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.
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