By Mary T. Sarnecky, DNSc, RN, Colonel, U.S. Army (ret.) Field Expediency: How Army Nurses in Vietnam ‘Made Do’ An ability to improvise is a valuable nursing skill, on and off the battlefield.

Overview: In the early years of the Vietnam War, when resources were in short supply, nurses improvised in the field to provide care to the sick and wounded under extremely .S. Army Nurse Corps officers serving in combat adverse conditions. This “field expediency” settings often have confronted acute shortages of was the result of nursing knowledge as well essential supplies and equipment. Such deficits recurred throughout the Vietnam War (1961 to as flexibility, creativity, audacity, and prag- 1975) and were particularly common during the war’s early years, from 1964 through 1968, matism. Nurses in other settings—for exam- when Army nurses made extensive use of field ple, those practicing in remote areas, in Uexpediency—essentially, an ability to improvise under adverse circumstances—to cope with them. By examining developing nations, or during natural disas- the practices of nurses during the Vietnam War, nurses can gain familiarity with field expediency, which can also be ters—may also find themselves facing used as a way of handling deficits in facilities, personnel, severe shortages or too few essential sup- supplies, and equipment by both military nurses and civilian nurses in adverse circumstances. plies or a lack of equipment. Familiarity with BACKGROUND the methods associated with field expedi- Most acute shortfalls of medical supplies and equipment in ency will help nurses adapt quickly—on the U.S. military field have surfaced in the initial stages of a deployment. (Although this article focuses on those of the battlefield and off. Vietnam War, such shortfalls were not exclusive to that war; every major conflict the United States has been involved in since the Revolutionary War has shown deficits in medical supplies.) One primary cause during the Vietnam War was inefficient planning for Army Medical Department (AMEDD) Mary T. Sarnecky is a retired colonel in the U.S. Army mobilizations. Also, in the years before the Vietnam War, Nurse Corps and the author of A History of the U.S. AMEDD field hospitals lacked the technical equipment, field Army Nurse Corps (University of Pennsylvania, 1999). facilities, and specialized staff found in civilian settings. Many Contact author: [email protected]. The opin- factors caused this, including stringent constraints on budgets ions expressed in this article are those of the author and do not necessarily reflect the views of the Department of and a national reluctance to prepare for or even contemplate the Army or the Department of Defense. the possibility of another war.

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ł A view from the water tower of the 85th Evacuation in late September 1965.

Aerial view of the Ł 85th Evacuation Hospital

Since before the Civil War, most members of the AMEDD have been civilian draftees or volunteers serving during times of war. The Vietnam War was no exception. With only their experiences as civilian clinicians to go by, the AMEDD clinicians initially sought to apply peacetime expectations of health care practice to military combat. But there are con- siderable differences in the standards of civilian peacetime and military wartime. To bridge this gap, citizen soldiers employed the art of field expediency: and meeting a challenge. In current usage the word they learned to improvise, to “make do.” connotes the use of unconventional yet readily accessible means. In its modern, military sense, field THE CONCEPT OF FIELD EXPEDIENCY expediency suggests a course of action used in the Definitions of field expediency in the nursing, med- absence of a more suitable or traditional method to ical, military, and general literature are all but nonex- achieve an objective. istent. According to the Oxford English Dictionary An ethical dilemma is inherent in the concept of (OED), the adjective expedient is derived from the field expediency. The OED notes that expediency Latin verb expedire, translated as “to forward mat- considers what is “useful or politic as opposed to ters, be helpful or serviceable.” Historically the [what is] just and right.” It adds that in certain word referred to “a contrivance or device adopted cases, “prudential considerations” may outweigh for attaining an end”; it now means something those based on “morality or justice.” In practice, “conducive to advantage” and fitting “a definite then, field expediency may involve actions that are purpose.” Expediency is thus a way of approaching illegal or morally questionable (for example, obtain- [email protected] AJN M May 2007 M Vol. 107, No. 5 53 ł Lieutenant Sharon Forman (now Bystran) of the 85th Evacuation Hospital at Qui Nhon, which supported the First Cavalry Division. n a r t s y B

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S One of the 85th’s early operating rooms, an

