Tag Archives: navy medicine

The Grog, Issue 37, 2013 (A Journal of Navy Medical History and Culture)

The latest “ration” of The Grog, A Journal of Navy Medical History and Culture, is now online and can be found on our website here.

According to Andre Sobocinski, editor and historian, “In this edition, we look back at the U.S. Navy’s long history with sharks–from curious cases of shark attacks documented by Navy physicians to the development of “full-proof” repellents.  We follow this with an assortment of original stories and sidebars ranging from a look back on the life of a long-living World War II Prisoner of War and the service of Navy flight nurses in the Pacific and in Brazil to the recollection of Surgeon General Edward Stitt’s “Budget Battles” and a glimpse at the Navy Medical Department in 1963.

As always, we hope you enjoy this journey on the high seas of Navy Medicine’s past!”

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Benevolence Sunk!

This is the headline – emblazoned on a facsimile of a yellowed newspaper front page – that greeted me when I opened my home town newspaper, the Vallejo Times-Herald, yesterday morning.

USS Benevolence was  laid down on 26 July 1943 as a transport ship, SS Marine Lion, at Sun Shipbuilding and Drydock Company in Chester, PA. A year later, facing a surge in casualties in the Pacific Theater of Operations,the U S Navy designated her a hospital ship, AH-13. Todd Erie Basin Shipyard in Brooklyn completed her conversion to hospital functions, and she was commissioned on 12 May 1945. Benevolence transited the Panama Canal on 22 June, and after a brief stay in Hawai’i, made her way to the Eniwetok lagoon, where she provided care for war-wounded and sick Marines, sailors and soldiers until the end of hostilities. After a period of time at Yokosuka, where she gave care and comfort to liberated US POWs and civilian internees, she brought her first 1000 patients back to San Francisco in November. By 15 February 1946, she had completed her third “Magic Carpet” mission of bringing service personnel from Pearl Harbor back to  San Francisco.

USS Benevolence Anchored in Bikini Atoll for Atomic Tests, 1946 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

From May to September 1946, Benevolence provided medical support for the Bikini atomic tests. After a 19 day rest in San Francisco, she deployed again, this time to serve as a station hospital off Tsingtao, China. After nearly six months, she returned to the US, this time to be decommissioned at Hunters Point Naval Shipyard in San Francisco. She was laid up in the Pacific Reserve Fleet until the outbreak of the Korean Conflict. She underwent refurbishment at the Mare Island Naval Ship Yard.

On her return from sea trials, with a small medical contingent and a large number of civilian technicians aboard, in heavy fog and zero visibility, Benevolence collided with the commercial ship SS Mary Luckenbach. The stricken hospital ship sunk within 25 minutes. Fortunately, all but 31 of her crew and passengers of more than 500 were able to get off the ship and into the frigid waters off San Francisco Bay. 18 people died or were lost. If she had had patients embarked, the tragedy could have been much worse.

USS Benevolence on her side off San Francisco Bay, 1950 (Photo: NavSource Online: Service Ship Photo Archive, http://www.navsource.org/archives/09/12/1213.htm, accessed 26 August 2012)

The ship lay in the shipping lane for 16 months while attempts were made to salvage her. When these were unsuccessful, salvage workers used three explosive charges to demolish her. She was stricken from Navy rolls on 20 December 1950.

I extracted the ship’s history  from Navy records, accessed 26 August 2012, http://www.history.navy.mil/danfs/b5/benevolence-i.htm
 
©2012 Thomas L Snyder

A Step Away From the Past and Into the Present and the Future – An Old Doc’s Look at Health Care Reform

My son James recently sent me a link to a New Yorker article on health care delivery with this question: “Is Kaiser [-Permanente] like the Cheesecake Factory?” He might also have asked, “Is military medicine like the Cheesecake Factory?”

Health Care Reform - Change and Hope

In “Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, Boston surgeon and medical writer Atul Gawande tries to apply the lessons he learned, as a result of a meal at a Boston-area Cheesecake Factory, to health care delivery. While noting that the Cheesecake Factory chain has managed – very well – to control both cost and quality while assuring an excellent customer experience, Dr Gawande points out that medicine doesn’t do nearly as well.

