DeWitt and was not put into effect at either of the other centers.
The large amount of paper work required in vascular cases, because of the many and repeated tests performed, made secretarial assistance of unusual importance. It was provided without too much difficulty at Ashford and Mayo General Hospitals but was a problem at DeWitt because of its inaccessible location. The situation was somewhat relieved shortly before the center was deactivated by the assignment of WAC personnel who served as medical clerks.
Because of the shortages of experienced personnel previously mentioned, the training of additional professional and nonprofessional personnel proved an important part of the function of the vascular centers.
The numbers of medical officers qualified for assignment to the vascular centers were augmented in several ways. Staff officers who were attached to these centers and who had had no previous experience in vascular injuries and diseases were rotated through the medical and surgical wards and eventually assigned to the operating room. This procedure enabled them to become familiar with methods of examination, diagnosis, and treatment. Medical officers with previous experience, but assigned to other stations, were sent to the centers where they were given intensive refresher courses. In addition, young medical school graduates who had completed their preliminary training at Carlisle Barracks, Pa., were sent to the centers for instruction. This training
program proved fruitful for not only were specialists augmented in number but also some developed such skill, dexterity, and judgment that they became capable of handling independently complicated vascular lesions and major vascular operations.
The training of nonprofessional personnel was a more informal, and practically continuous, process. Ward personnel were instructed in the specialized requirements of patients with various types of vascular injury. X-ray technicians, who had already received their basic training, were instructed in the techniques of arteriography and phlebography. Other technicians were trained in the operation of recording apparatus used in the constant-temperature, constant-humidity rooms, and in the performance of special tests.
PHYSICAL PLANT AND EQUIPMENT
Ashford General Hospital
Ashford General Hospital, White Sulphur Springs, W. Va., was housed in the Greenbrier Hotel. This hotel, one of the most beautiful in the world, was converted to its new purpose without the loss of any of its traditional beauty and charm. Patients in the vascular center located in this installation were therefore cared for in a structure that was physically adequate, well maintained, and extremely attractive. Furthermore, the natural surroundings and recreational facilities were of great value in the rehabilitation of patients after their definitive treatment had been accomplished. All the necessary facilities for a modern hospital were available including an operating pavilion, a roentgenologic department, clinical laboratories, a physical therapy section, a reconditioning section, and photographic laboratories. Initial difficulties in obtaining precision instruments and other equipment necessary for the management of patients with vascular injuries and diseases were overcome at the center by the loan of the personal instruments of one of the officers attached to the staff. Some of his equipment was used throughout the operation of the center because the Army was unable to supply certain special types of instruments needed.20 Within a few months after the establishment of the center at this installation a constant-temperature, constant humidity room was constructed and provided with elaborate electrical controls which permitted a range of temperature from 40o to 110o F., as well as varying degrees of humidity. This room was equipped with delicate precision instruments including Boulitte oscillometers of both the recording and the manual type, apparatus for skin surface temperature determinations, instruments for measuring skin resistance, and a plethysmograph. Special lights, simulating daylight, were provided for all examining rooms. A chemical laboratory was set up for blood volume studies and a ballistocardiograph installed for the study of the circulation in the presence of vascular lesions.
20 In addition, great help was received from Dr. John M. Emmett and directors of the Chesapeake and Ohio Railroad Hospital located at Clifton Forge, Va., in the loan of instruments and linens, and the use of their operating rooms for sterilization.
Percy Jones--Mayo General Hospitals
When the vascular center at the Percy Jones General Hospital was first activated no special equipment was provided for the study of patients with vascular injuries and diseases. The difficulty was overcome by a member of the staff who loaned his own thermocouple and recording oscillometer. Oscillometers, thermocouples, cutaneous resistance apparatus, intermittent venous occlusion apparatus, a Sanders oscillating bed, and an ultraviolet light unit for intravenous fluorescin studies were requisitioned. Not all of these items were standard, however, and there was considerable delay in securing them. Since a controlled temperature room was not available, studies which are preferably done in a cool atmosphere were carried out in one of the air-conditioned operating rooms at times when it was not being utilized for surgical work.
Shortly after the transfer of the vascular center from Percy Jones to the Mayo General Hospital, the May Institute for Medical Research, Cincinnati, loaned the center a thermocouple, an oscillometer, and a plethysmograph. An additional thermocouple and four oscillometers were eventually obtained through Army channels. A controlled temperature room which permitted the constant maintenance of temperatures at any desired level between 40o and 90o F. was completed in September 1945 and until that time a serviceable room was achieved by the use of an air-conditioning unit of the room type.