ł f o eight-by-ten-foot shipping crate, vividly illustrates the y s e t

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The Second Medical Dispensary was one of the first American military medical units assigned to the Republic of Vietnam. Although its main body arrived in South Vietnam on October 1, 1964, it did not become operational until December 4, 1964, in Soc Trang, in the Mekong River delta. Its mission was to operate a 10-bed emergency facility for ing critically needed supplies through unauthorized wounded soldiers who, after resuscitative surgery, “borrowing” from another unit, which circumvents would be evacuated to better-equipped hospitals for Army regulations and is probably illegal). Whether more definitive treatment. Unfortunately, the unit’s the end justifies the means in a given case can be supplies conflicted with its mission. A letter written debated, perhaps without resolution. Still, the prac- October 27, 1964, to Colonel Mildred I. Clark, the tice of field expediency has often proven its value Chief of the Army Nurse Corps, by Captain Robbie during wartime, as the following examples show. It Cooper, the dispensary’s chief nurse and a nurse is unlikely to disappear. anesthetist, reported that their delivery containers arrived from the storage depot at Fort Sam VIETNAM: DEALING WITH SHORTAGES IN THE FIELD Houston, Texas, with minimal and largely inappro- To circumvent scarcities early in a campaign, Army priate supplies and equipment. Cooper stated, nurses used myriad tactics, many of which fall “There was no single item of surgical or anesthesia under the rubric of field expediency: jury-rigging, equipment and a minimum of ward and dispensary adapting, improvising, filching, supplicating, barter- items was included. Most of the equipment was for ing, and borrowing. Army nurses implemented all X-ray and dental operations.” Despite the condi- of these tactics with a single intent—to improve the tions, the unit’s staff was able to carry out emer- quality of care provided to American soldiers. gency surgery. It’s possible that the Second Medical

54 AJN M May 2007 M Vol. 107, No. 5 http://www.nursingcenter.com Dispensary staff borrowed surgical instruments from the Eighth ; situated several hundred miles away in Nha Trang, the Eighth was one of only two designated central supply points for Army med- ical units in Vietnam at that time, providing support to 20,000 troops—a huge responsibility.1 The provisions allotted to the Second Medical Dispensary were not only unsuitable, they were insufficient. A second letter from Cooper to Clark, written December 5, 1964, the day after the unit became operational, described deficits in linens and sterilization equipment and a lack of laundry facili- ties: “The enlisted personnel [medics] were washing surgical linens in GI cans [galvanized metal trash ł The ICU storage area at the 85th. At the upper left are cans] with immersion heaters and broom handles at cardboard boxes transformed into cabinets for storing small items. 0130 this morning. The linen is drying outside the hospital on telephone wire lines.” Such collabora- tion among enlisted medics and Army nurses in improvising ways to deal with exceedingly difficult situations was a common occurrence. In May 1965, the Third Field Hospital began pro- viding services in what had once been the Saigon American School. As I described in my book, Major Edith Nuttall, the chief nurse, and her small team of nurses refashioned the former school into a working health care facility.2 The complex of school buildings, connected by walkways, enclosed a courtyard that served as a lounge area for convalescing , where canopies fashioned from parachute silk shading tables and chairs afforded patients a relatively tranquil place to relax. The school’s gymnasium became the mess hall for both hospital personnel and patients. The nurses transformed classrooms into care ł Urinals and bedpans dry in the sun outside the 85th wards, with desks serving as bedside tables. Black- Evacuation Hospital’s ICU, October 1965. boards and bookshelves became nursing station work- tables. From this austere beginning, the Third Field Hospital evolved into a state-of-the-art urban health recalled that there were “bugs in chests, in bellies, care facility, ultimately becoming the United States and in extremity wounds.”5 The OR nurses and Army Hospital, Saigon, before closing its doors at the technicians handled this breach of sterile technique end of the war.2 with flyswatters; although primitive and unsterile, it The 85th Evacuation Hospital was also ordered was the only method available for coping with the to Vietnam early in the war. The main body of the insects. The lack of clean, running water for hand- hospital staff had traveled together by U.S. Navy washing and surgical scrubbing was another chal- ship and, as a result of the enforced togetherness, lenge. Eventually, staff jury-rigged either 50-gallon arrived as a relatively cohesive unit at Qui Nhon, a barrels or “large rubber bladders” on elevated South Vietnamese coastal town, in August 1965.3 frames above the OR, so the clean water flowed by The 85th was charged with supporting the First gravity. Army water trucks refilled these reservoirs Cavalry Division (Airmobile). In November the “every day or two.”5 division was involved in the battle for the Ia Drang Her creative solutions to supply and equipment Valley, the first major battle of the war; the fighting shortages earned Lieutenant Peggy Adams, an OR was fierce, with casualties averaging 70 to 80 daily.4 nurse with the 85th, a reputation as a magician Initially the 85th’s operating rooms (ORs) were capable of producing virtually anything out of set up inside wooden “boxes” under two large can- almost nothing. Faced with a lack of orthopedic vas tents—a hot, dark, and dirty environment. At surgical instruments, Adams borrowed from the night lantern lights illuminated the operating field, U.S. Navy ship Iwo Jima a claw hammer, a chisel, attracting all manner of flying insects. Colonel and a pair of pliers.6 After the OR staff had steril- William Burkhalter, the unit’s orthopedic surgeon, ized these tools in a steam sterilizer numerous times, [email protected] AJN M May 2007 M Vol. 107, No. 5 55 Wounded soldiers telephoned news of Ł their injuries to their families at home. The soldier’s bed had to be pushed to the tele- phone in the nurses’ area, and the call was patched through to the United States.

