NAVY MEDICINE July-August 1993 Suqeoo Geaeral of the Navy Chief, BUMED NAVY MEDICINE VADM Donald F. Hagen, MC, USN Vol. 84, No. 4 July-August 1993 Deputy Surgeon General Deputy Chief, BUMED Chief, Medical Corps RADM Richard I. Ridenour, MC, USN Department Rounds 1 Autotransfusion Technique Saves Navy Hospital a Bundle Editor Jan Kermeth Herman A. Marechal-Workman

Assistant Editor Interview Virginia M. Novinski 4 Flight Surgeon on the Spot: Aboard USS Franklin 19 March 1945 J.K. Herman Editorial Assistant Nancy R. Keesee Features 10 Risk-Taking: Analysis and Intervention J. Lark NAVY MEDIONE. Vol. 84. No. 4. (ISSN 089S-8211 USPS 316-070) 11 publisbed bimonlhly by lhc Dcpanmenl of lhc Navy, Bureau of Medicine and 5ur&crY (BUM ED 14 Medicine in the Tropics Course: Preparing Navy Doctors for 09H). WuhiiiJIOII, DC 20372-5300. Second-elisa poat­ Global Medical Challenges qe paid II WuhiiJI(on, DC. and ldditional mailiq offic:cs. CDR J.M. Crutcher, MC, USNR POSTMASTER: Send lddrcssc:banps10Novy Medi­ CAPT H.J. Beecham III, MC, USN mw care of Naval Pubhellions and Forms Dim:tora~e. A1TN. Code 10363.5801 Tabor Avemae. Philadelpbia, PA 19120. POLICY: Navy Mtdirow is lhc official publicllion of 21 Chronology--World War II: Navy Medicine July-August 1943 die Navy Medical Depanmenl. It is illlalded for Medieal J. Mitchum DqJartmcat ~and coatainl professiooal iafonna­ liOII rdlliYe 10 mediciae, dc8istry. IDd die allied bealth ICJeDCa. Opioi-e&praiCd are diose ofdie audlon and Notes do IMJl IICCICIIUIIy repraeal die official position of die Dcparancnl of die Navy. die Bureau of MedicJDC IDd 28 Naval Medical Research and Development Command Highlights SuraerY. oraay olberJO¥-'clcpu1medor aacncy. Tndc --are IIICd for idealification only and do not rcpracniiD ClldoiiiCIIICIIl by die Depanmcm of die Navy Professional or die Bureau of MediCIIIC and 5urJery. Allboulb Navy Mtdicuw may cne or elllael from directives. aulhonty for 29 IV Antibiotic Self-Infusion for Active Duty Personnel IICbolllbould be obtained from die ciled reference. LT K. Summers, NC, USN DISTRIBUTION: Navy Medirow is diltributed 10 acave duty Medical Depanrncnl penonncl via die Stan­ dard Navy Dilcr1but1011 List. Tile fotlowina distribution is A Look Back audlorized: one copy for each Medical, Denial. Medieal ServiCe. and Nurse Corps ofr~eer; one copy for eacb 10 33 Navy Medicine 1922 enlisted MediCI! Dcpal'llllenl memben. Requests 10 m­ creue or decreue lhc number ofalloued copies lbould be forwarded 10 Navy Mtdicuw via die local command. NAVY MEDICINE 11 publisbed from appropriated rundl by alllhor!ly of die Bureau of Medicine and Suqery m -*nee Mlh Navy Publtcations IDd Prialina Reau­ lationl P-35. Tile Secretary of die Navy bas decermincd lhat dill pubiiCiliOII II nc:ccssary ID die UII1SIClioa of business reqwred by law of the Dcpartmenl of the Navy. COVER: One of the most gripping stories to come out of World War Fuads for pnlllliiJ IIIII pubiiCiliOII have been approved by die Navy l'llblicalionJ and PrilllliiJ Policy COIIIIIIiaee. II is the account of USS Franklin (CV-13). While conducting flight An~elcs. leacn. and lddress cbanccs may be forwarded 10 operations off the Japanese coast, a single Japanese bomber turned the the Ednor. Novy Mftllcilll!, Dcpal'llllenl of die Navy. Bureau of MediCine and SwJcry (BUM ED 09H). Wuh- carrier into a blazing inferno. LCDR Samuel R. Sherman, MC, 1111'011. DC20372-5300. Tclcpllonc(AreaCode202)6S3- USNR, was on the flight deck that day and won the Navy Cross for 1237. 653-1'1!¥7: DSN 294-1237. 294-1'1!¥7. C0111ribulions from die fidel are welcome and w111 be published as space his heroism. Story on page 4. Photo courtesy National Museum of pcnnill, subjectiO edllill& and possible abrid&JDCIII. American Jewish Military History. For sale by the Supcri111cndcm of Documcnll, U.S. Govcmmcn1 Printma Office. Wuhina10n. DC 20402.

NA VMED P·SOII Department Rounds

Autotransfusion Technique Saves Navy Hospital a Bundle

LCDR Paul Potter hooks up the suction on the Cell saver 111.

WHEN LCDR PaulS. Potter, MC, originally trained on." the surgery; clean the red cells and USNR, became a staff anesthesiolo­ That was 20 years ago. Since then, reinfused them back into the patient. " gist at Oak Knoll, CA, in 1991, he after getting out of the Navy in 1977, Using this method, the autotransfuser saved the command $175,000 in 1992 Potter started medical school on a operator can give back up to 80 cc's and $173,000 for the first 6 months of health professional scholarship and from every 100 cc 's of blood lost -- a 1993. He was able to cut thousands of worked with Dr. Malcolm Orr, the recovery of 80 percent. dollars from his department's budget physician who "invented all these sys­ According to LCDR Potter, use of by revising the autotransfusion sys­ tems. " Orr was the chairman of the the autotransfusion machine has more tem. Anesthesia Department at the Univer­ than budget-saving significance, how­ Potter was introduced to sity of Texas. Prior to the Bentley, ever. In terms ofdisease transmission, autotransfusion as a corpsman at Na­ Potter explained, "During surgery, as the medical implications are far reach­ val Hospital Portsmouth, VA, where patients bled, the blood was suctioned ing, especially since hepatitis and AIDS he used the Bentley Auto Transfuser. and simply thrown away. It could not came on the scene. This marked the beginning of an era be reused. This meant an awful lot of "If you look at statistics for disease that revolutionized surgical blood trans­ waste, so Dr. Orr, myself, and a lot of transmission from banked blood, there fusionlautotransfusion practices inter­ other people devised a system whereby is 1 in 40 to 1 in 100,000 chances of nationally. the blood could be salvaged and trans­ contracting AIDS and 1 in 400 chances "That was one of the original sys­ fused back into patients, as needed. " for hepatitis and parasitic diseases tems designed during the Vietnam era To describe the procedure briefly, such as malaria and, now, the dreaded to salvage blood from wounds and Potter said, "We collect the surgical HIV," Potter remarked. He added recirculate it to the patient," he said, blood in a sterile container; wash out that the autotransfusion technique -­ referring to the Bentley machine. "It all the fat, bone chips, and debris the ability to pick up the surgical blood had some problems, but this is what I picked up in the vacuum line during during a procedure, filtering it and

July-August 1993 1 Front view of the Cell Saver Ill. putting it back into the patient -- has been available nationally since about 1975. "But it wasn't used in anything but major heart cases until the mid- 1980's, when HIV came on the stage and scared everybody. According to statistics from 1988, in the United States, 1. 8 million units of blood were donated and transfused. Of that, .18 million units were from autotransfused blood. This means that only about 10 percent of blood was self-salvaged. It's projected that by the year2000, the percentage should be raised to about 35 to 40 percent." Dr. Potter has been doing his best in this regard since he came to Oak Knoll, first as a resident anesthesiolo­ gist in July 1988, then when he took over as director of the autotransfusion service in October 1991 . He explained that, while he was a resident, the service was provided by a civilian contract group whom he felt was "sort of plus and minus in their abilities." When he became staff, he decided that he could do the job much more effi­ ciently and at greatly reduced cost to the government. So, he "took over the service, organized it, purchased ma­ chines, trained the corpsmen, and started running a technician service." Potter was quick to point out that the salvage technique is being done throughout the world and that the significance of Oak Knoll's contribu­ tion is its prominence in the realm of separate it into the blood components plasma from the blood bank, thus platelet and plasma salvage. "We've that are normally obtained from blood cutting down the risk of disease trans­ revolutionized that," he said. "Prior to banks -- platelets, red cells, serum, mission considerably." [our intervention], the salvage was and fresh plasma. We store those dur­ All of this means that, with the undertaken as a reaction to major ing the surgery and, as they're needed, dedication of the technicians who are blood loss. What we've done is take we return those blood components to trained on a "strictly voluntary basis," the process one step further. the patient. Naval Hospital Oakland's Anesthesi­ "We come into the operating room "This means that, not only have we ology Department has become a lead­ prior to the start of the surgical proce­ cut down the amount of red cells ing authority in autotransfusion. Pot­ dure, hook up our machines, tap into needed because of the bleeding, but ter said that, routinely, he gets re­ the patient, remove the blood, and now we no longer need platelets or quests for information on how they run

2 NAVY MEDICINE HN Sandi Lloyd hooks up the system cisco not only requires use of state-of­ on the Cell saver Ill to start the blood· the-art autotransfusion technology, it cleaning process. demands Oak Knoll-trained techni- cians in their services. " The patient population needs to ated . . . we can put them in field Jearn about this revolutionary tech­ hospitals, salvage the blood, thereby nique too, Potter concluded, stating greatly reducing the amount of blood that, in accordance with the mandate that would need to be transported to a of the Paul Gann Blood Safety Act, war theater. Blood platelets are only prior to surgery, patients are informed good for 5 days," he continued. "If the of risks involved and given alterna­ American Red Cross were to draw a tives to blood transfusion and unit of blood from a donor today, hemotherapy. The Act became Jaw in separate the platelets out of that blood, the State of California on 1 Jan 1990. it would not be possible to get those "Autotransfusion is one of the options platelets to a battlefield in 5 days. But, given to surgery patients," he stressed. with the technique developed at Naval "Yet the vast majority of the civilian Hospital Oakland, we can salvage lay population knows nothing about their service from other military and plasma, we can salvage red cells right this technology. I think it needs to be civilian hospitals. in the battlefield situation." widely publicized so that everyone The service has gained such reputa­ Secondly, Potter was passionate in recognizes its value as an option." tion, in fact, that Potter just left for expressing his conviction that there At a time when interest in health Guanzhan ( fom1erly Canton), in main­ are no limits to the benefits that can be care reform is intense throughout the land China, to speak on autotransfusion derived from disseminating the Oak nation, the public is ready for good during a symposium entitled "Current Knoll-developedautotransfusiontech- news. Naval Hospital Oakland's pio­ Practices in Anesthesia." This 10-day nology to as many medical institutions neering work in autotransfusion is symposium was organized by Dr. Ray as possible. It is very well known in the _ good news, and now is the time to Tom, a San Francisco Navy reservist Bay area medical community where share the knowledge with everyone. who runs an organization called "Help our Oak Knoll-trained autotransfusion and Hands." Tom is chairman of the technicians are sought after when they -Story by AndreeMarechal-Work­ Anesthesiology Department at St. leave the Navy. "They filter out in the man, Public Affairs Office, Naval Francis Hospital in San Francisco. community," he said. "In fact, the Hospital, Oakland, CA. Photos by SN The Oak Knoll autotransfusion ex­ University of California San Fran- Wael lssa. pert made it clear that, in his opinion, dissemination of information on this new technology is very important, and he has some ideas on how to do just And the Band Plays On that. First, he would like to help estab­ Dr. Potter's creative energy didn't this gel helps to greatly decrease risk lish a military school inautotransfusion. stop with autotransfusion. Right now, of infection, chronic drainage cysts, The implications of such a project are he and his colleagues are developing a etc. It is important in major unlimited, he explained, given the promising fibran sealant closure agent neurosurgery or lumbar laminectomy cost-savings and improved patient care called plasma gel. "This is not to be for dural closure (the covering around his department has documented dur­ confused with fiber glue from the the spinal cord or around the brain); it ing the past year and a half. "Unless blood bank," he clarified. "Fiber glue is important to ENT surgery, to vascu­ we have military personnel trained in is an FDA-registered trademark. But lar surgery to seal the leaking blood the operation of these machines," he our plasma gel offers the ability to vessels. It is also important in urology; said, "Ifwegotowar, the civilians are create watertight closures. This is very for example when we dissect half a not going to go with us and we will lose important to almost any surgical inter­ kidney."- Andree Marechai-Work­ this technology in the field. ventions that are made today because man "These machines are easily oper-

3 July-August 1993 Interview

Flight surgeon on the spot

Aboard USS Franklin 19 March 1945

4 NAVY MEDICINE Hours after a Japanese bomber scored two direct hits on uss Franklin, the ship is still ablaze and listing dan­ gerously to starboard. At left crew­ members of USS Santa Fe watch the action as their vessel stands by to lend assistance.

