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Chapter VIII

Contents

CHAPTER VIII

Second Service Command

Robert H. Kennedy, M.D.

EXPERIENCE AND ORIENTATION

    Col. Robert H.. Kennedy, MC, was Chief of Surgical Services at Percy Jones General Hospital, Battle Creek, Mich., from September 1942 to August 1944 and at Mayo General Hospital, Galesburg, Ill., from August 1944 to January 1945. Both hospitals were in the Sixth Service Command. During this period he also served on a number of occasions as acting surgical consultant to the Sixth Service Command headquarters, which had no consultants assigned to its medical division. This arrangement of combined duties as chief of surgical service and acting surgical consultant was unsatisfactory, yet it did give some orientation as to the possible problems and opportunities of a surgical consultant.

    Colonel Kennedy was given no guidance as to his duties from the Office of the Surgeon General or the local command at the time of his assignment as surgical consultant, Second Service Command, on 18 January 1945. Neither was there any period of orientation. The value of his work, therefore, depended on the attitude of the service command surgeon toward administrative and professional problems. It was necessary that mutual confidence be developed first and that, once mutual confidence had been established, a continuous effort be made to keep the new consultants work mainly on the professional rather than the administrative level. Colonel Kennedy was accorded full cooperation from the Office of the Surgeon General and the service command surgeon throughout his tour of duty, which ended 31 January 1946.

ADMINISTRATIVE DUTIES

    There was a border zone between administrative and professional decisions and details in which a consultant was of much assistance to the service command surgeon, but as a rule the consultant employed his time to the greatest advantage in supervising patient care--indeed it was his primary responsibility to see that such supervision took precedence over his other duties. For example, each commanding officer in the Second Service Command submitted a monthly request for promotion. Also, each division in the service command headquarters was asked to rate monthly, in order, all officers on the roster with regard to priority for promotion. This entailed Colonel Kennedy's going over several hundred names in which scores of changes occurred each


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month. It was natural that few, if any, promotional vacancies should exist for the surgical staff each month. The time spent on trying to appraise these men, conscientiously in order to preserve morale, was largely wasted and would have been spent more wisely on clinical problems.

ADMINISTRATIVE FACTORS IN PROVIDING PATIENT CARE

Hospital Construction

    The type of hospital construction made a great difference in the efficiency of administration and of professional care. There were five general hospitals in the Second Service Command. One, which was of the cantonment type, built after the war began, could be operated efficiently. Another, a considerable portion of which had been built before the war, consisted of two cantonment type units a mile and a half apart and could never be properly integrated. Two new State hospitals were taken over and ultimately functioned well, but only after numerous structural changes and adaptations. The changes were so extensive that the State could barely recognize these institutions when they were returned. The fifth general hospital was made up of several resort hotels in an area in which all hotels were not released to the Army. This setup was never satisfactory for effective administration and resulted in much wasted effort. Good patient care was rendered in all, but the consultant's time required at each institution was definitely proportional to the effectiveness of hospital construction.

Location of Hospital

    The site of a hospital played a vital part in its efficiency. A hospital within New York City was over an hour's travel from the traditional centers of recreation in Manhattan. Patients could go to Manhattan rarely, but were always restless because of its proximity. Well-meaning lay persons came in hordes to try to help, and interfered considerably with orderly care. A hospital at a shore resort had good individual morale among patients, difficulties in maintaining discipline, and constant spoiling of troops from exposure to tourist crowds (fig. 29). A general hospital within a training post was unsatisfactory from a morale and recreation standpoint. The cantonment type of hospital 6 or 8 miles from a small inland city seemed to keep its patients uniformly satisfied and adjusted.

Personnel

    The nonavailability of competent professional personnel throughout 1945 was a great problem. Bed occupancy in Zone of Interior installations was constantly increasing. The amount of required operating and rehabilitation was stepped up markedly. In each of the surgical services, there was a scarcity of experienced personnel except among a few top key men. By the fall of 1945, a steady stream of medical officers were returning through New York


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FIGURE 29 - Recreational and exercising facilities for amputees. A. Amputees swimming. B. Quadruple amputee riding exercising bicycle. Note tourists on open beach.


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City from abroad and had to be assigned to posts according to their experience. The major interest of many of these officers was discharge. It was remarkable that the greatly increased volume of work was carried on so efficiently. Even at that late period in the war, the greatest lack was still in trained orthopedic surgeons.

    The most efficient organization to head a surgical service proved to be that consisting of a chief, an assistant chief, and an administrative assistant to the chief. There was much paperwork to be done, and the chief should have been relieved of this as far as possible. The assistant chief, preferably, should have been a mature key man in one of the specialties, an officer who could have assumed the responsibilities of the chief in his absence but who otherwise had no office duties. The executive assistant to the chief should have been a young medical officer with an orderly mind, who probably was unavailable for over-sea service, and who could have acted as a buffer for the chief. In the future, Medical Service Corps officers may be effective in this position, but not many members of the wartime Medical Administrative Corps were customarily ready for such a position.