ł Captain Elizabeth Finn of the 93rd Evacuation Hospital participated in a Medical Civil Action Program event, in which military personnel provide services to the local populace, at an orphanage in Bien Hoa. n n i F h t e b a Lieutenant Colonel P. Evangeline Jamison, Ł z i l

E chief nurse at the 93rd. Behind her is what f o Finn calls the unit’s most sophisticated piece y s e t

r of equipment, an oxygen tank with an inter- u o c mittent positive pressure breathing device. s o t o h P

the hammer’s handle developed splinters, but “still guard, she and some enlisted men loaded the genera- worked fine,” as did the other improvised instru- tor onto their truck and drove it back to the hospital. ments. When sterilization wrappers for surgical Adams was also adept at developing “nonstan- instruments were lacking, Adams found that B-ration dard supply lines.”6 She established relationships cans and seasickness bags were adequate substitutes. with the crews of incoming U.S. Air Force medevac Lacking liquid solution for sterilizing suture materi- planes and U.S. Navy ships. She gave medevac nurses als, she bartered with the Graves Registration (mor- lists of needed supplies, which the nurses obtained on tuary affairs) staff, trading a surfeit of cotton balls for trips to Japan or the United States and delivered to formaldehyde. When there were no glass rods for Adams upon their return, and regularly convinced bowel surgery (used externally to anchor a loop of ships’ crews to give her supplies from their sick intestine to prevent it from slipping back into the bays, knowing they could readily restock in the abdominal cavity), she secured aluminum rods from Philippines. At one point, Adams learned that a fire a boat-repair detachment, shaped them on a lathe, at a field hospital in Fort Bragg, North Carolina, and sanded them by hand into workable facsimiles. had damaged the hospital but left most of its surgi- At one point, an OR generator exploded and its cal instruments unscathed, and that these had been replacement was delayed. Noticing an unclaimed delivered to the OR at Womack Army Hospital, generator at the beach depot, Adams “ripped off its Fort Bragg’s main health care facility. Adams sent ticket and in a loud voice affirmed that here was the her list of desiderata to the Womack OR supervisor, 85th[’s] generator.”6 Unchallenged by the depot who forwarded the extra instruments (along with

56 AJN M May 2007 M Vol. 107, No. 5 http://www.nursingcenter.com much-needed toilet paper, facial tissues, and a bottle of Scotch whiskey) to Vietnam. Lieutenant Sharon Forman (now Bystran) described other inventive solutions she and her counterparts at the 85th Evacuation Hospital devised to address shortages.7 Disposable syringes and needles were scarce; what were available were uncomfortable, large-bore, 16- gauge needles that had been sterilized and reused many times. To ensure patient comfort, the nurses filed the needles to remove any burrs that might inflict pain before central supply processed them for reuse. iv solutions came in sturdy boxes with dividers; Forman trans- formed these into “cabinets” for storing small objects. Describing the ICU facilities, Forman reported that recycled glass IV bottles were used in draining chest wounds and for collect- ing and measuring urine drawn from Foley ł The 100-bed malaria and hepatitis ward at the 36th Evacuation catheters.8 Abdominal wounds were common Hospital in Vung Tau, February 1968. It became a surgical ward dur- and typically resulted in colostomy, but there ing the Tet Offensive. were no colostomy bags. Forman and the other ICU nurses maintained colostomy sites with “fluffs and ABD pads and changed them con- stantly.” There were no Stryker or Foster frames for positioning patients with spinal cord injuries. Lieutenant Kathleen Rockwell recalled that she and the other nurses contrived a clever, albeit uncomfortable, substitute: “We used two litters with a hole cut for the face opening in one.”8 She also recalled that such patients “required a lot of coaxing” from nurses to remain on their abdomen: “They n e

hated this position—they felt out of control b i l i h and begged to be turned to their backs.” P