Samuel Robert Sherman, MC, USNR, Officer burst into the operating room was the flight surgeon aboard the and said, "When are you going to get carrier and the only physician on the t:rro:.tgh with this operation?! answered, jlightdeckaftertheattack. NavyMedi­ "In about a half hour. " He said, cine recently interviewed Dr. Sherman "Well, you better hurry up because I about his World War II experiences. just got orders for you to go to Pensacola to get flight surgeon's training. " I joined the Navy the day after Pearl Nothing could have been better Harbor. Actually, I had been turned because airplanes were the love of my down twice before because I had never life. In fact, both my wife and I were been in a ROTC reserve unit. Since I private pilots and I had my own little had to work my way through college airfield and two planes. Since I wasn't and medical school, I wasn't able to go allowed to be near the planes at to summer camp or the monthly week­ Alameda, I had been after the senior end drills. Instead, I needed to work in medical officer day and night to get me order to earn the money to pay my transferred to flight surgeon's train­ tuition. Therefore, I could never join a mg. ROTC unit. I went to Pensacola in April 1943 When most of my classmates were for my flight surgeon training and called up prior to Pearl Harbor, I felt finished up in August. Initially, I was quite guilty, and I went to see ifl could told that I was going to be shipped out get into the Army unit. They flunked from the East Coast. But the Navy me. Then I went to the Navy recruiting changed its mind and sent me back to office and they flunked me for two the West Coast in late 1943 to wait for minor reasons. One was because I had Air Group 5 at Alameda Naval Air my nose broken a half dozen times Station. while I was boxing. The inside of my IN March 1945, as the Pacific war nose was so obstructed and the septum Air Group 5 drew closer to the Japanese home was so crooked that the Navy didn't Air Group 5 soon arrived, but it islands, the aircraft carrier USS think I could breathe well enough. I took about a year or so of training to Franklin (CV-13) was engaged in bomb­ also had a partial denture because I had get up to snuff. Most of the people in ing raids on Japan as part of Task lost some front teeth also while box­ it were veterans from other carriers Force 58. Early on the morning of 19 ing. that went down. Three squadrons March, as the ship was steaming just But the day after Pearl Harbor, I formed the nucleus of this air group-­ 50 miles offthe coast, an enemy bomber went back to the Navy and they wel­ a fighter, a bomber, and a torpedo slipped through the combat air patrol comed me with open arms . They told bomber squadron. Later, we were screen and dropped two semi-armor me I had 10 days to close my office and given two Marine squadrons; the rem­ piercing bombs on the ship. Both bombs get commissioned. At that time, I went nants of Pappy Boyington's group.* exploded among a number of armed to Treasure Island, CA, for indoctri­ and fueled aircraft. The resultant ex­ nation. After that, I was sent to Alameda plosions and fires claimed the lives of Naval Air Station where I was put in *MAJ Gregory Boyington, USMC, shot down charge of surgery and clinical ser­ 28 Japanese aircraft in a 4-rnonth pe riod. That over 800 Navy and Marine personnel achievement and superb leadership of his squadron and nearly sank the vessel. LCDR vices. One day the Team Medical won him the Congressional Medal of I !onor.

July-August 1993 5 Since the Marine pilots had been land-based, the toughest part of the training was to get them carrier certi­ fied. We used the old Ranger (CV-4) for take-off and landing training. We took the Ranger up and down the coast from San Francisco to San Diego and tried like hell to get these Marines to learn how to make a landing. They had no problem taking off, but they had problems with landings. Luckily, we were close enough to airports so that if they couldn't get on the ship they'd have a place to land. That way, they wouldn't have to go in the drink. Anyhow, we eventually got them all certified. Some of our other pilots trained at Fallon Air Station in Nevada and other West Coast bases. By the time the Franklin came in, we had a very well-trained group of people. I had two Marine squadrons and three Navy squadrons to take care of. The Marines claimed I was a Marine. The Navy guys claimed I was a Navy man. I used to wear two uniforms. When I would go to the Marine ready rooms, I'd put on a Marine uniform and then I'd change quickly and put on my Navy uniform and go to the other one. We had a lot of fun with that. As their physician, I was everything. I Eventually, the Franklin arrived in the flight deck. All of a sudden, out of had to be a general practitioner with early 1945. It had been in Bremerton nowhere, a Japanese plane slipped them, but I also was their father, their being repaired after it was damaged by through the fighter screen and popped mother, their spiritual guide, their a Kamikaze offLeyte in October 1944. up just in front of the ship. My battle social director, their psychiatrist, the In mid-February 1945 we left the West station was right in the middle of the whole thing. Of course, I was well Coast and went to Pearl first and then flight deck because I was the flight trained in surgery so I could take care to Ulithi. By the first week in March, surgeon and was supposed to take care of the various surgical problems. Ev­ the fleet was ready to sail. It took us of anything that might happen during ery once in a while I had to do an about 5 or 6 days to reach the coast of flight operations. I saw the Japanese appendectomy. I also removed some Japan where we began launching aerial plane coming in, but there was nothing pilonidal cysts and fixed a few strangu­ attacks on the airbases, ports, and I could do but stay there and take it. lated hernias. Of course, they occa­ other such targets. The plane just flew right in and dropped sionally got fractures during their train­ two bombs on our flight deck. ing exercises. I took care ofeverything The Attack I was blown about 15 feet into the for them and they considered me their Just before dawn on 19 March, 38 air and tossed against the steel bulk­ personal physician, every one of them. of our bombers took off, escorted by head of the island. I got up groggily I was called Dr. Sam and Dr. Sam was about 9 of our fighter planes. The crew and saw an enormous fire. All those their private doctor. No matter what of the Franklin was getting ready for planes that were lined up to take off was wrong, I took care of it. another strike, so more planes were on were fully armed and fueled. The dive

6 NAVY MEDICINE Blazing aviation gas and water pour from the battered carrier Franklin as fire fighters heroically work amidst exploding ordnance to save her_

dreds and hundreds of crewmen who them were already wounded, dead, or needed my attention. had been blown overboard. Some, I was later told, gor panicky and jumped Medical Equipment overboard.Therefore, I couldn't find Fortunately, I was well prepared any corpsmen, but fortunately I found from a medical equipment standpoint. some of the members of the musical From the time we left San Francisco band whom I had trained in first aid . I and then stopped at Pearl and then to had also given first-aid training to my Ulithi and so forth, I had done what we air group pilots and some of the crew. call disaster planning. Because I had The first guy I latched onto was LCDR worked in emergency hospital service MacGregor Kilpatrick, the skipper of and trauma centers, I knew what was the fighter squadron. He was an An­ needed. Therefore, I had a number of napolis graduate and a veteran of the big metal containers, approximately Lexington (CV-2) and the Yorktown the size of garbage cans, bolted down (CV-5) with three Navy Crosses. He on the flight deck and the hangar deck. stayed with me, helping me take care ' ._) These were full of everything that I of the wounded . needed--splints, burn dressings, ster­ I couldn't find any doctors. There ile dressings of all sorts, sterile surgi­ were three ship's doctors assigned to cal instruments, medications, plasma, the Franklin, CDR Francis (Kurt) and intravenous solutions other than Smith, LCDR James Fuelling, and plasma. The most important supplies LCDR George Fox. I found out later were those used for the treatment of that LCDR Fox was killed in the sick burns and fractures, lacerations, and bay by the fires and suffocating smoke. bleeding. In those days the Navy had CDR Smith and LCDR Fuelling were a special burn dressing which was very trapped below in the warrant officer's bombers were equipped with this new effective. It was a gauze impregnated wardroom, and it took 12 or 13 hours "Tiny Tim" heavy rocket and they with vaseline and some chemicals that to get them out. That's where LT immediately began to explode. Some were almost like local anesthetics. In Donald Gary got his Medal of Honor of the rockets' motors ignited and took addition to treating burns, I also had to for finding an escape route for them off across the flight deck on their own. deal with numerous casualties suffer­ and 300 men trapped below. Mean­ A lot of us were just ducking those ing from severe bleeding; I even per­ while, I had very little medical help. things. It was pandemonium and chaos formed some amputations. Finally, a couple of corpsmen who for hours and hours. We had 126 Furthermore, I had a specially were down below in the hangar deck separate explosions on that ship; and equipped coat that was similar to those came up once they recovered from each explosion would pick the ship up used by duck hunters, with all the little their concussions and shock. Little by and rock it and then turn it around a pouches. In addition to the coat, I had little a few of them came up. Origi­ little bit. Of course, the ship suffered a couple of extra-sized money belts nally, the band was my medical help horrendous casualties from the first which could hold things. In these I and what pilots I had around. moment. I lost my glasses and my carried my morphine syrettes and other shoes. I was wearing a kind of mocca­ small medical items. Due to careful Evacuation Efforts sin shoes. I didn't have time that planning I had no problem whatsoever I had hundreds and hundreds of morning to put on my flight deck shoes with supplies. patients, obviously more than I could and they just went right off inm1edi­ I inm1ediately looked around to see possibly treat. Therefore, the most ately. Regardless, there were hun- if I had any corpsmen left. Most of important thing for me to do was

July-August 1993 7 triage. In other words, separate the me if I don't go?" I went down and got a whole batch serious wounded from the not so seri­ He answered, "I could shoot you or of them. They were in eyedropper ous wounded. We'd arranged for evacu­ I could bring court-martial charges bottles and we gave them to these ation of the serious ones to the cruiser against you." guys. They put them in their eyes and Santa Fe (CL-60) which had a very I said, "Well, take your choice." immediately they could tolerate the well-equipped sick bay and was stand­ And I went back to work. smoke. That enabled them to get the ing by alongside. As MacGregor Kilpatrick left he boilers going. LCDR Kilpatrick was instrumental told me, "Sam, you're crazy!" in the evacuations. He helped me Aftermath organize all of this and we got people Getting Franklin Under Way It was almost 12 or 13 hours before to carry the really badly wounded. After the Air Group evacuated, I the doctors who were trapped below Some of them had their hips blown off looked at the ship, I looked at the fires, were rescued. By that time, I had the and arms blown off and other sorts of and I felt the explosions. I thought, majority of the wounded taken care of. tremendous damage. All together, I well, I better say good-bye right now However, there still were trapped and think we evacuated some 800 people to my family because I never believed injured people in various parts of the to the Santa Fe. Most of them were that the ship was going to survive. We ship, like the hangar deck, that hadn't wounded and the rest were the air were just 50 miles off the coast of been discovered. We spent the next 7 group personnel who were on board. Japan (about 15 minutes flying time) days trying to find them all. The orders came that all air group and dead in the water. The cruiser I also helped the chaplains take care personnel had to go on the Santa Fe Pittsburgh (CA-72) was trying to get a of the dead. The burial of the dead was because they were considered tow line to us, but it was a difficult job terrible. They were all over the ship. nonexpendable. They had to live to and took hours to accomplish. The ships' medical officers put the fight again in their airplanes. The Meanwhile, our engineering offic­ burial functions on my shoulders. I ship's company air officer of the ers were trying to get the boilers lit off had to declare them dead, take off their Franklin came up to LCDR Kilpatrick in the engine room. The smoke was so identification, remove, along with the and myself as we were supervising the bad that we had to get the Santa Fe to chaplains' help, whatever possessions evacuation between fighting fires, tak­ give us a whole batch of gas masks. that hadn't been destroyed on them, ing care of the wounded, and so forth. But the masks didn't cover the engi­ and then slide them overboard because He said, "You two people get your neers' eyes. Their eyes became so we had no way of keeping them. A lot asses over to the Santa Fe as fast as you inflamed from the smoke that they of them were my own Air Group can." LCDR Kilpatrick, being an couldn't see to do their work. So, the people, pilots and aircrew, and I rec­ Annapolis graduate, knew he had to XO came down and said to me, "Do ognized them even though the bodies obey the order, but he argued and you know where there are any anes­ were busted up and charred. I think we argued and argued. But this guy thetic eye drops to put in their eyes so buried about 832 people in the next 7 wouldn't take his arguments. they can tolerate the smoke?" days. That was terrible, really terrible Resaid, "Getoverthere. You know I said, "Yes, I know where they to bury that many people. better. " Then he said to me, "You get are. "I knew there was a whole stash of over there too." them down in the sick bay because I Going Home I said, "Who's going to take care of used to have to take foreign bodies out It took us 6 days to reach Ulithi. these people?" of the eyes of my pilots and some of the Actually, by the time we got to Ulithi, He replied, "We'll manage. " crew. we were making 14 knots and had cast I said, "Nope. All my life I've been He asked, "Could you go down off the tow line from the Pittsburgh. trained never to abandon a sick or there (that's about four or five decks We had five destroyers assigned to us wounded person. I can't find any doc­ below), get it and give it to the engi­ that kept circling us all the time from tors and I don't know where they are neering officer?" the time we left the coast ofJapan until and I only have a few corpsmen and I I replied, "Sure, give me a flash­ we got to Ulithi because we were can't leave these people." light and a guide because I may not be under constant attack by Japanese He said, "You better go because a able to see my way down there al­ bombers. We also had support from military order is a military order." though I used to go down three or four two of the new battlecruisers. I said, "Well what could happen to times a day."