    The general hospitals varied so greatly in their construction, location, and special missions that a table of organization had little practical value. For example, officers at Halloran General Hospital, Willowbrook, Staten Island, N.Y., had to become debarkation officers about twice a week; those at Tilton General Hospital, Fort Dix, Wrightstown, N.J., were flooded with problems from the separation center after September 1945; and Thomas M. England General Hospital, Atlantic City, N.J., as an amputation and neurosurgical center, and Halloran General Hospital, as a neurosurgical center, required many more operating surgeons if the load was to be kept moving. The consultant had to jockey assignments constantly among hospitals according to the particular load and the available medical manpower.

PROFESSIONAL ACTIVITIES

Patient Service

In spite of all administrative problems, the basic job of the consultant was ward rounds. He learned how the chief of each section handled his patients and his professional personnel; who was happy and who, disgruntled; who was being used in a most effective spot, and who was not hospital material. Were patients being kept too long? Did they belong to a convalescent. hospital? Had they reached maximal improvement? Would they be unfit for further military service, and should they be ready for their civilian life immediately without further rehabilitation? Were the men who constituted the disposition board taking all these factors into account? Clinical lectures might have been of value in slack times, but with the normal overload of duties during the author's service as a consultant, personal contact with the ward officer in examples of


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his immediate problems was more important. Drs. William Darrach and William W. Plummer, as civilian consultants in orthopedic surgery, visited all the general and regional hospitals during Colonel Kennedy's tenure and were a constant source of stimulation to officers in group conferences. Thus left Colonel Kennedy free at the same time to delve into other hospital details.

CONFERENCES

    A Second Service Command anesthesia conference was held on 17 June 1945 at Headquarters, Second Service Command, Governors Island, N.Y. It was attended by 74 persons and it spread much valuable information. A conference on spinal cord injuries was held at Halloran General Hospital on 19 October and at Thomas M. England General Hospital on 20 October 1945 and was attended by 95 people. These sessions reviewed the most recent findings in the treatment of paraplegics.

Interhospital Visits

    On several occasions there was sufficient lull in the load of work to permit the sending of the chief of surgical service at a general hospital to another general hospital in the command for from 2 to 4 days observation. Similarly, the chiefs at the general and regional hospitals spent one day together at Camp Upton Convalescent Hospital, New York, N.Y. Several chiefs of sections were placed on temporary duty for short periods at hospitals outside the command for observation of particular types of treatment. All of these visits were vital in improving the care and lessening the morbidity of the individual soldier.

    The consultant had an opportunity to visit a number of installations and facilities outside of the command. This was usually at the time of some special conference. In all instances, new valuable ideas were obtained from observing the manner in which problems were being met in other commands.

SURGERY IN GENERAL HOSPITALS

Amputation Center

    The amputation center at Thomas M. England General Hospital was authorized to have 1,200 beds for amputees. In only 3 months was its census as low as 1,200; the maximum number of patients the hospital registered at one time was 1,625. Maj. Rufus H. Alldrege, MC, was Chief, Amputation Section, and did an outstanding piece of work. His results in Syme's amputations were particularly noteworthy.

    In compression bandaging of the stumps, 2,000 to 2,200 Ace bandages had to be washed daily. Washing was being done in the hospital laundry, but the bandages were dried in open corridors in the basement, creating a most untidy appearance. What had been the hotel bakery adjoined the area and


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was not in use at this time. It was found that the bandages could be spread out over the trays used for baking rolls and that each of the 8 trays of a single unit would accommodate between 20 and 40 bandages. Two motor driers with heating units were developed and the entire load of bandages could be dried in a total of 6 hours. Other problems were more difficult for solution.

    The limb shop created many problems since as many as 292 prostheses were completed in one month. Personnel had to be changed too rapidly. Students always were in training. The limb shot personnel strength reached a high of 82. Individuals worked on day and night shifts. Research went on concomitantly with production, so that changes in material and types were too frequent. It would have been more efficient if research could have been carried on in a smaller unit and not where 1,500 amputees were waiting for their prostheses so that they could be discharged.

    The work of the physical therapy personnel for the amputee was outstanding. Remedial gymnasiums with pulleys, steps, walking lamps, and mirrors were set up in two hotels. A new training program was set up late in 1945 according to which no soldier was allowed to wear his prosthesis until he had developed proper muscle balance of all parts of his body (fig. 30).