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36th Evacuation Hospital in Vung Tau. Here, t r First Lieutenant Anne Philiben, left, at the 36th’s post-op ICU nurses’ u ł o too, running water was not readily available. c

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Instead, the staff met infection control objec- o h tives by plunging their hands into basins of P germicide, followed by rinsing in a bucket of clear water.9 The practice was hardly ideal, but prob- patient’s name and bed number as well as the med- ably effective. ication name, dosage, route, and frequency of Philiben used innovative approaches in adminis- administration; the nurse would refer to the card tering medications to patients on the hospital’s mas- when she drew a medication from a bulk supply sive 100-bed malaria and hepatitis ward (which and again when she administered it to the patient. became a surgical ward during and after the Tet This system remained in effect until it was largely Offensive of 1968). Since medicine cups were rarely replaced during the 1970s by the unit-dose distribu- available, she saved the discarded plastic tops of tion method.) On another occasion, Philiben containers designed to hold new, unused syringes to recalled, she poured medications for all 100 patients use as medicine cups. To save time, Philiben some- into paper medicine cups and placed them on two times carried the pill bottles in her pockets and the large trays. She recalled that this would have medication cards in the sleeve pocket of her worked out brilliantly had she not carried the trays fatigues, handing out drugs to patients as she passed in front of several huge fans being used to cool the through the ward. (During the Vietnam War era, wards. In an instant, pills and cups were flying medication cards were used to facilitate drug through the air into every corner of the nursing unit. administration. On each card was recorded a Not every innovation proved workable! [email protected] AJN M May 2007 M Vol. 107, No. 5 57 Field Expediency and Operation Iraqi Freedom n August 2005, I was one of several NPs on a year- incinerator had arrived at the FOB, I quickly arranged I long mission to serve as medical advisers to the Iraqi through my contacts to have it transferred to the Iraqi Army Army. We were part of the Coalition Military Assistance at K1. I hired two Iraqi civilians, a plumber and an electri- Training Team (a section of the Multinational Security cian, to connect the incinerator to the clinic’s generator. Transition Command–Iraq), which was tasked with train- After some creative electrical work—lacking a connecting ing and equipping the Iraqi security forces. I was cord, the two civilians scrounged electrical cables from old assigned to a 10-man team on a small, remote base buildings and spliced them together—the clinic soon had named K1 on the northern outskirts of Kirkuk. I was the an operational incinerator. senior medical adviser to the base clinic, which pro- vided complete laboratory, pharmacy, radiology, and dental services. Two other medical advisers and seven I learned early in my military career that nonmedical personnel completed the team. Training and equipping the clinic’s Iraqi nurses, medics, making friends and networking enables you and with American medicine and equipment was to get things done in times of need. sometimes challenging. Because some of the equipment was- n’t designed for local use, we had to be creative in adapting it to the Iraqi environment: the air and water were often com- We also put the Internet to good use. For example, the promised by dust and other contaminants, and the electrical clinic also served as an equipment supply point for sur- generators were unreliable, resulting in power surges and rounding units. Three Land Rover destined for outages. One striking example of a field-expedient solution one of those units arrived and were not combat ready: involved the clinic’s portable ventilators. When the clinic ran each lacked a full set of keys to its doors, including the out of the necessary tubing, we got one of the ventilators door to the rear treatment compartment. I located the Web working again by adapting suction tubing and using a site of the ambulances’ manufacturer in neighboring Turkey makeshift connector. To make the connector, I whittled a and e-mailed the company with the assistance of my nonessential hard-plastic part from the suction equipment into Turkish interpreter. We made the $50,000 ambulances the required shape with a pocketknife. fully combat operational by having three new sets of keys During the early days of the clinic’s operation, the local express delivered to FOB Warrior. medical supply warehouse, run by the Iraqi Ministry of Americans are not the only ones to use field-expedient Health, provided inadequate supplies of antibiotics and pain measures. Several of the Iraqi Army ambulances at K1 medication. We had extra vehicle first-aid kits. I convinced were used to transport patients over dangerous roads to the clinic director to offer several kits to the warehouse man- hospitals in Kirkuk. To make the ambulances less conspicu- ager in exchange for the drugs we so desperately needed. ous to insurgents, the Iraqi clinic director exchanged the The first-aid kits were such a hit that we were able to trade license plates for the kind used on civilian ambulances. He them for a three-month supply of medication. also ordered his soldiers to wear civilian clothes during I learned early in my military career that making friends transport missions. As a result, no clinic staff or patients and networking enables you to get things done in times of were injured during these missions. need. During my tour I made a concerted effort to get to I agree wholeheartedly with author Mary Sarnecky that know members of the U.S. Army’s 101st Airborne Division it takes attributes such as flexibility, creativity, audacity, and and a U.S. Air Force contingent stationed at Forward pragmatism to solve unconventional problems. I would add Operating Base (FOB) Warrior, who also had missions at this motto: Never take no for an answer—keep asking until K1. On my trips between K1 and FOB Warrior, I made it you find the person who says yes.—Curtis Aberle, MSN, a point to visit all my contacts. These relationships proved RN, APRN,BC, FNP, Major, U.S. Army, staff family NP at helpful when I had to address the difficulty of hazardous Brooke Army Medical Center, , TX. waste disposal. The local incinerator was 15 miles away Contact author: [email protected]. The opinions over dangerous roads—the terrain was rough, and expressed in this article are those of the author and do not ambushes and roadside bombs were common—and dis- necessarily reflect the views of the Department of the Army posal fees were excessive. Learning that a surplus portable or the Department of Defense.