8 NAVY ME DICIN E or. Sherman and a colleague

At Ulithi, I got word that a lot of my people in the Air Group who were taken off or picked up in the water, were on a hospital ship that was also in Ulithi. I visited them there and was told that many of the dead in the Air Group were killed in their ready rooms, waiting to take off when the bombs exploded. The Marine squadrons were particularly hard hit, having few sur­ vivors. I have a list of dead Marines which makes your heart sink. The survivors of the Air Group then regrouped on Guam. They requested that I be sent back to them. I also wanted to go with them, so I pleaded my case with the chaplain, the XO, National Museum of American Jewish Military History and the skipper. Although the skipper felt I had earned the right to be part of Nimitz. He remembered me from Officer, who said he would either the ship's company, he was willing to Alameda because I pulled him out of shoot me or court-martial me, well, he send me where I wanted to go. Luck­ the wreckage of his plane when it didn't shoot me. He talked about the ily , I rejoined my Air Group just in crashed during a landing approach in court-martial a lot but everybody in time to keep the poor derelicts from 1942. He simply said, "Unless I hear higher rank on the ship thought it was getting assigned to another carrier. a medical opinion to the contrary to a really bad idea and made him sound The Air Group Commander wanted CDR Sherman's, I have to agree with like a damned fool. He stopped mak­ to make captain so bad, that he volun­ CDR Sherman." He decided that the ing the threats. teered these boys for another carrier. Air Group should be sent back to the Most of them were veterans of States and rehabilitated as much as Dr. ShermanreceivedaNavy Cross theYorktown and Lexington and had possible. in recognition of his bravery on the seen quite a lot of action. A fair In late April 1945, the Air Group Franklin. Upon leaving the Navy, Dr. number of them had been blown into went to Pearl where we briefly re­ Sherman resumed his medical prac­ the water and many were suffering united with the Franklin. They had to tice. He retired about JOyearsagobut from the shock of the devastating make repairs to the ship so it could has kept very busy maintaining a num­ ordeal. The skipper of the bombing make the journey to Brooklyn. After a ber ofofficial duties in several medical squadron did not think his men were short stay, we continued on to the associations. His positions have in­ psychologically or physically quali­ Alameda. Then the Navy decided to cluded: President of the California fied to go back into combat at that break up the Air Group, so everyone Medical Association and chairman of particular time. A hearing was held to was sent on their individual way. I was numerous committees ofthe American determine their combat availability given what I wanted--senior medical Medical Association. He has also and a flight surgeon was needed to officer ofa carrier-- the Rendova (CVE- worked with voluntary health agencies check them over. I assembled the 114), which was still outfitting in Port­ in San Francisco: The Cancer Society, pilots and checked them out and I land, OR. But the war ended shortly The Heart Association, and The Men­ agreed with the bombing squadron after we had completed outfitting. tal Health Association. Dr. Sherman skipper. These men were just not I stayed in the Navy until about also helped to institute the regulations ready to fight yet. Some of them even Christmas time. I was mustered out in of the federal Medicare program. He looked like death warmed over. San Francisco at the same place I was currently lives with his wife in San The hearing was conducted by ADM commissioned. As far as the Air Group Francisco. --JKH

July-August 1993 9 Features

Risk-Taking: Analysis and Intervention

James Lark

FASCINATING! How people will take risks! Foran This essay offers a point of departure for that attention advantage or just a thrill, they will challenge chance, and suggests how Navy occupational health providers and flirt with ruin, and try to beat the odds; and they, we, safety professionals--the NAVOSH Team--may cooperate I do it everyday because, as physician and popular to keep on-duty risk-taking in check. The intent is not to author Dr. Melvin Konner comments, risk-taking take fun out of life, but to cast doubt on certain means for "is part of being alive. " ( 1) having "fun." The proposed intervention, being based on In the workplace, however, risk-taking, physical risk­ the principles of leadership and health psychology, is taking in particular, has to be more than fascinating: it has designed to make winners of all concerned. to be a vital concern. Working aloft without fall protection, Behavioral and social scientists who study risk-taking trying to clear jammed machinery by hand with the attribute the phenomenon to a variety of personal and social machinery still energized, adjusting electrical equipment factors. There is little doubt about some of the fmdings, with the power on, hitching a ride on a forklift, neglecting while other fmdings are very controversial. The theorists to wear a respirator though exposed to toxic air contami­ and their fmdings seem to fall into two categories, and these nants, and so on, are all signals that mishap probability has categories bear a remarkable resemblance to the nature/ increased, that personal and command well-being may be nurture, organic/functional divisions seen in other behav­ in jeopardy, and that there are forces . playing at cross ioral issues. purposes with total quality and continuous improvement. One representative of the nature/organic camp is David Conditions demand management attention. Lykken of the University of Minnesota. Lykken believes

10 NAVY MEDICINE that genetics accounts for a person's tendency to take risks. less, the correlation between the biochemical data and the He has come to this belief by means of a long-term project preference for sensation-seeking and risk-taking is what called "The Minnesota Study of Twins Reared Apart." In has led Zuckerman to posit a biochemical, nature/organic this study, Lykken and his colleagues test subjects with the basis for the tendency to take risks.(! ,3,4,5) Activity Preference Questionnaire. The subjects are asked A proponent of the nurture/functional basis for risk­ what they prefer; for example, sleeping one night on the taking behavior is Stephen Lyng, professor of sociology at floor, or asking someone to pay owed money; washing a Virginia Commonwealth University. Lyng "focuses on the car, or driving it at 95 miles per hour; arriving at a circus relationship between relevant psychological factors and the and finding that tickets have been forgotten, or being at the broader social historical context in which risk-taking circus when two lions suddenly get loose. occurs." When the subjects are identical twins (raised together or Agreeing with accepted psychosocial theory, Lyng says apart), two out of three times the answers are identical. that in any society people seek self-fulfillment in work. When the subjects are fraternal twins, there is a randomness Fulfilling oneself means enjoying spontaneity, and exercis­ in the answers that you would see in the general population. ing creativity, skill, and control. But, says Lyng, in our These statistics make Lykken believe that genetics has a social historical context, work is encumbered with forms, significant impact on the tendency to take risks.(2) institutions, and roles. People cannot be all they can be. So, Another scientist in the nature/organic camp is Marvin he says, they look elsewhere for fulfillment, and find it in Zuckerman of the University of Delaware. He has studied contrasting pursuits. a type of person that he calls "sensation-seeking." To For Lyng, the premier contrasting pursuit is "edgework." Zuckerman, there is a definite correlation between sensa­ He defmes edgework as: the spontaneous, anarchic, tion-seeking and risk-taking. By way of his own "Sensa­ impulsive experience of living "on the edge"--on the tion-Seeking Scale," a valid psychometric test, Zuckerman boundary between order and chaos, control and helpless­ measures the desire people have for thrills and advenn1re, ness, life and death. Edgework is the antithesis of the status for new experiences, and for unconventionality; also their quo. susceptibility to boredom. High scores suggest a person Edgework may take a number of forms. First and who seeks stimulation. After the test, Zuckerman inter­ foremost, there is skydiving (Lyng developed his theory by views subjects to see how scores jibe with real life. skydiving). There is also rock climbing, aircraft test Zuckerman reports that high scorers on the scale do piloting, and combat soldiering. As Lyng points out, each favor stimulating behavior in real life, behavior with an of these forms demands a highly developed skill and unmistakable element of risk. High scorers, says Zuckerman, stimulates the sense of acting instinctively, of being in are people who are very apt to do at least three things: to control. Paramount in each form, however, is a clearly gamble, to place themselves deliberately in physical dan­ observable threat to physical or mental well-being. In a ger, and to volunteer for experiments. In addition, word, there is risk Zuckerman comments that, compared to low scorers, high Having gotten to know edgeworkers well, through his scorers will consume more alcohol, tobacco, and drugs. own participation in the activity, Lyng says that risk is Their sex lives are more promiscuous and unusual, too. exactly what attracts edgeworkers. They want to deal with Zuckerman also reports that high scorers will demon­ it, to control it, and themselves; and they have this desire, strate physiological (organic) characteristics that low scor­ because the status quo just isn't enough.(6) ers do not display. High scorers, for instance, generally Three social psychologists who research and write on have relatively little of the enzyme monoamine oxidase, risk-taking, and who also fall into the nurture/functional high levels of which are associated with psychological category, are Paul Slovic of the University of Oregon, Neil depression. High scorers generally have little of the Weinstein ofRutgers University, and William Freudenberg enzyme dopamine beta hydroxylase, low levels of which of the University of Wisconsin. are usually associated with manic states. High scorers Slavic has commented that people take risks because of generally have a lot of gonadal hormones, high levels of social and cultural factors, like the influence brought to which are related to aggressive behavior. Put them together bear by family, friends, fellow workers, or respected and what do you have? A person who is usually in good officials. The social group, says Slavic, can emphasize or spirits, bursting with energy, and obnoxious, to boot. downplay risks as a means of maintaining and controlling Somebody in the passing lane on the Interstate! Neverthe- itself.(?)