    Striking work was done at Halloran General Hospital by combined neurosurgical and orthopedic operators in cases with healed wounds which required both a bone graft and peripheral nerve suture. The neurosurgeon exposed the involved nerves. With the aid of the neuropathologist doing frozen sections, the amount of necessary nerve was removed until there was no longer scar involvement. The orthopedist then entered the picture and was told by the neurosurgeon in upper arm cases how much shortening of bone was needed, if any, in order to bring the nerve ends together without tension. The orthopedist then prepared the bone ends and did his bone graft, and the neurosurgeon returned to the case and did the nerve suture and closed the wound. In some instances these procedures required as much as 12 or 14 hours, but, in no instance was there severe shock. Thus shortening of bone, of course, was done only in upper extremity cases.

Neurosurgical Centers

    In cases of herniated nucleus pulposus, if operation was indicated, the question of whether a fusion was to be done was decided by agreement of the neurosurgeon and the orthopedic surgeon.

    The load of paraplegic patients at Thomas M. England General Hospital reached 110 and that at Halloran General Hospital, 108. Much thought and effort was exerted to obtain the best care for paraplegic patients. All fields of medicine concerned cooperated in the effort with a neurosurgeon in charge at Thomas M. England, and a urologist, at Halloran. At the latter hospital, large decubitus ulcers over the sacrum were closed after March 1945 by full


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FIGURE 30 - Gymnastics in the reconditioning program at Thomas M. England General Hospital, Atlantic City, N.J.

thickness flaps mobilized by undercutting out over the buttocks, even approaching the great trochanters. It was often a 4- or 5-hour plastic procedure, but the results were excellent. The writer believes that Thomas M. England General Hospital was the first Army hospital to perform this operation. At this same hospital, a dining room was set up on the ward floor with tables so arranged that wheelchairs could be wheeled to the table with the patients' extended legs under the table. The dietitian was particularly valuable in the recovery of paraplegics. A printing press was obtained and a newspaper started. The paraplegics served as reporters, editors, typesetters, pressmen, and newsboys. One physical therapist was assigned full time to this ward, with a number of WAC personnel trained in physical therapy to assist her. At Halloran General Hospital, a large ward was set up as a gymnasium with mats, parallel bars, overhead ladders, wall ladders, and other similar equipment. An open-air swimming pool was completed in midsummer 1945 and was available to the paraplegics. The progress made in the professional and psychological care of these patients at both institutions was outstanding.


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Orthopedic Sections

    Thoroughly competent chiefs of the orthopedic section were present in all hospitals, but, except for the key men, the large load was under the direct care of men with too little experience or interest. The change in officers was so rapid that, in spite of much effort, the use of suspension-traction was never too satisfactory. Too many patients were kept in plaster encasement. The maintenance of proper length and axis while an open fracture was healing was accomplished particularly well at Halloran General Hospital as was also the conditioning of the quadriceps and the maintenance of proper power of the Achilles tendon. This was due to an exceptional section chief, Maj. George Carpenter, MC. At Thomas M. England Hospital, the amputation center made considerable fresh homologous bone available. Maj. Rafe N. Hatt, MC, chief of the orthopedic section, used this in many instances to replace loss of major bone length with excellent results. This was before the idea of a bone bank had been conceived.

    In all but one hospital, the chief of orthopedic section was in charge of physical therapy. The least valuable physical therapy department was the one in which a full-time officer in physical therapy was in charge. In Halloran, the major portion of physical therapy treatment was performed on bed cases. This was as it should have been, rather than waiting for bed cases to become ambulatory. Massage should not have a major use in Army physical therapy.

    The value of occupational therapy depended entirely on the imagination of the personnel. At that, time, too few technicians were, trained to give functional occupational therapy, and the stress was chiefly on recreational therapy. This was little needed outside of neuropsychiatric sections.

Miscellaneous Patient Care

    The plastic, artificial-eye center at Halloran General Hospital, under Maj. Victor H. Dietz, DC, did beautiful work (fig. 31). Maj. Dietz was one of the originators of this process.

    Anesthesia schools for nurses were conducted at four hospitals. Twenty-four nurses were graduated during 1945. The nurse anesthetists were of great assistance.

    Cantonment type buildings lent themselves readily to the installation of a recovery ward adjacent to the operating suite. This was done at Rhoads General Hospital, Utica, N.Y., and at Tilton General Hospital. With a recovery ward, for which the anesthesia section was responsible. much better attention could be given to postoperative treatment as regards fluids, sedation, atelectasis, et cetera.

    A central supply proved valuable in all hospitals. Because of the prevalence of hepatitis, a system was introduced at Rhoads General Hospital in the summer of 1945 by which all syringes and needles were carefully cleaned, then separately wrapped and autoclaved.


