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 hospitals 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. 52 AJN M May 2007 M Vol. 107, No. 5 http://www.nursingcenter.com n a r t s y B n o r a h S f o y s e t r u o c s o t o h P ł A view from the water tower of the 85th Evacuation Hospital 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 n o r a h 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 r primitive conditions. u o c s o ŀ Craniotomy in progress in OR box. t o h P 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 Field Hospital; 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 patients, 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 patient 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.