In 1967, Captain Elizabeth Finn arrived at the improvised from wooden hoists used for hauling 93rd Evacuation Hospital at Long Binh Post, heavy equipment. Ammunition cans may serve . . . Vietnam. Finn dealt with many small challenges as waste baskets, or painted they make good con- using field-expedient tactics. Describing some of tainers for bulky supplies. these measures in an article for the hospital’s quar- Finn concluded, “This sort of native do-it-yourself terly newsletter, Finn wrote10: has greatly enhanced our nursing armamentarium.” Stones in a Red Cross ditty bag make excellent weights for traction. A piece of Levine tube CAN FIELD EXPEDIENCY BE LEARNED? serves as a drinking straw. Colostomy bags are Nurses’ ability to implement field expediency (such made from plastic dressing wrappers, a nebuliz- as jury-rigging or bartering for needed equipment) ing oxygen apparatus can be improvised from an stands out as an important characteristic of Army IV bottle, chest drainage bottles made from soap Nurse Corps officers. It requires a sound knowledge bottles or iv bottles, and pulleys for traction of nursing theory and an understanding of the fun-

58 AJN M May 2007 M Vol. 107, No. 5 http://www.nursingcenter.com damental nursing principles that govern physical on the time each procedure took, calculating the and psychosocial care, so that one can adapt to nursing staff needed in the combat or field setting. In unfamiliar or adverse circumstances and, if neces- presenting evidence to the JSNAG regarding various sary, deviate from traditional practices with relative nursing procedure times, the corps relied heavily on impunity. It also calls for such attributes as flexibil- Lieutenant Colonel Susie M. Sherrod’s Nursing Care ity, creativity, audacity, and pragmatism, as well as Hour Standards Study, which had timed virtually all the ability to draw upon one’s previous life and pro- nursing procedures performed at nine military hospi- fessional experiences. tals over a one-year period.12 The JSNAG’s initial cal- Although some nurses may have a natural talent culations were challenged and revised many times for improvising in difficult situations, field-expedient before it arrived at staffing levels that were consid- nursing skills can be learned in military or civilian ered austere but adequate. These levels have been health care settings, honed in military or humanitar- further revised as additional field and combat nurs- ian relief environments, and implemented in combat, ing data have become available, and they are cur- mass-casualty, or humanitarian relief settings. For rently in wide military use. As a result, Army Nurse example, an instructor might encourage students to Corps officers today are probably less likely to have use their imagination to come up with possible solu- to employ field-expedient nursing skills than their tions to a given problem or situation. Or an instruc- predecessors were. tor or colleague might demonstrate an innovative But preparedness and an ability to improvise solution to a problem and discuss how it was formu- under adverse circumstances are always advanta- lated and implemented. geous. Civilian nurses who practice in remote envi- ronments, in developing countries, or in IS FIELD EXPEDIENCY STILL PRACTICED? mass-casualty situations often face issues remark- In my view it’s unlikely that the specific circum- ably similar to those faced by nurses during stances described in the vignettes above would wartime. All nurses can benefit from incorporating occur in the modern army. In the decades since the the concept and strategies of field expediency into Vietnam War, the Department of Defense (DoD) has their practices. M sought to improve readiness, develop better supplies and equipment, and enhance the ability of military REFERENCES health care workers to provide excellent care. 1. Neel S. Medical support of the U. S. Army in Vietnam, Shortly after the Vietnam War, the Army, the 1965–1970. Washington, DC: Department of the Army; Navy, the Marines, and the Air Force began plan- 1973. Vietnam studies. 