July-August 1993 11 Weinstein says he has identified among people an Levenson includes a distinctive observation in his find­ "optimistic bias. " When interviewing people about risk­ ings. He reports that he has seen "antistructuralism" in taking, he has heard them claim, in one way or another, that certain risk-takers whom he has studied. These are people they are less affected by personal risks than are their peers. who are adequately socialized and who adhere to a rather They are biased, he says, optimistically toward themselves. strict moral code, but who, from time to time, purposely Underlying the bias, says Weinstein, is everyone's desire turn their backs on social convention and go, say, to climb to be better than everybody else.(8) rocks. Freudenberg has studied the workers on oil well drilling One other person who has an opinion on why people take platforms. He comments that in that kind of environment risks is Dr. Melvin Konner, who I mentioned earlier. An people take risks because they wish to avoid public eclectic thinker, he is not a research scientist; but he is a embarrassment, or they fear losing their jobs.(9) keen observer of the human condition. I like him, because Frank Farley of the University of Wisconsin at Madison he cuts through the fog which scientific inquiry often brings seems to be in both the organic and the functional camps. to debatable issues. He puts his fmger on realities which we There is both "nature" and "nurture" in his thinking. all know to be true and which, in the end, science cannot Farley sees risk-taking as a matter of physiological arousal. controvert, but can only confirm. Each person, he says, has a unique optimal arousal level In relation to risk-taking, Dr. Konner has given due that is constantly, but unconsciously, sought. According to credit to people like Zuckerman and the work they have Farley, some people need a lot of stimulation to reach their done and the findings they have amassed. But, he has also optimal arousal level, while others don't need much reminded his readers that we moderns descend from stimulation at all. Risk-takers, he says, need a lot of ancestors who became our ancestors (they survived) by stimulation. It's the "tension-raising situations" and the instinct, quick reflexes, physical skill, and physical strength­ "sensory variability" they experience when taking risks -not by ponderous risk assessment. Although evolution has that get them to their optimal arousal levels. brought us a long way, our instincts, reflexes, skill, and Farley suggests that there is a distinct sensation-seeking, strength derive from those ancestors; and we shouldn't be risk- taking personality. He calls it the "type T personality," surprised if occasionally we act impetuously, to see if we and the "T" stands for "thrill-seeker." Farley calls type T's still have "the right stuff." Says Dr.Konner, it's the human high profile people who purposely seek more than a mid­ thing to do. (1) level of stimulation. They are adventurers who seek So, physical risk-taking may not happen because of a excitement wherever they can find or create it. They like logical process and conscious decision; and "attitude" may uncertainty, unpredictability, novelty, variety, complex­ not be a part of it at all. Nevertheless, not every risk taken ity , ambiguity, flexibility, low structure, high intensity, results in a positive outcome; sometimes the consequences and high conflict. are devastating. Physical risk-taking must be countered. A Compared to most people, says Farley, type T's take form of health promotion may be the answer.(13) many more risks; they demonstrate more creativity and At any location, the promotion could start right at the extroversion; they prefer experimental art, and they may be top; that is, the commanding officer of the medical facility unsafe drivers. The personality is most strongly expressed could formally express to the responsible line commander when the individual is from 16 to 24 years old. Farley's type (RLC) a desire to support total quality leadership (TQL) in Tis Zuckerman's high scorer. a very practical way. The medical commander could assert Yet, Farley--also Michael Levenson of the Veterans that, in concert with base safety professionals, occupational Administration Outpatient Clinic in Boston--points out an health providers would do their utmost to promote self­ interesting correlation between the kinds of risks a risk­ protective behavior, as opposed to risk-taking behavior. taker takes and the social factors in that person's life; in This offer would be an important contribution to the base­ other words, the nurture factors. If a risk-taker has been wide climate for TQL. exposed to, and has absorbed, a positive attitude toward Given that the RLC accepted the offer, occupational prosocial initiative and originality, that person may well health providers would conduct examinations as before; become a hero, like a decorated firefighter or police but they would do two other things as well. In the clinic, officer. If, on the other hand, a type T has had antisocial role they would make a point of reinforcing safe behaviors and models, no constructive outlet for all the type T energy, and punctuating their value. Out on base, they would do some peer pressure for antisocial behavior, then a drug user may practical epidemiology with the local safety professionals. take a place on the street.(10-12) With the safety practitioners, the health providers would

12 NAVY MEDICINE answer questions like: How well do different shops comply taking and mishap occurrence. Health promotion, in com­ with personal protective equipment requirements or safe bination with the management of safety, would not block operating procedures? Have near-misses or actual mishaps creative energy; rather, it would open channels fo r optimal been related to risk-taking? How are workers from the energy flow. various shops performing on their occupational health Risk-taking is a part of life. It is impelled by powerful physical exams?(14-17) personal and social forces which the individual alone Then, in the clinic, the health provider would apply that cannot completely control. In Navy workplaces, risk­ "medical intelligence." With good exam results, the pro­ taking must be a vital concern, because the gamble is with vider might say: "These results are just what they should limited resources and mission accomplishment. The be" or "You're making good use of your protective NAVOSH Team may counteract risk-taking, intervening equipment" or "All the folks in your shop should be taking with a strategy that blends health promotion and safety such good care of themselves. " management. Although risk-taking should be a vital con­ The good news and the compliment would be welcome cern, it is also a challenge to grow: to Navy safety and to the examinee. They would confirm the health belief, occupational health professionals, and to the sometimes which would probably be motivating the person, that job reckless, but continuously improving, people whom we injury and illness are not inevitable, and that "self-efficacy" care for. is possessed.(l8) Good news and compliments would also help the examinee to persevere in the face of scofflaws in References the shop. The examinee might even be inspired to set the 1. Konner M. Why the Reckless Survive. New York, NY: Viki ng Penguin; 1990. pace for self-protective behavior. 2. Lykken DT. Fearlessness. Psycho[ Today . September 1982:20-28. Of course, poor exam results would also be addressed; 3. Zuckerman M, Kolin EA. Zoob I. Development of a sensation-seeking and, again, the health provider could put the epidemiologic scale. J Consult Psycho/. 1964;28:447-482 . 4. Zuckerman M, Buchsbaum MS, Murphy DL. Sensation seeking and its data to good use. The provider might say: "Do you ever biological correlates. Psycho/ Bull. 1980;88:187-214. notice the (stressor) even with your protective equipment 5. Weiss R. How Dare we? Sci News. July 25. 1987:57-59. on?" or "Does your protective equipment fit OK?" 6. Lyng S. Edgework: a social psychological analysis of voluntary risk After listening to the examinee's answers, the provider taking. Am J Social. 1990;95(4):851 -885. 7. Slovic P. Perception of risk. Science. 1987;236:280-285. could go on to behavioral questions, asking, in the manner 8. Weinstein ND. Optimistic biases about personal risks. Science. of a "helping relationship, "(19) about safety-related be­ 1989;246: 1232-1233 . 9. Freudenberg WR: Perceived risk, real risk: social science and the art of havior in the shop: "Do people generally protect their probabilistic risk assessment. Science. 1988;242:44-49. (eyes/ears/respiratory tract/extremities)?" "Do you?" "Do l 0. Farley F, Farley SV. Extraversion and stimulus-seeking motivation. In: people usually use safe operating procedures?" "Do you?" Eysenck HJ, ed. Readings in Extraversion-Introversion 1: Theoretical and Methodological Issues. New York, NY: John Wiley & Sons Inc; 1970:259- "Is the feeling there that everybody has to get hurt 261. somehow, sometime?" "What do you think?" Answers II. Farley F. The big Tin personality. Psycho/ Today. May 1986:47-51. 12. Levenson ML. Risk taking and personality . J Pers Soc Psycho/. would furnish points of departure for a discussion of a 1990;58(6): 1073-1080. health-enhancing perspective. 13. Mason JO, Ogden HG, Berreth DA, Martin LY. Interpreting risks to The perspective would be this. While risk-taking may be the public .. Am J Prev Med. 1986;2(3): 133-139. 14. DeJoy DM. Behavioral-diagnostic model for self-protective behavior appropriate during wartime military operations, it is not in the workplace. Projes Saf 1986;31(12):26-30. appropriate during routine industrial operations; there isn't IS. DeJoy DM. Toward a comprehensive human factors model of supposed to be war in the workshop. While many personal workplace accident causation. Projes Saf 1990;35(5)11-16. 16. Krause TR, Ridley JH. Behaviorally based safety management. Projes and social forces may seem to compel risk-taking, the Saj. 1989;34(10):20-25. expectation is that it shall not occur because on-the-job risk­ 17 . Krause TR, Ridley JH, Hodson SJ. Broad-based c hanges in behavior taking contradicts total quality and continuous improve­ key to improving safety culture. Occup Health Saf July 1990:34-37 & 50. 18. Bandura A. Self-efficacy: Toward a unifying theory of behavioral ment. It's no great accomplishment just to beat the odds, change. Psycho[ Rev. 1977;84(2):191-2 15. and the epidemiologic data show, objectively, that the odds 19. Shertzer B, Stone SC. Fundamentals of Counseling. Boston, MA: are not always beaten. It is an accomplishment to make a Houghton Mifflin Co; 1968. system, and oneself within the system, do what it should do, every time. Self-efficacy is not only its own reward; it benefits everyone. I think such health promotion, if consistently and Mr. Lark is on the staff of Naval Environmental Health Center professionally done at a given location, would reduce risk- Detachment, Portsmouth, NH.

July-August 1993 13 Medicine in the Tropics Course: Preparing Navy Doctors for Global Medical Challenges

CDR James M. Crutcher, MC, USNR CAPT H. James Beecham III, MC, USN

WHY Tropical Medicine? A 25-year-old marine has just re­ What is the recommended therapy for Although doctors educated in the turned to the United States after a 6- this infection? United States receive excellent overall month deployment to Thailand (no a. Diethylcarbamazine medical training, they are generally other pertinent travel history). He now b. Quinine and doxycycline unprepared for the medical challenges presents with a 2-day episode of fever, c. Chloroquine and primaquine occurring in other parts of the world, headache, muscle aches, and mild d. Suramin especially tropical environments.* The diarrhea. All of the following are (Answersonpage20. Also, see Tropi­ reason is simple. Many of the diseases possible causes of his illness, except: cal Medicine Quiz following the ar­ present in tropical areas do not exist, a. Malaria ticle.) or are very rare, in the United States. b. Dengue Test your knowledge of tropical dis­ c. Visceral leishmaniasis Most physicians in the United States eases with the following scenario. d. Filariasis rarely have to deal with patients such The organism shown in Figure 1 is as this. Military physicians, however, *The tropics is defined as the area bordering the seen on peripheral blood smear. What routinely see persons who travel to all equator, from 23 112 degrees north (the Tropic of Cancer) to 23 112 degrees south (the Tropic of Capricorn). Because is your interpretation? parts of the world. It is therefore of perennially warm temperatures and generally high a. Malaria essential that they know how to pre­ rainfall, the tropics support a large and varied population ofanimal and insect life, many of which serve as reservoirs b. Filariasis pare travelers (both individuals and or vectors of disease. Additional increased risk of disease c. Trypanosomiasis entire military units) for the risks of is due to the impoverished status of most tropical nations and their subsequent inability to provide safe food and d. Leishmaniasis international travel, and how to evalu- water or to institute disease control measures.

14 NAVY MEDICINE v·...... ntE CARIBBEAN ISLANDS

ATLANTIC OCEAN

~,_ •. u.s.e~t~~Br. Cayman •• .... /1. St. r.,__ f:" : ..,~~ AnQUIIII • ~·'~- ~\· Q- "'u''''s.bl oSt. ,.,,.,., q-~ . "" .st. B•rt• Puerto Rico ... ;c•-:ot.Kitt• o oAntlgu• Jem•lca~ "" Nevi• MontHrr11° ~Guadllou,.

~Dominica CARIBBEAN SEA ~Martin/qUI St. Lucia a

St. VIIICIIIt ~ ~lrbadOI flSanAndrea . Aruba • ~~--Rn~= ate the returning traveler with an ill­ refugee care. To meet these chal­ Origins of Tropical Medicine ness. Lacking this knowledge may not lenges, the modern military medical The study of tropical diseases be­ only place individuals at risk ofdisease officer must be knowledgeable ofglob­ gan in earnest in the late 1800's as a but also adversely affect operational al medical issues. The Navy's Medi­ result of the problems encountered by readiness. Additional challenges to­ cine in the Tropics course has strived Europeans as they colonized tropical day come from the military's potential for 23 years to prepare Navy medical countries.(]) There they encountered involvement in international peace­ officers for the challenges of global numerous infectious disease problems keeping forces, disaster relief, and medicine. with which they were unfamiliar, gen­ erally related to contaminated food and water, animal reservoirs, and flour­ ishing insect and snail vectors--dis­ eases such as malaria, schistosomiasis, filariasis, and trypanosomiasis to name just a few. Long before the period of coloniza­ tion there were reports of almost entire crews lost during trading expeditions to the tropics. The risk to life was considered so great that it was initially felt it might not be possible for Euro­ peans to colonize the tropics. An un-

Figure 1. Blood smear of patient with a febrile illness after visiting Thai­ land. !Reproduced with permission from American society of Clinical Pa­ thologists)

July-August 1993 15 Right: LT David Lane holding the baby he just delivered in a small village near samana, Dominican Republic. Also pictured is LCDR Rob Cillis Lebanon in Manson (referred to as the Father of tropical, developing countries. 1958, 30-50 percent of the force was Tropical Medicine), who first demon­ In U.S. military history, wartime afflicted with diarrhea within several strated the mosquito transmission of infectious disease casualties and deaths days of the landing.(3) Malaria had filariasis, and Sir Patrick Ross, who have always outnumbered those in­ significant impact on U.S. military first demonstrated the mosquito trans­ curred on the battlefield. During the forces during the Vietnam conflict, at mission of malaria. Two of the great American Civil War greater than 25 times rendering entire combat battal­ names in the early history of tropical percent of all fatalities were due to ions ineffective. And the infectious medicine in the United States were diarrhea and dysentery alone.(3) In disease threat remains in effect today. U.S. Army physicians Walter Reed, the Spanish-American War only 243 A survey conducted during Operation who proved the mosquito transmission soldiers died of combat wounds com­ Desert Shield indicated that over 50 of yellow fever, and William Gorgas, pared to 1,580 who died of typhoid.( 4) percent of ground troops in theater whose work in controlling yellow fe­ During World War II attack rates of were experiencing diarrhea, and 20 ver and malaria in Panama made pos­ malaria on Guadalcanal reached 1, 781 percent of these missed time from sible the building of the Panama Ca­ per 1,000 soldiers during part of work as a result of their illness. ( 6) And nal.