According to Dr Gawande, even in the erudite halls of Boston’s vaunted teaching hospitals – presumably models of the best medical care America has to offer – physician approaches to patient care are individualistic – even idiosyncratic; this results in patient complication rates that vary by as much as threefold within the same hospital; and patient / family experiences have historically been almost invariably wretched. While these hospitals may be at the forefront of research and innovation in health care, they don’t seem to be doing a very good job of delivering quality “every day health care” to “every day patients”.

What are the lessons health care could learn from Cheesecake Factory?

The first is a consistent – and consistently good – product. In the restaurant business, consistency means “standardization”, a consistent way of doing the same thing over and over again. My first lesson in medical consistency came during residency: I trained in a Chicago hospital that catered both to “carriage trade” patients and people from a very poor “mile-square” area in the City. In caring for our patients, our attending physicians very early on cautioned us to use the same care procedures for both the very rich and the very poor, because the instant we tried to “customize” our care (either for the rich or for the poor), we risked introducing opportunities for  medical mistakes. Undoubtedly, in medicine just as in the cooking business, you need to apply the individual judgement of a well-trained and experienced professional to each case. But doctors are notoriously a restive group, very protective of their independence. How do you get a “herd of cats” to practice in a consistent manner, even while permitting those individual judgment calls that hone the standardized approach to each individual patient’s needs? Here, I believe, is the first place my Kaiser-Permanente and my military experience becomes instructive. In both Kaiser and the military, practitioners are salaried. Thus, they aren’t competing with each other for patients and for income. I believe this makes for an environment that encourages true collegiality and a sense of “we’re all in this together”. When you combine true collegiality with a strong culture of “best practices”, I think it becomes relatively easier to develop a department-consistent (or even a hospital-consistent) approach to any aspect of medical care delivery. Of course, this takes effective leadership – something both the military and the Kaiser-Permanente model have spent some resources in cultivating.

Another lesson from my experience not necessarily highlighted in Dr Gawande’s piece is the importance of “doctor-based” decision-making. My favorite example comes from northern California Kaiser-Permanente. I was the chief of urology at my Kaiser hospital. At one of our quarterly Chiefs meetings at the Oakland, California headquarters of The Permanente Medical Group, the 13 of us were pondering a question brought to us by the Chief of the 13 Chiefs of Medicine: what should “company policy” be regarding the use of PSA screening for prostate cancer? Then, as now, with the possible exception of one or two very well circumscribed situations, the data are not at all certain. And then, as likely we would now, we argued the pros and cons at some length. Finally, with no consensus forthcoming, we turned in frustration to the representative from “Higher Headquarters” and begged “What do you want us to do?”. The answer was “You are the content experts. When you decide a policy, that shall be the policy of Kaiser-Permanente.” (We’d probably be urged, today, to look for a “best practice” model to follow, subject to change, of course, as experience and research refined our understanding of the medical matter at hand.) What a reassuring message I could bring back to my colleagues, and to my patients! No “bureaucrat” is making health care decisions for you!

Back to the Cheesecake Factory, Professor Gawande takes notice of the extensive use of computers, with screens at face level throughout the kitchens. These provide the company recipes and serving suggestions, readily accessible throughout all 160 restaurants in the chain. Both the military and Kaiser-Permanente have adopted extensive computer operations throughout their systems. In fact, Kaiser was looking to introduce system-wide computerized health care records and data sharing as early as the late 1980s. Computerized systems permit a secure sharing of medical information – lab test results, radiology images and medical history information – at every hospital and clinic in the system. The value of this is immeasurable in the reduction of unnecessarily duplicated tests and exams, and the easy discussion of such things as Xray images between specialists within the system. When my wife was facing arthroscopic knee surgery recently, her orthopedist just pulled her MRI images up on the screen right there in the exam room and went over them with her and me in detail! With the computerization of health records comes a similar easy collaboration between primary care provider and a specialist or specialists who might be located – at least in the military – half way around the world. The Kaiser organization offers an electronic version of a patient’s health record – on a thumb drive – that he or she can take on vacation, at nominal cost.

The Cheesecake Factory has an active product development establishment that produces an updated menu about every six months. Each of the military services has the equivalent – a research arm which searches for innovations in preventive medicine and the special health requirements of people operating in challenging environments whether that be in submarines, in space, or in the mountains of Afghanistan. The Kaiser-Permanente Division of Research, based in Oakland, California, has published more than 4000 peer-reviewed medical articles in its 50 year history. In 2010, its budget of nearly $100,000 supported more than 50 researchers involved in more than 200 research projects largely but not exclusively oriented to the health of large populations.