2. Sarnecky MT. The era of the Vietnam War. In: Sarnecky MT, ning the development of deployable medical sys- editor. A history of the U.S. Army Nurse Corps. Philadelphia: tems (DEPMEDS), a system of field health care University of Pennsylvania Press; 1999. p. 321-90. Studies in facilities with standardized construction, staff, sup- health, illness, and caregiving. 3. Bystran SF, et al. 85th Evacuation Hospital history. In: Bystran plies, and equipment. The first DEPMEDS hospital, SF, editor. 85th Evacuation Hospital, Phu Tanh Valley and set up as a training site in Texas, was deployed in Qui Nhon. Aptos, CA: Sharon Bystran [self-published]; 1993. 1987.11 In extensive field use today, DEPMEDS p. 3-6. 4. Dorland P, Nanney J. Dust off: Army aeromedical evacua- employ several kinds of modules that can be config- tion in Vietnam. Washington, DC: Center of Military ured in almost unlimited ways. Hard-walled con- History, ; 1982. tainers, which are standard ISO shipping containers 5. Burkhalter W. Early days of the 85th Evacuation Hospital, (the acronym stands for International Organization 1972 oral history. In: Bystran SF, editor. 85th Evacuation Hospital, Phu Tanh Valley and Qui Nhon. Aptos, CA: for Standardization), house OR, radiology, labora- Sharon Bystran [self-published]; 1993. p. 22-3. tory, pharmacy, and central supply units. Soft-sided 6. Adams P. Operating room service. In: Bystran SF, editor. tents known as TEMPERs (an acronym for tent, 85th Evacuation Hospital, Phu Tanh Valley and Qui Nhon. Aptos, CA: Sharon Bystran [self-published]; 1993. extendable, modular, personnel) accommodate p. 39-41. areas, ICUs, and inpatient wards. 7. Bystran SF, et al. First impressions. In: Bystran SF, editor. To determine what resources a facility would need, 85th Evacuation Hospital, Phu Tanh Valley and Qui Nhon. the DoD convened panels of experts who used data Aptos, CA: Sharon Bystran [self-published]; 1993. p. 19-21. 8. Bystran SF, et al. . In: Bystran SF, editor. from past wars to identify more than 300 combat- 85th Evacuation Hospital, Phu Tanh Valley and Qui Nhon. related diagnoses and the regimens for treating them. Aptos, CA: Sharon Bystran [self-published]; 1993. p. 42-4. Precise lists of the supplies and equipment required to 9. Gruhzit-Hoyt O. A time remembered: American women in treat each diagnosis were created.11 the Vietnam War. Novato, CA: Presidio Press; 1999. 10. Finn EP. Nursing, intensive care and recovery in a combat The next step was to determine adequate staffing environment. 93rd Evacuation Hospital Quarterly levels for DEPMEDS facilities. The Joint Services Newsletter 1967(Oct 10):37-41. Nursing Advisory Group (JSNAG), a task force with 11. Medics train in new field hospital. HSC Mercury 1987; Army Nurse Corps representation that was formed in 14(10):12. 12. Sherrod SM. Patient classification system: a link between 1988, was charged with determining what nursing diagnosis-related groupings and acuity factors. Mil Med procedures each diagnosis required and, based largely 1984;149(9):506-11. [email protected] AJN M May 2007 M Vol. 107, No. 5 59