Tropical Medicine and the Military History has proven time and again the importance of infectious diseases upon the outcome of military cam­ paigns. An infectious disease threat to military operations is defined as any disease capable of influencing the out­ come of a battle by producing excess morbidity, mortality, morale distur­ bance, or resource consumption. Ac­ cordingly, the major infectious dis­ ease threats of military concern are: (1) diarrheal diseases (2) malaria (3) arboviral diseases (arthropod-borne viral diseases), including dengue, sandfly fever, Japanese encephalitis, and other, (4) acute respiratory infec­ tions, and (5) viral hepatitis.(2) It is

Long-term effects of leprosy with trauma and wasting of distal extremi­ ties due to nerve damage.

16 NAVY MEDICINE as of June 1993, 131 cases of malaria proper predeployment preparation for rial Lab in 1969 and has continued have occurred in U.S. military person­ the risks there, the battle may be lost with minimal interruptions since then. nel from operations in Somalia.(7) before they ever arrive. Because of political instability in The need to understand the disease Panama, the course relocated to San threats present in areas of military Medicine in the Tropics Course Juan, Puerto Rico, in 1989. From the operations and how to prevent and One of a Kind Program. The outset, the philosophy has been to treat them is obvious. If troops deploy Medicine in the Tropics course was locate the training in the setting of the to tropical environments without the begun in Panama at the Gorgas Memo- diseases discussed so that students could have a clinical experience in addition to didactic training. This also allows students to experience the tropical and developing world environments. Al­ though the Army and the Air Force also have tropical medicine courses,* the Navy's course is the only one which offers a practical experience in a tropical country. The course is 6 weeks long and is held four times per year. Courses begin in early January, April, July, and October. Each class consists of 10 Navy physicians and currently oper­ ates out of the Veteran's Administra-

*The Army offers a yearly 6-week trop ical medicine course at the Walter Reed Army Institute of Research in Washington, DC, and the Air Force has a 2-week global medicine course offered yearly in San Antonio, TX.

Elephantiasis due to the filarial nema­ tode Wuchereria bancrofti

July-August 1993 17 CDR Larry carsha (right) evaluates a child with a swollen abdomen near Rio san Juan, Dominican Republic. tion Hospital in San Juan. Four weeks are spent in the classroom with core lectures in tropical diseases and in the laboratory with microscopic diagnosis of parasitic diseases. The course stresses the diseases of military imp or­ tance. In addition to didactic training in tropical diseases there are practical experiences in issues relevant to the military. Several classroom exercises present practical scenarios in military medicine, such as preparing forces for deployment, controlling an infectious disease outbreak on a ship, and evalu­ teresting and memorable experiences mothers and young children are given ating a febrile patient in the field for the students. The class visits a vitamins. Vitamin A has proven ben­ setting. poor, rural area and sets up a clinic for eficial in reducing the mortality asso­ The Practical Experience--The the day. Together with a Dominican ciated with measles and other infec­ Heart of the Course. The clinical translator (usually a physician) each tious diseases in children. ( 8) Skin experience is achieved during a 2- student spends the day evaluating and diseases are prevalent in tropical coun­ week trip to the Dominican Republic. treating persons in the community. tries; many people are treated for The Dominican Republic shares the These missions provide students scabies and fungal infections. Other­ island of Hispaniola with Haiti and is not only the opportunity to see inter­ wise the focus is on identifying infec­ located between Puerto Rico and Cuba. esting diseases but also to witness the tious disease problems which can be While there the students visit several problems associated with living in a helped with a short course of antibiot­ Dominican hospitals and clinics where developing country--extreme poverty, ics, such as otitis media or pneumonia they go on rounds with local staff and malnutrition, unsanitary living condi­ in children. Children with diarrhea residents. Diseases commonly seen tions, lack of waste disposal systems and dehydration are treated with oral during rounds include tuberculosis, and safe drinking water, widespread rehydration salts. Chronic medical tetanus, typhoid fever, leptospirosis, intestinal parasite infection, and lack problems are beyond the capabilities malnutrition, meningitis, andHIV dis­ of routine immunizations and health of these missions, and persons with ease. Malaria cases are seen occasion­ care. Students also experience the dif­ such problems are referred to the local ally. The visit to the dermatology ficulties of practicing medicine in a health care system. clinic allows students to see leprosy, setting in which routine diagnostic Working in the "campos" (rural cutaneous leishmaniasis, and deep fun­ tests, medications and supplies, and villages) allows for many interesting gal infections. Several patients are medical followup are not available-­ experiences for the students. On a usually presented at the filariasis clinic. things we take for granted in the United recent mission a woman was in labor The trip to the Dominican Republic States. These are valuable lessons for in a small shack close to where the is the first time many of the students military medical officers supporting class was working. Although women see severely malnourished children. troops in developing countries. routinely give birth there without the Although a painful sight, it opens ones Although student training is the aid of a doctor, one of the students, Dr. eyes to the realities of the world, and focus, great effort is made to provide David Lane (a family practice resi­ few people walk away unchanged. as good medical care as possible under dent) took the opportunity to deliver The class also conducts two 1-day the circumstances. All children under the baby in a little different setting than field missions while in the Dominican the age of 13 are treated for intestinal he is accustomed to. Republic. These provide the most in- helminths, and pregnant and nursing One of the most rewarding aspects

18 NAVY MEDICINE of the work in the Dominican Republic forces in these environments. But the cut costs and eliminate duplication of is the interaction with the Dominican course has an additional benefit--the training, this effort is directed at re­ physicians who work with us as trans­ personal growth and expanded vision structuring training programs so that lators. This interaction gives the stu­ that comes from direct involvement in curricula accurately target and match dents the opportunity to share ideas a part of life and medicine that is new current operational needs. and experiences with doctors from a to us, sometimes shockingly so. Such In response to this directive, an different culture--doctors who may experiences tend to make us better interservice Tropical Medicine Com­ have a different point of view than our physicians and persons in general. mittee was formed and had its first own of health and sickness, and what The Future of Tropical Medicine meeting in June 1993 to review current to do about it. It is a growing experi­ Training. Interest in short courses in programs and to establish a tri-service ence for all involved. tropical medicine is increasing in both plan for tropical medicine training. A Unique Learning Experience. the civilian and military medical com­ The outcome of this process on the Overall, the 6 weeks of the Medicine munity. Recently, the American Soci­ military's current tropical medicine in the Tropics course attempts to pro­ ety of Tropical Medicine and Hygiene courses is unknown at present. How­ vide a total experience in the health approved a grant to the American ever, the recent U.S. combat and care issues of the tropics, from the Council of Clinical Tropical Medicine humanitarian involvement in the Car­ organisms of disease to the economic, and Traveler's Health to fund the ibbean, the Middle East, and Africa environmental, social, and political process for certification of Tropical show clearly the operational impor­ forces which affect health in develop­ Medicine as a medical specialty. (9) tance of quality training in tropical ing, tropical countries. The primary This past November, in concert medicine. goal is to prepare the physician for the with the philosophy of force restruc­ How to apply for the course. Calls many and varied challenges he or she turing, the Chairman of the Joint Chiefs for applications are sent out from the may face as a military medical officer. of Staff, General Colin Powell , initi­ Health Sciences Education and Train­ The knowledge gained in the course ated a 3-year, servicewide review of ing Command (HSETC), Bethesda, undoubtedly enhances the medical all military training programs (includ­ MD, to all medical facilities two times officer's ability to support operational ing medical). In addition to looking to per year; each call advertises for two courses. Point of contact at HSETC concerning applications is (301) 295- 2355. For other information about the course contact the staff in San Juan at (809) 758-7575, ext. 5677; FAX (809) 766-6113. In general, many more per­ sons apply than there are spots available.Preference is given to those who are more likely to use the infor­ mation in present or future assign­ ments and to those with longer mili­ tary commitments. To improve your chances of selection it is important that you give as much information as pos­ sible concerning these issues.

Tropical Medicine Quiz 1. Eosinophilia is associated with which of the following parasitic dis­ ease? (Choose all that apply)

Dominican dentists perform extrac· tions during the field missions. Badly decayed teeth and severe gum dis­ ease are common in rural areas.

July-August 1993 19 A. Malaria should you consider? tion. Amebic liver abscess is a poten­ B. Schistosomiasis A. Malaria tial complication ofamebiasis. Fasciola C. Giardiasis B. Shigellosis hepatica (a liver fluke) and Ascaris D. Filariasis C. Dengue lumbricoides (the giant round worm) 2. Chloroquine-resistant P. D. AandC may cause disease due to their pres­ falciparum malaria is endemic in all of E. All of the above ence in the biliary tract. the following countries, except: 5. C. A. Brazil Answers 6. False. Chloroquine resistance to B. Haiti Scenario from page 14: This non­ P. falciparum emerged in the early C. Kenya specific febrile illness in its early stages 1960's and is now present in most parts D. Thailand could be due to any of the diseases of the world. Chloroquine resistant P. 3. All of the following protozoa are listed here except visceral vivax has recently been discovered on potential causes of diarrhea, except: leishmaniasis, which is not present in the island of New Guinea in the south­ A. Dientamoeba fragilis Thailand. Knowledge of geographic west Pacific. B. Entamoeba coli medicine is necessary when evaluat­ 7. B,C,D. "Creeping" or "wander­ C. Cryptosporidium parvum ing the sick traveler. The crescent­ ing" types of skin eruptions are often D. Balantidium coli shaped (or banana-shaped) organism due to the subcutaneous migration of 4. Parasitic causes ofliver or biliary in Figure 1 is a gametocyte of Plasmo­ helminths (worms), such as cutaneous tract disease include: (Choose all that dium falciparum, the organism which larva migrans, strongyloidiasis, and apply) causes the most serious form of ma­ gnathostomiasis. A. Schistosomiasis laria. Failure to recognize this form 8. E. This presentation is compat­ B. Amebiasis and begin therapy promptly could re­ ible with all three of the diseases listed C. Fascioliasis sult in the patient's death. The correct (as well as many others), and all are D. Ascariasis therapy for this patient is quinine and significant threats in Somalia. 5. Common causes of splenomegaly doxycycline. (Note: The small cell Shigellosis may present initially as a in tropical areas include all of the beside the gametocyte is a platelet.) febrile illness without diarrhea, pro­ following, except: gressing to significant diarrhea hours A. Malaria Tropical Medicine Quiz to 1 or 2 days later. B. Visceral leishmaniasis 1. B,D. Eosinophilia due to infec­ C. Filariasis tions is caused primarily by tissue­ References D. Schistosomiasis I. Warren KS . Tropical medicine or tropical health: invading helminths (worms), such as The Heath Clark Lectures, 1988. Rev Infect Dis. 6. P.falciparum is the only malaria schistosomiasis and filariasis. The pro­ 1990; 12:142-156. species which has developed resis­ 2. Walter Reed Army Institute of Research, Division tozoal diseases malaria and giardiasis of Preventive Medicine, Washington, DC; May 1993. tance to chloroquine. True or false do not cause eosinophilia. 3. Oldfield EC, Wallace MR, Hyams KC , et a!. 7. Which of the following cause a Endemic infectious diseases of the Middle East. Rev lnfec 2. B. Dis. 1991;13(suppl 3):S199-217. "creeping" type of skin eruption? 3. B. All these protozoa are con­ 4. Benenson AS. Immunizations and military medi­ (Choose all that apply) cine. Rev Infect Dis. 1984;6:1-12. tracted by ingestion of contaminated 5. Beadle C, Hoffman SL. History of malaria in the A. Cutaneous leishmaniasis United States naval forces at war: World War I through the food or water, a common problem in Vietnam conflict. Clin Infect Dis. 1993;16:320-329. B. Cutaneous larva migrans tropical, developing countries. All may 6. Hyams KC, Bourgeois AL, Merrell BR, et a!. C. Strongyloidiasis Diarrheal diseases during Operation Desert Shield. N Eng/ cause a diarrheal illness except Enta­ J Med. 199 1;325:1423-1428. D. Gnathostomiasis moeba coli, a commensal organism. 7. CDC. Malaria among U.S. military personnel 8. You are called to see a 20-year­ returning from Somalia, I 993. MMWR. I 993;42:524-525. Its presence in the stool, however, 8. Sommer A. Vitamin A, infectious disease, and old marine at your unit's Battalion Aid indicates exposure to contaminated childhood mortality: a 2 cent solution? J Infect Dis. Station located near Mogadishu, So­ 1993; 167:1003-1007. food or water and the possible pres­ 9. Trop Med Hygiene News. Feb ruary 1993;42: !0. malia. He has been in country for 1 ence of pathogens. month and now complains of high 4. A,B,C,D. The granulomatous fever, chills, and headache for less response to schistosome eggs in the CDR Crutcher and CAPT Beecham are both assigned to the Naval School of Health than 1 day. He denies cough, sore liver can result in significant impair­ throat, abdominal cramps or diarrhea. Sciences, Bethesda Detachment, VA Medical ment due to compression and obstruc- Center, San Juan, Puerto Rico. Which of the following diagnoses