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FIGURE 31. - Constructing and fitting artificial eyes at Halloran General Hospital. Staten Island, N.Y. A. Painting the iris. At far left is mold for preparation of the cornea and the basic artificial globe is in the center. B. Affixing primary veins to the cornea. C. Patient wearing completed left eye.


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SURGERY IN OTHER HOSPITALS

Station and Convalescent Hospitals

    Twenty-eight visits were made to regional or station hospitals. The hospitals had many problems. In apportioning his time among these hospitals, the consultant took into consideration the greatest good for the greatest number.

    The Camp Upton Convalescent Hospital required much time. Its census reached 4,100. Many patients were admitted directly from debarkation ports with no more than a field medical record. Many patients were sent from general hospitals to the reconditioning centers in braces and splints, at a time when directives were issued to clear general hospitals as much as possible. Orthopedic and neuosurgical consultants from Halloran General Hospital visited Camp Upton Convalescent Hospital weekly to advise as to care and disposition. Two fine remedial gymnasiums were opened in the fall of 1945 where patients were taken by companies for therapeutic exercise. It was a long hard pull for those concerned to succeed in their desires at this post. By January 1946, Colonel Kennedy believed that this hospital offered a tremendous opportunity for pretechnical and educational, as well as physical, reconditioning of the soldier under conditions in which his needed medical care was properly supervised and continued, and his disposition was determined after proper survey by competent officers.

Hospitals Not Under Jurisdiction of Second Service Command

    There were within the Second Service Command area three AAF (Army Air Forces) hospitals and three port of embarkation hospitals, the latter being directly under the Chief of Transportation, Washington. The surgical consultant could visit the embarkation hospitals, according to regulations, only by the following chain of events: The request for consultation had to be initiated by the chief of surgery to the hospital commander, who, in turn, endorsed it to the commanding officer of the port of embarkation; the port commander then endorsed it to the Chief of Transportation; the request then went to The Surgeon General of the Army, to the Second Service Command Surgeon, and finally, to the consultant. Naturally, this process took several days and the soldier concerned was likely to be beyond the need of consultation. A similar chain of events was required in AAF hospitals. The situation was particularly unhappy because Camp Kilmer Station Hospital, Stelton, N.J., had a complement of 1,524, and the hospital at Camp Shanks, Orangeburg, N.Y., provided 1,259 beds. After the first visit of the consultant to each of these hospitals, the situation was corrected so that the chief of surgery telephoned his request directly to the consultant, who then made a visit, to the hospital sub rosa. In the future, such situations should be corrected at a high level.


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STREPTOMYCIN

    Much of the early clinical work with streptomycin was carried out in the Second Service Command. In May 1945, a small quantity of this drug was obtained from Merck & Co. for use in bladder infections in paraplegics at Halloran General Hospital. In June, approval was obtained for a streptomycin pool in the Second Service Command, and 50,000,000 units were maintained at the Second Service Command Laboratory, New York, N.Y., and 10,000.000 units each were maintained at Thomas M. England, Halloran, Rhoads, and Tilton General Hospitals. The drug was to be issued only on authorization of the service command consultants after the case had been discussed with hospital personnel.

    In several instances, streptomycin was used in acute abdominal emergencies, such as general peritonitis following ruptured appendix. Sometimes it was injected within a few hours of operation before cultures were obtained. In its use in infected bladders, it was found at Halloran that time Proteus bacillus could be promptly eliminated within 48 to 72 hours with a dosage of 1,200,000 units, but that the bacillus usually recurred within 5 or 7 days. When the administration was repeated, it was found that the bacteria were much more resistant to streptomycin. It was therefore determined that an initial dosage of from 2,500,000 to 3,000,000 units was necessary in these cases.

    In August, the entire output of streptomycin was taken over by the Army and a certain amount of the drug was made available to Thomas M. England, Halloran, and Rhoads General Hospitals, which acted as pools for the rest of the command. During the last 3 months of 1945, streptomycin was used as little as possible because, due to the changeover of method of manufacture, little could be made available in comparison with the demands. In September 1945, under the direction of Capt. Edwin J. Pulaski, MC, a research project concerning the effect of streptomycin in war wounds was begun at Halloran. Certain ward beds were assigned to Captain Pulaski, and a special laboratory was set up.

SUMMARY

    In the Zone of Interior, a consultant system was necessary in surgery. The consultant was able to diffuse knowledge at the various installations for the benefit of the soldier. He was able to assign surgical personnel so that they would be used at their greatest value. He was able to support professional personnel in positions involving responsibility often greater than that to which they had been accustomed. He was also the eyes and ears of the service command surgeon in the handling of the professional problems of the command. Close mutual understanding and cooperation between the surgeon and the surgical consultant were required. and when they were lacking a change in incumbents was indicated.