Both the military and the Kaiser-Permanente systems of health care offer a feature Dr Gawande doesn’t mention – the regionalization of very specialized care. For example, in northern California, Kaiser-Permanente’s more than 3 million patients receive their cardiac surgery at specialty centers in San Francisco and Santa Clara. Neurosurgical care is centered in Redwood City and in Sacramento.  The military system has similar echelons of care, from clinics to primary care hospitals to specialty hospitals. This regionalization avoids unnecessary duplication of expensive specialty care and equipment, and, as a bonus, assures that super-specialty surgeons and physicians are constantly busy – one determinant of successful outcomes.

Then there is the matter of “size”. The Cheesecake Factory, with its 160 restaurants, experiences economies of scale in purchasing of everything from eggs to refrigerators. The Department of Defense medical establishment is huge – the largest in the country. If if were so oriented, its huge purchasing power could effect amazing savings of scale. One example of Kaiser-Permanente marketplace power comes from some years ago. As the story goes, one domestic insulin manufacturer bought out its competition and then announced a large increase in the price of insulin. Promptly the northern California Kaiser pharmacy operation, as a major purchaser of insulin,  reached out to a large Scandinavian insulin producer and offered to partner with them to bring product to market in the US. This effort was successful, and the price of insulin dropped promptly.

Health care reform, in my view, requires one more thing that was implicit in Dr Gawande’s New Yorker restaurant piece: competition. Even while it was struggling to grow in its early years, the Kaiser-Permanente organization realized that healthy competition is a necessity. From the early 1940s, the Kaiser mantra became something like “unless patients have choices in the care they receive, we will have no opportunity to show how good we really are”. When I was practicing Navy medicine as a General Medical Officer, lo, those many years ago, I remember resenting my patients going to the doctors “downtown”, on the civilian side, for their care. I knew we were giving every bit as good care as the “townies” did, but the knowledge that our patients had a choice kept us all on our toes to do the best we could, even in the”captive” care system that is military care.

There you have it: consistency of medical procedures while encouraging the application of sound judgement; salaried health care providers to eliminate destructive competition and encourage collegiality and unity of approach; doctors- or professionals-driven policy decision-making based on consensus best practices; extensive application of computer technology to record keeping, data sharing and promulgation of consistent practice; regionalization of super-specialized care; scale of economy based on large regional or national systems of organization; and vigorous competition among provider systems.

By way of background, I practiced medicine in all three practice settings: active duty military (Navy, for 3 years), fee for service in a small multispecialty group (5 years), and in the large northern California Kaiser-Permanente Health Care system (20 years). In addition, with 20 years in the Naval Reserve, I had contact and conversations with physicians from around the country who practiced in a variety of settings. These experiences all convince me that a salaried system of care providers virtually eliminates the extra and often unnecessary medical procedures engendered by the fee-for-service model where a physician is paid for each procedure carried out. Fee-for-service puts the emphasis, in my view, on health care providers (the more procedures, the higher the income), rather than their patients and what’s best for them. It’s much more natural for salaried providers to be driven by what’s best for their patients, since salaries are going to be paid whether procedures are performed or not.

©2012 Thomas L Snyder

Medical Care at the Battle of Midway, Part II: Combat Casualty Care Aboard a Sinking Ship; Rescue Ships and Medical Care

Last week, I commented that some lessons of previous wars have to be learned anew; the case I cited was that of flash burn prevention, relearned only after the Battle of Coral Sea. This week, we read how the chaos of ships under attack complicates the delivery of casualty care. We also learn a lesson or two about medical preparedness.

I mentioned last week that I depended on on-line sources for these postings; in particular, the Battle Reports of the Commanding Officer of USS Yorktown(1), sunk at Midway, and Commander Destroyer Squadron SIX (TF 17.4)(2). These reports, written just days after the events they portray, are as raw as they are economical in words.

The medical paragraph in the Yorktown report is especially informative:  the initial bombing attack on Yorktown resulted in the near-destruction of battle dressing station 5 in the wardroom annex. Personnel there “were badly shaken but were not otherwise injured… These personnel proceeded to the flight deck and hangar deck to assist wounded there.” In the following torpedo attack, battle dressing station number 4 was flooded and destroyed. I could find no comment about medical personnel injuries or deaths.