20 NAVY MEDICINE Chronology ~ ------~------~vvvv~ .. II +50th ~ Navy Medicine July-August 1943

Jennifer Mitchum

WITH Guadalcanal and the Russell Other Movements in the New kits and each battalion member had a Islands under Allied control, U.S. Georgia Area supply of Atabrine, halazone, salt tab­ forces continued their offensive in the lets, aspirin, band-aids, and a mor­ Because the United States wanted western Solomon Islands in the face of phine syrette, all in a metal container. Viru Harbor as a small-craft base, enemy opposition. On 2 July, Japa­ To the south of Viru, on Vangunu U.S. forces landed at Viru Village, nese bombers and fighter planes at­ Island, where troops had landed on 30 New Georgia Island, on 1 July to tacked the camp which Seabees had June, medical staffers established an rendezvous with the arrival of Fourth set up on Rendova Island. Taken by aid station in a Japanese mess hall. Marine Raiders corning overland from surprise, casualties piled up quickly In the Viru and Vangunu opera­ Segi Point.(J) En route to Viru, the with 59 killed and 77 wounded. For tions, medical personnel encountered Fourth advanced rapidly and front hours, Navy and Army medics cared several difficulties. In evacuating ca­ lines were not clearly developed. As a for ship and shore wounded. Burying sualties over jungle trails, about six result, snipers and machine guns often the dead took about 3 days.(l) On men per litter were needed to carry the operated behind U.S. troops, making Independence Day, the enemy wounded and the litter bearers had to first-aid difficult and the setting up of launched another aerial attack on the stop and rest every 300 to 500 yards. an aid station initially impossible. camp destroying several landing craft Incidentally, many of the seriously Later, personnel moved wounded on and damaging two landing craft, in­ wounded died along the way. Because the trail to Viru at night, and medics fantry (LCI's). Despite the attacks, ambulatory patients became litter pa­ set up an aid station in a native hut at 28,748personnel(25,556Army, 1,547 tients when given morphine, medical Tetamere Village. Corpsmen assigned Navy, and 1,645 Marines) landed and personnel administered the drug cau­ to the Fourth carried unit 3* medical approximately 30,000 tons of equip­ tiously. Corpsmen also found the ment were unloaded at Rendova Har­ packaging of first -aid units 1 and 3 to bor between 30 June and 31 July.(2) be impractical because the units be­ After the Independence Day raid, the came jumbled after several battle dress­ Japanese Army refused to contribute ings were removed. Often-times, *The Unit 3 medical kit was one type of first-aid kit more planes for the defense of the carried by corpsmen in the field. Within the thick purselike corpsmen had to empty the kits to find Solomons. Instead, they concentrated bag, which weighed about 10 pounds. were first-aid specific items. Thus, many corpsmen materials and surgical instruments such as suturing needles, on holding the New Georgia Island needle holders, surgical knives, tourniquets, and several used Navy pouches in which items mainland as an outpost. types of bandages. could be located more promptly.

July-August 1993 21 PAPUA IIIEW GUINEA

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Sanitation and Disease in New of the campaign, 10 percent of the ting up laboratories and diagnosing Georgia force was affected with diarrhea blood smears, malaria experts found Unsanitary conditions with related weekly.(7) Medical personnel treated little evidence of initial infection, con­ fly, mosquito, and screening problems dysentery rather effectively with cluding most of the cases to be relapses as well as contact with native civilians sulfaguanidine. Because of fewer in­ or reoccurrences. Atabrine continued accounted for combat units losing 25 fected anopheles mosquitoes and im­ to be used as a prophylactic as well as to 50 percent of their combat effi­ proved control measures, malaria was a suppressant. ciency to disease.( 4) Fungus infec­ not regarded as a serious problem as it War neurosis--which included com­ tions occurred in about 25 percent of had been during the Guadalcanal cam­ bat fatigue , exhaustion related prob­ the New Georgia OccupationForce.(5) paign. A malaria control unit consist­ lems, and temporary mental distur­ These conditions were mainly among ing of two naval officers, eight Navy bances--was reported to be the most Seabee members because the nature of corpsmen, and one Army enlisted man serious medical problem in the New their work made it difficult to maintain arrived on Rendova Island 14 July and Georgia campaign. Between 30 June good personal hygiene. Thirty percent immediately began surveying and oil­ and 30 Sept, about 2,500 were admit­ of the troops had foot infections.(6) ing troop areas. Following surveys, ted with the diagnosis; 1, 750 cases Early on, diarrhea and dysentery were troops abandoned areas that showed occurred in July, 650 in August, and also problems. During the first 6 weeks heavy mosquito breeding. Upon set- 100 in September. ( 8) Two hundred of

22 NAVY MEDICINE on a beach in scoglitti, Sicily, a cam· ouflaged tent serves as a temporary first-aid station for those wounded during the invasion. On 15 Aug, SCAT (South Pacific Combat Air Transport) planes landed at Munda Air Field and regular air evacuation began. By the end of Au­ gust, SCATs had flown out 132 pa­ tients.(JO) During the period of 30 June and 31 Aug, evacuations by all ~. means of transportation totaled 6,693; of these 5,736 were from Army units, 241 from Navy, 716 from the Marine • - Corps.(JJ) ... Photos from BUM ED Archives New Georgia Medical Supplies Most of the supplies used in the these cases were Navy and Marine Wounded from Wickham Anchorage, New Georgia operation came from the Corps. Combat fatigue constituted Segi, and Viru were evacuated by Army medical supply depot on about 50 percent of the war neurosis returning supply boats to the Russell Guadalcanal. The 43rd Army Divi­ cases; exhaustion comprised about an­ Islands. Similarly, wounded on Vella sion, responsible for medical supplies other 20 percent of the cases. Given Lavella, Rendova, and Rice Anchor­ from 30 June to 28 July, had difficulty proper rest, relaxation, and good diet, age and Enogi on New Georgia Island carrying out its supply handling and 75 to 80 percent of those diagnosed were evacuated to Guadalcanal. distribution plan. Under the plan, field with war neurosis completely recov­ Rend ova's East Beach served as evacu­ units were to carry 30 days supply with ered. ation port for tank landing ships (LST' s) them and another 30-day supply was to going to Guadalcanal. LST's had the be transferred later. Due to disorgani­ Hospitalization and Evacuation capacity to evacuate between 100 and zation in unloading and confusion in in New Georgia 200 casualties. During the first4 weeks embarking for combat, personnel car­ With the exception of medical units of the campaign, one medical officer ried only small portions of the huge which accompanied Army, K avy, and manned each LST. At a battalion aid stores. Consequently, units had about Marine forces, area hospital facilities station in the vicinity of the beach, 10 days worth of medical supplies were nonexistent in the initial stages of medics treated many evacuees for instead of 30 days. Within 3 days after the campaign. Hospital facilities were shock prior to their further evacua­ landing, more medical supplies were not available in the New Georgia area tion. Although the sailing time to urgently needed. Fortunately, medi­ until the Army established the 17th Guadalcanal was about 20 hours, ca­ cal units that arrived later brought Field Hospital, a 250-bed facility on sualties, many who had received little adequate supplies with them and Kokurana Island, on 28 July. Before first-aid treatment on New Georgia, handled them more efficiently. then, the nearest hospital was on often reached Guadalcanal medical Navy medical units secured sup­ Guadalcanal, about 200 miles away installations about 72 to 84 hours after plies from Mob-8 which was officially and 20 hours by boat. Incidentally, they had been injured. Such time gaps established on Guadalcanal 7 Aug because the airfield at Munda was not and space limitations aboard LST's 1943. In cases of emergency, medics totally secured by the Allies until later, contributed to the incidence of gas used Army supplies. In the beginning emergency air evacuation was initially gangrene early on in the campaign. of the campaign, Navy medical per­ limited. By the time regular air evacu­ The First Corps Medical Battalion had sonnel had scant antimalarial supplies; ation began, fighting had decreased. 24 patients with gas gangrene, of they later received more when the Because of the limited hospital beds, whom 6 died; Mobile Hospital No. 8 malaria control unit arrived and when medical personnel evacuated patients admitted 20 patients with gas gan­ additional supplies arrived from within 24 hours of their injuries. grene, of whom one died.(9) Guadalcanal.

Julv·August 1993 23 Personnel carry wounded to Kiska Aleutian Islands, shoreline to b~ evacuated for medical treatment.

In the Scoglitti area, enemy opposi­ tion was slight initially but increased as the troops advanced inland. The Navy Medical Department was to provide medical and surgical care for all personnel on Navy vessels from the time of embarkation until they landed on invasion beaches. Navy medical personnel were also to evacu­ ate sick and wounded from beaches during the assault until adequate shore medical facilities could be established. In the Licata area, troops landed continuously and thrusted inward de­ spite heavy surf and enemy counterfire. Surprisingly, the losses were initially ous night landings. The main land­ few. Nonetheless, Navy medical per­ Sicily ing areas were Licata, Gela, and sonnel established land-based facilities Firmly affixed in French North Af­ Scoglitti. Forces landing in the in the area quickly. rica, the Allies moved quickly to take immediate vicinity of Licata and On the day of the initial landings, a advantage of their gains in the Mediter­ Gela encountered strong opposi­ Navy medical unit landed and aided ranean with the next Allied objective tion. However, troops landing on survivors. Then on 19 July, another being Sicily. The Sicilian campaign be­ beaches farther away from the cit­ unit arrived at Licata and proceeded gan on 10 July with a series of amphibi- ies met little resistance. overland to Porto Empedocle and set up a dispensary. LST's, which were principal troop lifts, were used for evacuation. Casualties were transported to hospitals in the Tunis-Bizerte area with Army overflow going to medical facilities in Bone. Gela turned out to be the most bitterly contested landing by the en­ emy. Beaches were heavily mined against vehicles destroying a number of DUWK's (two-and-a-half-ton, 6x6 amphibious trucks) and bulldozers. As , daylight approached, the enemy em­ ployed air forces and later tanks. Such resistance, coupled with beach conges­ tion and problems unloading LST's, slowed troop advance in the area. Many paratroopers, tasked with capturing

On Rend ova Island, Navy corpsmen tend wounded at a front line dressing sta­ tion. Jeeps, seen in the background, serve as ambulances. I ..