Letterman--Torney--DeWitt General Hospitals
According to reports from Letterman General Hospital in 1943, facilities and equipment were adequate for investigating and treating patients with vascular disorders. 21 However, the hospital was becoming crowded by the flow of evacuees from overseas and since more beds were needed to handle an expected increase in numbers, 22 the situation was solved by shifting the patients requiring specialized treatment to other hospitals. 23
When the vascular center at Torney General Hospital was first activated, a 33-bed ward constituted the facilities of its vascular center. The initial requisition for equipment included oscillometers, thermocouples, a derimeter, and an intermittent suction apparatus. Shortly before the center was transferred to DeWitt, two sets of equipment for intermittent suction and two portable potentiometers were received, though the thermocouples ordered were not. This equipment was transferred to DeWitt and there efforts were made by the staff to secure the items missing from the original requisition, as well as to secure additional equipment. These efforts were not entirely successful.
A Collins oscillometer was received in July 1945, but the Boulitte and the Tycos recording oscillometers which had been requisitioned never materialized. A Van Slyke blood gas apparatus requisitioned in May 1944 arrived in July 1945. Other apparatus received after a considerable length of time
21 See footnote 5, p. 2.
22 Health-Monthly Progress Rpt, 28 Feb 43. HD: 720.-1.
23 See footnote 16, p. 11.
included a photoelectric cell apparatus for determination of the circulation time, an ultraviolet dark lamp, and a Samuels pulsimeter. Supplies of fluorescin and Blakemore-Lord anastomosis ferrules were also late in arriving. A Henderson-Haldane gas analysis apparatus and a plethysmograph were requisitioned but never received. The two oscillating beds finally delivered were used to good advantage in surgical cases before and after operation. Special operating room equipment included pneumatic tourniquets, Bethune tourniquets threaded and padded with split rubber tubing for direct arterial compression, and a manometer for direct measurement of intravascular and intra-aneurysmal pressures.
When the vascular center was transferred from Torney to DeWitt General Hospital a request was made for a constant-temperature, constant-humidity room. When it was finally constructed and put into operation, alternating hot and cold currents of air, readily discernible to anyone in the room, were created every 6 minutes. Engineers corrected this condition in part by reducing the rate of air exchange.
In spite of the difficulties and delays encountered in securing special essential equipment for the vascular centers, and in spite of the fact that some apparatus requisitioned was never received, it was the consensus of the staffs that in no instance was the care of a patient seriously hampered nor the outcome of any procedure seriously influenced by these lacks. Shortages in operating room equipment were met by improvisations; those in diagnostic equipment by greater reliance upon clinical methods supplemented by judgment and experience.
It should be mentioned that the photographic aboratories established at each of the vascular centers proved valuable, since much of the progress of patients with vascular lesions can best be recorded pictorially.
Aside from the fact that careful and detailed records are essential in the management of patients with vascular lesions, it was considered particularly desirable to keep precise records at vascular centers because of the unique opportunity provided for the collection of mass data concerning vascular injuries. The compilation of these records was tedious and time-consuming and was sometimes accomplished with difficulty since medical personnel were overloaded with work and secretarial assistance was frequently inadequate.
Army medical history blanks proved unsuitable for the purposes of the vascular centers and special forms were developed.24 They were found efficient and timesaving.
Much valuable material was collected from the photographic laboratories. This included black and white photographs of clinical conditions and pathologic lesions, colored photographs, transparencies for exhibit purposes, and drawings
24 Vascular Surgery-Forms. HD: 730.
of operative procedures. These were used to great advantage in the training program.
Delay in securing certain essential equipment prevented the carrying out of some of the clinical studies which had been planned. Blood-oxygen studies, for instance, outlined at DeWitt General Hospital were never initiated because of delay in the receipt of the chemicals required for use with the blood-oxygen apparatus. Despite plans, no plethysmographic studies were carried out at this center because the apparatus arrived after the patient load was so heavy that it was impossible to perform these time-consuming tests. It is regrettable that these and other studies could not be carried out because the amount of clinical material available in time of war can never be duplicated in a peacetime civilian practice nor, in time of peace, can available clinical material be concentrated and controlled as it can in time of war. In all the centers, however, clinical studies of immediate and future value were made on such subjects as trenchfoot and other cold injuries, thrombopblebitis, vasospastic states, ischemic paralyses, collateral circulation, the circulatory and other effects of aneurysms and arteriovenous fistulas, and the use of sympathectomy on various indications.