Shrapnel caused the vast majority of injuries among the 55 men who went on to require hospitalization. Many patients experienced severe penetrating shrapnel wounds; these cases required blood transfusions and plasma administrations, most if not all administered in the battle dressing stations. 60 men received minor wounds or rope burns from sliding down ropes into the water.

Yorktown survived the initial attacks. Severely wounded men were prepared for surgery, and the operating room activated. Within minutes, however, torpedoes hit the ship. All lights and communications went down, and the ship immediately developed a heavy list. When the Captain issued “abandon ship” orders, medical personnel immediately commenced evacuating the casualties. This process was made almost impossible because ladders leading from sick bay were damaged so that stretchers could not be used to lift patients out of the hold. Slippery decks and the ship’s list made it impossible to carry stretchers, so men were reduced to sliding them across the deck, or bodily man-handling casualties. Rescues below the main decks had to be carried out in pitch-black darkness, perhaps with the aid of flashlights only.

Lifeboats on the high side of the ship could not be launched, so wounded men were lowered over the side in straps from other ships, or onto life rafts, or into the water, and picked up later.

Destroyers Balch, Benham, Russell, Anderson, Morris, Hughes, Hammann (she sank quickly when two torpedos struck her as she lay along side Yorktown providing engineering support to salvage efforts) and Bidell provided rescue operations, and it fell to the medical departments aboard these small ships to care for about 2270 survivors. Claude M Lee, Jr, LT (jg), MC, USNR and his assistants aboard USS Balch cared for 544 survivors. “His all night occupation with the operative and surgical care of injured men, his forethought in providing adequate and special medical supplies and in training of personnel to handle this particular emergency” came in for special commendation from ComTaskFor17.4.

Few medical “lessons learned” find their way into these after action reports. The Destroyer Task Force commander did point out that “[t]horough instruction and stationing of officers and men for rescue work is essential”. It makes sense: once the fighting is done, or when a ship can no longer be fought, the combat work of officers and men is done. The emphasis now shifts to rescuing survivors, and this should be almost an “all hands” operation, with all hands trained to properly carry it out.

Another lesson is not stated in these reports, but I think this has significance in today’s naval activities. Big naval units (translate this “aircraft carriers” in the U S Navy) are the big targets, too. They are also well supplied with sophisticated medical and surgical personnel and equipment. But if one of these big targets is successfully attacked, use of these medical assets may be compromised or lost, and casualty care then falls to smaller rescue ships – destroyers- whose medical “kit” often consists of a senior hospital corpsman and one or two junior assistants. These ships need to have their medical staffs – and their medical equipment and supplies – beefed up significantly when combat is anticipated. I believe that the US propensity to depend upon helicopter evacuation of casualties can’t be depended upon in the chaos of naval battle because the airspace may be dangerous from enemy action, or too full and too confined around an aircraft carrier for orderly and rapid evacuation of something like 2500 or 3000 casualties.

We should learn and apply these lessons now, lest they have to be re-learned in future naval battles.

(1) Buckmaster, E. (Commanding Officer, USS Yorktown): Report of Action for June 4, 1942 and June 6, 1942, 18 June 1942, http://www.history.navy.mil/docs/wwii/mid7.htm, accessed 7, 8, 15 June 2012.
(2) Sauer, E. P. (ComTaskFor17.4), Japanese Torpedo Plane Attack on U.S.S. Yorktown During Battle of Midway, June 4, 1942 — Report of, June 12, 1942, http://www.history.navy.mil/docs/wwii/mid8.htm, accessed 7, 8, 15 June 2012.
 

©2012 Thomas L Snyder

U S Navy Medical Corps Beginnings

A death in the family takes me away from writing this week. Herewith, I post an article I wrote in my role as Surgeon General of the Naval Order of the United States. It should appear in the Order’s spring newsletter, publish date to be determined.

Historical Note

The US Navy was a relative latecomer to the establishment of a permanent corps of physicians to serve the health of sailors. While the navy assigned medical officers – doctors commissioned in the naval service – to ships and shore establishments from the very beginning, surgeons (the other term commonly used for navy physicians) did not have their own organization in the Navy until the establishment of the Medical Corps on 3 March 1871.