24 NAVY MEDICINE roads and high ground in which to day of the landings and arrival in Oran, Included in the Allied medical ele­ command the plain, were lost, drowned Scoglitti area transports received 531 ment for Sicily were about 15 hospital or shot down. Survivors trickled into Army, 157 Navy and Coast Guard, ships and hospital carriers available Gela. Doctors and pharmacist's mates and 16 POW's for treatment. Trans- for evacuation once transports left; 2 aboard ships worked nearly around ports did not reach their capacity for were Army hospital ships and the the clock tending wounded. Likewise, casualty handling. The average num- others were British and Canadian. aNavymedical unit landed 11 July and ber of casualties per AP and APA was However, administrative problems set up a small dispensary and sick bay. 40 to 45. (12) At Oran, some Army and hampered their operations. Thus, land­ Despite opposition, the Allied had Navy casualties were admitted to area based Army hospitals became over­ captured Ponte Olivo airstrip by the medical facilities while others were crowded while awaiting the arrival of morning of 12 July, and the situation evacuated stateside. hospital ships. became more favorable in the Gela area. Wounded were evacuated to Oran by transports (AP's). The Scoglitti landings were delayed and once under way heavy surf, lack of definite landmarks, and inexperi­ enced boat crews made landing and unloading difficult. Despite delays, the Navy managed to unload trans­ ports and prepare for the evacuation of wounded within 3 days. Army collect­ ing companies and Navy medical com­ ponents of beach parties rendered first aid to wounded prior to their evacua­ tion to ships. Transports, attack transports (APA's), and attack cargo ships (AKA's) were used in evacuating pa­ tients to medical facilities in North Africa. Landing craft, vehicle and personnel (LCVP' s) and landing craft, tank (LCT's) were used to evacuate wounded to the larger ships. Forty-six LCT's divided into three groups carried a total of three doctors and six pharmacist's mates. Inciden­ tally, the Army found DUWK's espe­ cially useful in evacuating wounded from shore-to-ship. The casualty load in the Scoglitti area was reported to be relatively light the first 2 days, allow­ ing medics to render extensive defini­ tive treatment aboard transports. The third day after the assault troops Kiska casualties are transported from uss Harris

July·August 1993 25 conjunction with the pool, a medical supply dump was established to en­ sure that evacuation supplies were constantly circulated to beaches. The U.S. Army Mediterranean base sec­ tion furnished the supplies. Each LST had cots for about 150 patients. The largest number evacu­ ated in one ship was about 120. Four hospital corpsmen and one medical officer were sufficient to care for casualties coming aboard, for many ships received less than 12 patients. '~ ·-· LST's were especially suitable for evacuating minor casualties over short -~- ...... -~ ,,., hauls. Early on, LST's came under criticism because corpsmen and fa­ cilities were not being fully utilized. On 17 Aug, Army troops entered Messina officially ending the Sicily campaign. Lipari and Stromboli Is­ lands, north of Sicily, surrendered to U.S. destroyer and PT boats.

The Aleutians Continued At 1330 on 15 Aug, Allied troops landed unopposed at Kiska. The Japa­ nese had seized Kiska and Attu in June 1942. U.S. forces had reclaimed Attu in May 1943. The Kiska task unit consisted of an invasion fleet and a In northern Sicily, a Navy medical gery. There was usually one small group of men who were to begin unit established a dispensary at Palermo. pharmacist's mate first class aboard setting up a naval station. Because of On 28 July, the Naval Operating Base each and one medical officer in each prior enemy evacuation, the Kiska (NOB) Palermo was established. By division of 4 to 6 ships. campaign seemed to be a practice drill the end of August, the smaller Navy To bolster these facilities, a medi­ for future campaigns. Nonetheless, medical units at Gela, Licata, and cal pool of 100 Navy medical officers medical personnel were kept busy.(13) Palermo had been consolidated into and 400 corpsmen was set up at the As at Attu, immersion foot and one unit at the NOB, having a total bed Bizerte embarkation port. The Navy catarrhal fever were primary medical capacity of 125 which could be ex­ used 52 medical officers and 250 problems; there were also cases of panded to 175. corpsmen; the rest were detailed for situational neurosis. In addition, inju­ duty with the Army. Thus, each ries resulting from booby traps and Mediterranean LST Pool outgoing combat-loaded LST car­ accidental wounds, caused primarily For the first time in the European ried one medical officer and five by careless handling of equipment, phase of the war, LST's were thor­ enlisted men in addition to the regu­ were reported . Medics aboard USS J. oughly used. Each LST had a compact larly assigned pharmacist's mate. Ap­ Franklin Bell handled 32 casualties sick bay for minor and routine medical proximately 72 LST's served the resulting from booby trap and acci­ concerns and occasional major sur- Licata, Gela, and Scoglitti areas. In dental wound incidents.

26 NAVY MEDICINE Similarly, while on antisubmarine Silver Star medals posthumously. In Naval Historical Center. Navy Deparunent. Wash­ patrol the night of 17-18 Aug, USS addition, a ship, Thaddeus Parker(DE- ington, DC: Government Printing Office; 1981. Dictionary ofAmeri can Fighting Ships, Volume Abner Read's stern hit a floating mine. 369), was later named after him. VII: S-T--Appendices: Submarine Chaser, Eagle­ Casualties were taken to the ward­ Class Patrol Craft. Naval History Division, Office room and the captain's and division of the Chief of Naval Operations, Navy Depart­ References ment. Washington, DC: Government Printing Of­ commander's cabins for emergency I. U.S. Navy Medical Departme/11 Administra­ fice; 1976. treatment. Those suffering from smoke tive History , 1941-1945: Narrative History. Vol!, Historical Data of U.S. Naval Mobile Hospital chaps 1-Vlll. Chap II , sec two, p 41. No. Eight, 1943. Unpublished paper. BUMED inhalation were carried below to the 2. Ibid ., p 40. Archives. CPO quarters or officers' country and 3. Viru Harbor was found to be unsuitable for His10ry of U.S. Naval Hospitals Vol. II : all given care. the proposed PT base and its only function was to remaining hospitals including Special Augmented repair small landing craft on a marine railway Hospital No. 6 Okinawa. BUMED Archives. By 0800 of 18 Aug, medics had installed by Seabees. Morison SE. History ofUnited Hospital Corpsmen Commended. Awards and completed emergency treatment and States Naval Operations in World War II. Vol VI, Commendations. Hosp Corps Q. May 1944; XVII( Breaking the Bismarcks Barrier 22 July 1942-1 those wounded were in bunks eating. 3). BUMED Archives. May 1944, p 153. Hosp Corps Q. January-October 1943; XVI. Subsequently, medical staffers reex­ 4. The History ofthe Medical Departmellt ofthe BUMED Archives. amined and classified the wounded U.S. Navy in World War II: A Narrative and Karig W, Burton E. Freeland SL: Battle Re­ Pictorial Volwne; I :77. port: The Atlantic War. New York: Rinehart & Co according to injuries, rendered defini­ 5. Ibid. , p 77. Inc; 1947. tive treatment, and recorded their con­ 6. U.S. Navy Medical Department Administra­ Karig W, Purdon E: Battle Report: Pacific ditions. Casualties totalled 48; of these tive History, 1941-1945: Narrative History. Vol!, War: Middle Phase. New York: Rinehart&Co Inc; chaps I-Vlll. Chap Ill, sec two, p 56. 1947. 1 died and 34 were transferred to a 7. Ibid., p 55. Miller JA. Wartime reminiscences of CAPT Naval dispensary at Adak.(14) 8. Ibid ., p 57. James A. Miller, MC, USNR, World War II 9. The History ofthe Medical Departmem ofth e surgeon assigned to Base Hospital No. 9 Oran, U.S. Navy in World War II: A Narrative and Algeria. BUMED Archives. Elsewhere Pictorial Volume; I :78. Morison SE. History of United States Naval I0. U.S. Navy Medical Department Administra­ Operations in World War II. Vol VI, Breaking the The Navy Medical Department tive History, 1941-1945: Narrative History. Vol I, Bismarcks Barrier 22 July 1942-1 May 1944. continued its expansion program com­ chaps I-VIII. Chap II, sec two, p 64. Boston: Little Brown & Co; 1950. missioning U.S. Naval Special Hospi­ II. Ibid., p 64. Morison SE: History of United States Naval 12. The History of the Medical Departme/11 of Operations in World War II. Vol IX, Sicily-Salerno­ tal, Sun Valley, ID, on 1 July, USNH the U.S. Navy in World War 11: A Narrative and Anzio January 1943-June 1944. Boston: Little Trinidad, British West Indies on 12 Pictorial Volume; I: 125. Brown & Co; 1954. Aug, and Mob-10 Russell Islands on 13. According to later reports, Navy medicine Oman CM: Doctors Aweigh. New York: was believed to be over represented in the Aleutians Doubleday Doran & Co; 1943. 26 Aug. In addition, Base Hospital campaign because of the lack of action. 111e History of the U.S. Navy in World War II: No.9 sailed for Oran, Algeria, on 21 14. U.S. Navy Medica/Department Administra­ A Narrative and Pictorial Volume. Washington, tive History, 1941-1945: Narrative History. Vol!, DC: Government Printing Office; 1953. Aug. chaps 1-VIII. Chap IV , p 14. Unit Citations. Hosp Corps Q. March 1944; XVII (2). BUMED Archives. Worth Mentioning a Second Bibliography United States Naval Chronology, World War II. Cooper P: Navy Nurse. New York: McGraw­ Prepared in the Naval History Division, Office of Time Hill Book Co Inc, 1946. the Chief of Naval Operations, Navy Department. July-August 1943 brought more sto­ Dictionary ofAm erican Fighting Ships, Volume Washington, DC: Government Printing Office; lll: G-K--Appendices One-Six. Naval History Divi­ 1955. ries of courage and dedication which sion, Office ofthe Chief of Naval Operations, Navy U.S. Navy Medical Departmel!t Administrative reinforced the Navy Medical Deparunent. Washington, DC: Government Print­ History, 1941-1945. Narrative History. Vol I. Chaps 1-Vlll. Unpublished typescript. BUMED Department's long medical tradition ing Office; 1968. Dictionary ofAmeri can Fighting Ships, Volume Archives. for service. There is the story of IV: L-M--Appendices: Amphibious Ships, Aviation U.S. Navy Medical Department Administrative pharmacist's mate Thaddeus Parker Auxiliaries, Destroyer Tenders, Ships-of-the-Line, History, /941-1945. Organizational History, Vol II. Chaps X-XVI. Unpublished typescript, BUM ED who was killed in action during the Classification of Ships. Naval Hiswry Division, Office of the Chief of Naval Operations, Navy Archives. New Georgia campaign on 20 July. Department. Washington, DC: Government Print- U.S. Nov Med Bull. September 1943; XL1(5). BUMED Archives. Disregarding his personal safety, ing Office; 1969. War Medicine. Chicago: American Medical Dictionary ofAmerican Fighting Ships, Volume PhM2c Parker moved forward into Association; July-December 1943. V: N-O--Appendices Stone Fleet, Minecraft, New World War II Dispatch . Deparunent of De­ areas swept by intense, hostile fire to Ships, Aircraft. Naval His10ry Division, Office of fense. Winter 1993; 1(4). render medical aid to two wounded the Chief of Naval Operations, Navy Department. Marines. In an attempt to evacuate the Washington, DC: Government Printing Office; 1970. second man, PhM2c Parker was killed. Dictionary ofAmeri can Fighting Sh ips, Volume He was awarded the Purple Heart and VI: R-V--Appendix: Tank Landing Ships (LSI).

July-August 1993 27 Naval Medical Research and Development command Highlights

o Cholera Vaccine Field Trial croscopy and radioimmunoassay, researchers are studying Historically, diarrheal diseases have been a major cause of the effects of cytokines, growth factors, and two known wartime morbidity in deployed military personnel. Cholera mediators of inflammatory reactions (lipopolysaccharide is a severe, dehydrating form of diarrhea caused by Vibrio and thrombin) on the expression ofcell adhesion molecules cholera. A safe, effective vaccine against cholera would and cytoskeletal reorganization in endothelial cells, mono­ offer a valuable preventive treatment for troops deployed cytes, and macrophages. The objectives of this research are in developing countries where cholera is endemic, and to define the cellular mechanisms that regulate inflamma­ would be a considerable improvement to the parenteral tion and to develop a pharmacologic and/or immunologic vaccine currently available. Peru was the first country in means for modulating the intensity of inflammation. For South America to be affected by cholera on a large scale in more information contactMs. Christine Eisemann, NMRDC more than a century. Factors of limited sanitation, lack of Associate Director for Research Management, DSN 295- potable water, lack of access to medical care, and devas­ 0882 or Commercial 301-295-0882. tating poverty have all compounded the spread of the disease (although the cholera outbreak in Latin America is o Patent Issued on New Membrane-Based Rapid less than 2 years old, there have been over a half million Dot Immunoassay Test Kit illness reports, 50,000 hospitalizations, and over 2,000 A patent (#5,200,312) was issued recently on a new deaths). Navy researchers at the Naval Medical Research membrane-based immunoassay and on the method of use Institute Detachment in Lima, Peru, have started a random­ which was developed by researchers at the naval Medical ized, controlled field trial of the killed Vibrio cholera whole Research Institute, Bethesda, MD. The new rapid dot cell plus recombinant B subunit cholera vaccine. This 30- immunoassay test, developed for use in the field, can be month study, involving 62,000 Peruvians over the age of easily and quickly performed without the use of special 2 years, is being conducted in collaboration with Cayetano equipment. The kit contains a chemically stable "test strip" Heredia University, Lima, Peru, and is funded by the U.S. comprised of a hydrophobic membrane to detect one or Army Medical Material Development Activity. For more several antigens or antibodies. Known antigens or antibod­ information contact CDR C.J. Schlagel, MSC, NMRDC ies which will form complexes with the antigens or Research Area Manager for Infectious Diseases, DSN 295- antibodies to be assayed are spot filtered with pressure 0881 or Commercial 301-295-0881. through the membrane. The membrane, either by itself or attached to a base material, is incubated with a test fluid. o Molecular and Cellular Mechanisms Regulat­ The resulting antibody-antigen complex is incubated di­ ing Inflammation rectly or after an intermediate anti-antibody incubation Navy personnel engaged in combat or hazardous opera­ with enzyme conjugated immunoglobulin and exposed to tions can suffer from traumatic injuries and infections substrate which produces a colored insoluble product if the resulting in adult respiratory distress syndrome, multiple test target is present. The test kit includes the proper test organ failure in sepsis, and impaired wound healing. In an strip, wetting solution, washing solution, buffer/surfactant effort to develop a therapeutic strategy for controlling the solution, buffer solution, enzyme conjugated immuno­ intensity of local inflammation, researchers in the Septic globulin solution, and substrate as well as containers for Shock Treatment Program at the Naval Medical Research carrying out the dilutions and incubations. For more Institute, Bethesda, MD, are investigating the molecular information contact Mr. A. David Spevack, NNMC Intel­ and cellular mechanisms regulating inflammatory reac­ lectual Property Counsel, DSN 295-6760 or Commercial tions. Using immunofluorescence, immunoelectron mi- 301-295-6760.

28 NAVY MEDICINE Professional

The author instructs patient on IV self-infusion. IV Antibiotic Self-Infusion for Active Duty Personnel

LT Kathryn Summers, NC, USN

EARLY patient discharge and home hospitalization except to receive par­ home on parenteral therapy. "Outpa­ health care are becoming much more enteral antibiotic therapy, can be well tient IV antibiotic self-infusion has essential to the military health care managed at home." (1) been used successfully in patients with system in our efforts to seriously con­ In the civilian community, there are infections related to the use of medical tain costs (Figure 1). "Experience has numerous home health agencies that appliances, pulmonary complications shown that selected patients on long­ provide teaching and supervision of of cystic fibrosis, bacteremia, term therapy, who no longer need patients who have been discharged to endocarditis, cellulitis, sinusitis, epi-

July-August 1993 29 glottis, adenitis, bacterial pneumonia, social worker (5) pharmacist (6) Navy and urinary tract infections including Relief nurses, and (7) clinical nursing TABLE 1 pyelonephritis. "(2) consultant. The initial planning phase In the military health care setting, of the program development included Factors to Consider in Selecting dependents and retirees can utilize the establishment of a patient selection Active Duty Patients for Home IV home health agency IV programs by criteria for self-infusion, standardized Antibiotic Therapy qualifying for these benefits from the patient protocol, a policy for phar­ Medical stability CHAMPUS Health Care Plan. How­ macy and supply support, a discharge Compliance ever, active duty personnel in need of criteria and followup plan, and the Ability to be educated long-term parenteral therapy are not development ofa patient teaching plan/ Manual dexterity eligible for these CHAMPUS ben­ competency evaluation. Proximity to the hospital efits; they must remain in acute care Light Care and Home Care Phase. Home environment inpatient beds for 2 to 8 or more weeks The IV Antibiotic Self-Infusion Pro­ to complete their antibiotic regime. gram was separated into two phases: In January 1990, a target popula­ the Light Care Phase and the Home tion of active duty patients in need of Care Phase. Patients referred to the long-term antibiotic therapy was iden­ program were screened by the Light tified. Of this group, the primary diag­ Care nurse. If the patient met the noses included osteomyelitis, cellulitis, criteria for self-infusion, then a 24- to 72-hour instruction period was started wound infections, and endocarditis. A ferred to the Light Care ward. Compe­ on the acute care ward. Patients were multidisciplinary team was formed to tency for self-infusion was measured instructed on the procedures for infu­ set up an IV Antibiotic Self-Infusion by a return infusion and a flushing sion, medication, use ofinfusion pump, Program for active duty patients at demonstration and an achievement of IV access site care, potential emer­ Naval Hospital, San Diego, CA. 90 percent accuracy on a written test. gency situations and interventions with If a patient did not meet the criteria for infusion, and needle disposal. Program Development home infusion, then he/she remained Once the patient demonstrated com­ The multidisciplinary team consisted on the Light Care ward for self-infu­ of (1) infectious disease physician (2) fort and competency with the self­ sion for the remainder of the antibiotic infusion procedure he/she was trans- light care RN (3) Orthopedic RN (4) course. The Light Care ward is a 25-bed Photos by HM1 Daniel Vasil, NSHS San Diego, CA multiservice ward designed to pro­ mote patient self-care. Patients are responsible for their own dressing changes and medications. The ward is primarily used for multitrauma pa­ tients in need of long-term rehabilita­ tion therapy. Light Care is staffed by one RN and five hospital corpsmen. Some of the primary reasons for Light Care IV self-infusion were that the patients lived in the barracks, on a

Patient self-infuses IV antibiotic into Hickman catheter.

30 NAVY MEDICINE ship, or in a home setting that did not DISCHARGE PLANNING have the facilities to support safe pa­ AND HOME CARE tient self-infusion. INFORMATION If a patient met the criteria for "It takes teamwork to reach home" discharge (Table 1) and had safely completed a 48-hour self-infusion on The followmg departments can asmt you tn managing the Light Care ward then he/she quali­ your pattents' continuing care fied for discharge home self-infusion. ADMISSIONS: 532-8366 Patients discharged home to self-in­ CHAMPUS: 532-8328 fuse would return weekly to the Light COLLECTION: 532-8395 Care ward for catheter checks, blood draws, and supplies. In addition, pa­ MEDICAL BOARDS: 532-7493 tients that were discharged into the MEDEVAC : 532-8311 home program are seen once in their SOCIAL WORK : 532-7150 home by a Navy Relief nurse to ensure ·Transfer and Placement Coordtnatton their home setting is conducive to - Communtty Servtces Evaluatton and Referral parenteral infusion. · Crtsts lnterventton and Counseltng

Cost Savings NHSD IV HOME INFUSION for ACTIVE DUTY : Beeper 968·1489 This program demonstrates a safe · Educatton and Coordtnatton of Home IV and economical alternative to contin­ Anttbtottcs•. Htcl::man and Gr oshong care ued hospitalization of active duty pa­ Nursing Discharge Planners: see back of card tients who require prolonged IV anti­ for beeper #'s biotic therapy. With careful selection · AsSISt wtth coordinatmg d1scharge for pat tents of candidates, adequate patient teach­ wtth complex home needs · AsSISt wtth coordtnattng pattent and family ing, and home health care support, this health educat1on level of complex health care can be Figure 1 safely managed at home. All patients who have participated in the self-infu­ sion program at Naval Hospital San criteria for home infusion; therefore, cost-effec tive means of providing par­ Diego have been males between the these patients self-infused their antibi­ enteral antibiotic therapy. ages of 28 and 46 years old . The otics on the Light Care ward. All The real benefits for both military majority, 43 percent, have been diag­ patients were surveyed for satisfaction and civilian health care settings are: nosed with osteomyelitis. The remain­ at the completion in the Light Care and (1) increase availability of acute care der of the patients have had varied Home Self-Infusion programs. Ninety­ hospital beds,(2) patient satisfaction diagnosis including joint sepsis , eight percent of the patients were sat­ and independence, (3) decreased hos­ endocarditis, and wound infections. isfied with both of these self-infusion pital staff work load, and (4) health As of 1 Oct 1991 , a total of 38 programs. They responded that the care cost containment. patients had participated in our IV instruction materials and required dem­ Antibiotic Self-Infusion Program. Of onstrations were adequate for safe References this group, 18 patients met the criteria self-infusion. Only one patient (2 per­ I. Corby D, Fud ge J, Schad R. Intravenous antibiotic therapy: hospital to home. Nurs Man. August 1986:52-61 . for home infusion. The average length cent) indicated that the hands-on teach­ 2. Brown R, Sands M. Outpatient intravenous antihi· of their home infusion was 24.7 days, otic therapy . Am Fam Practitioner. October 1989: 157- ing program needs to be briefer and 162. which equaled a total savings of 446 that the instruction materials alone 3. Barget C. Zink M. Evaluation of clinical indicato rs hospital days. The flat rate for a hos­ were sufficient for safe self-infusion. in IV home care. J Nurs Quality Assurance. 1989:64-71. pital bed is $701 per day. Thus, the LT Summers is a nurse discharge planner total inpatient hospital cost savings Summary at Naval Hospital , San Diego, CA. This article was written in cooperation with the Clinical was $312,646 for 18 patients. Twenty The self-infusion of IV antibiotics Investigat ion Department , Naval Hospital San of the 38 patients did not meet the for active duty personnel is a safe and Diego.

July-August 1993 31 Navy Medicine seeks Articles

WHILE many quality articles are submitted to Navy Editorial Guidelines Medicine, we are constantly looking for greater diversity. Text Because Navy medicine is a dynamic, changing institution, Submissions should be typed and doubled-spaced from we would especially like this journal to provide an oppor­ 1,000 to 2,000 words (two copies). If you use WordPerfect tunity for the free exchange of ideas and opinions. There 5.1, submission of a 5 114 or 3 1/2-inch disk would also be is no one topic that assures publication, but here are some very helpful. Please be sure to include the full name, rank, general topics we would like to see more of: and affiliation of author or authors, and a contact telephone 1. Research--cutting edge research of both a profes­ number and military address. sional/clinical nature. We are also interested in research articles geared to the lay reader. lllustrations 2. History--historical articles related to Navy medicine. Photos should, whenever possible, be 8" x 10" black and 3. Unusual experiences-first person accounts of cur­ white, captioned, and with photographer noted for credit rent events, such as natural disasters and deployments, i.e., purposes. Quality photography is essential. Snapshot pho­ Somalia, Persian Gulf, Hurricane Andrew. Third person tos, polaroids, or those not properly focused and exposed accounts are also encouraged as they generally add a cannot be used. Exceptional photos related to any aspect of broader perspective. Even if these articles are not pub­ Navy/Marine Corps medical practice are always in de­ lished, informative pieces will be entered into the BUMED mand for cover use. No color slides or large transparencies Archives for research purposes. please. 4. The Forum Section--Thought-provoking editorials Tables and figures should be fully marked and camera­ and opinions on whatever you feel is important: for ready. References must be properly footnoted, and the example, downsizing--how do current military reductions manuscript should have a bibliography if outside sources affect Navy medicine; the future--what does the future were used. For the proper format, consult a recent copy of portend for Navy medicine (fleet support, dependent care, Navy Medicine. etc.), and the individual corps. Professional/Clinical Articles--When writing profes­ Contact: Jan K. Herman, Editor sional/clinical articles, remember that the aspect of medi­ Bureau of Medicine and Surgery cine should be unique or particularly relevant to the practice BUMED-09H of Navy medicine, i.e. , treatment of tropical diseases which 2300 E Street N. W. afflict Navy personnel during deployments. General medi­ Washington, DC 20372-5120 cal information that one might encounter in a civilian DSN: 294-1297 medical journal is not desirable for our publication. Commercial: (202) 653-1297

Operation Restore Hope Were You There? The Navy Museum is collecting artifacts, including uniforms, standard issue and personal equipment, for possible use in an exhibit on the U.S. Navy's involvement in Somalia. Having already received items relating to the Seabees, we are most anxious to receive donations from the Navy's medical community. If you can help, please contact Edward Furgol at (202) 433-4882, Naval Historical Center, The Navy Museum, Washington Navy Yard, 901 M Street S.E. , Washington, DC 20374-5060.

32 NAVY MEDICINE A Look Back

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