Historically, in the west at least, mention of physicians serving aboard naval vessels goes back to the Greek poet Homer. The Roman navy is believed to have paid its surgeons double the army rate in order to encourage their service in the less prestigious military arm. During the late middle ages, the Italian maritime republics routinely posted surgeons aboard ships, and during the Crusades, naval surgeons established shore based facilities for the care of injured and sick sailors. Medical Officers of Genoa and Venice were responsible for issuing health certificates to sailors of these navies; these officers also established port quarantine (from Italian quarantina giorni–”forty days”) procedures for prevention of imported contagion, especially the plague.

In the modern era, the Spanish and French were early to adopt standing naval medical establishments, maintaining naval hospitals in colonial territories. While the British Royal Navy had surgeons aboard ships from the 15th century, they did not form what might be recognized as a formal medical corps until 1805, when for the first time, surgeons of the Royal Navy were granted rank similar to other military officers, and a distinguishing uniform.

From the beginning, U S navy regulations specified a unique uniform for medical officers, but they were not granted rank-equivalence with their line officers until around the time of World War I. Prior to that, medical ranks were Assistant Surgeon, Passed Assistant Surgeon, Surgeon, Medical Inspector and Medical Director. At the time of Medical Corps formation, the prescribed uniform feature that designated a medical officer was a strip of cobalt color between the rank-identifying gold sleeve bands:   (here the rank of Medical Inspector, equivalent to Commander).

Today the unique designator for a U S Navy doctor is the acorn-on-an-oak-leaf –  – a symbol of obscure origin instituted by Naval Regulations in 1897.

©2012 Thomas L Snyder

Everyday Medical Life Aboard Ships

I remember my days aboard destroyers as a Vietnam-era Squadron Medical Officer as requiring one to endure hours of boredom, gently punctuated by the occasional inspection of medical stores or the occasional consultation for a particularly pernicious case of gonorrhea. While the story of how the particular sailor caught his case of the gleet may have made for a good morality short story, everyday shipboard medical life is not the stuff that excites historians. Until now.

Society for the History of Navy Medicine member William P McEvoy (he goes by “Mac”) has recently had published “‘Experiences at Sea’: A Navy Doctor at War”, in the Journal of Military History. Mac, a PhD student in military history at Kansas State University introduces his topic in his Abstract thus:

This article identifies a significant hole in the literature of World War II.
Few works discuss the everyday life of medical personnel and fewer still
detail the lives of naval medical providers; those that do tend to focus on
the exciting and bloody aspects of a medico at war. Filling this gap, this
article argues that the most accurate picture of life at war should include
life’s routine features and then describes the everyday experiences of
a U.S. Navy doctor in the Pacific from September 1944 to December
1945, whose daily existence was far different from and more typical
than the one most often portrayed.

Mac’s paper is here: McEvoy. He’s very interested to have your comments of praise and of constructive criticism. Leave a comment below, or send me an email, and I’ll forward your comments to the author.

©2012 Thomas L Snyder

Holiday Greetings

Happy Holidays!

Warm best wishes for the holidays from the Society for the History of Navy Medicine.

We hope you are able to take a short pause from your busy labors over the next week. It’s time to enjoy visits from friends and family, to partake of a bit of the wassail, and, perchance, to share a child’s excitement at the prospect of Santa’s visit.

This might also be the week when we can reflect on our accomplishments of the year nearly past, and on those near-misses, too. We can start to plan the mid-course corrections that will, we hope, bring even more accomplishment and contentment in the year to come.

I invite you to consider adding a “public historian” element to your endeavors in 2012. Put together that PowerPoint you’ve been thinking about (I find that just organizing the slides forces me to look at my sources in an active sort of way), then take your historical knowledge out into your community. There is no end of groups who are very interested in what you have to say: Rotary, Soroptimists and other service groups; church groups; local historical societies; junior college history or student activities organizations; veterans groups; public libraries; the list goes on. I guarantee you: once word gets out that you have “something to say”, the invitations will flow in. And it’s fun. You will be amazed at the stories people will bring to you, information quite relevant to your topic at hand.

Finally, if you have a few bucks in your pocket as the year comes to an end, please consider a tax-deductible donation to the Foundation for the History of Navy Medicine. The Foundation sponsors the Society’s Student Travel Grants Program to promote interest in research, study and publication in our narrow little corner of the world of history.

©2011 Thomas L Snyder