THAILAND SEA CHINA SOUTH BOUNDARIES NOT AUTHORITATIVE U.S.S.D. VIETNAM STUDIES MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM 1965-1970 by Major General Spurgeon Neel DEPARTMENT OF THE ARMY WASHINGTON, D.C., 1973 Library of Congress Catalog Card Number: 72-600264 First Printing For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402. Price: Cloth — $3.35, domestic postpaid; $3.00, GPO Bookstore Stock No. 0829-00088 3 597 AGTT N431 Public Foreword Health The United States Army has met an unusually complex challenge in Southeast Asia. In conjunction with the other services, the Army has fought in support of a national policy of assisting an emerging nation to develop governmental processes of its own choosing, free of outside coer- cion. In addition to the usual problems of waging armed conflict, the assignment in Southeast Asia has required superimposing the immensely sophisticated tasks of a modern army upon an underdeveloped environ- ment and adapting them to demands covering a wide spectrum. These involved helping to fulfill the basic needs of an agrarian population, deal- ing with the frustrations of antiguerrilla operations, and conducting con- ventional campaigns against well-trained and determined regular units. As this assignment nears an end, the U.S. Army must prepare for other challenges that may lie ahead. While cognizant that history never repeats itself exactly and that no army ever profited from trying to meet a new challenge in terms of the old one, the Army nevertheless stands to benefit immensely from a study of its experience, its shortcomings no less than its achievements. Aware that some years must elapse before the official histories will provide a detailed and objective analysis of the experience in Southeast Asia, we have sought a forum whereby some of the more salient aspects of that experience can be made available now. At the request of the Chief of Staff, a representative group of senior officers who served in important posts in Vietnam and who still carry a heavy burden of day-to-day re- sponsibilities has prepared a series of monographs. These studies should be of great value in helping the Army develop future operational con- cepts while at the same time contributing to the historical record and providing the American public with an interim report on the perform- ance of men and officers who have responded, as others have through our history, to exacting and trying demands. All monographs in the series are based primarily on official records, with additional material from published and unpublished secondary works, from debriefing reports and interviews with key participants, and from the personal experience of the author. To facilitate security clear- ance, annotation and detailed bibliography have been omitted from the published version: a fully documented account with bibliography is filed with the Office of the Chief of Military History. 11 01352 Major General Spurgeon Neel is especially qualified to write a study of the Medical Department support of the U.S. Army in Vietnam. Not only is General Neel one of the most decorated Medical Corps officers presently on active duty, but he is also a specialist in a variety of military- medical disciplines. A Senior Flight Surgeon, Senior Parachutist, and Senior Gliderist, he is the Army’s leading authority on Aviation Medi- cine. This, coupled with his clinical expertise in the specialty of Preven- tive Medicine, and his broad and varied command and staff experience, place him in the forefront of those who can write authoritatively of the Medical Department’s role in Vietnam. General Neel has served two tours of duty in Vietnam, in positions of extreme responsibility, which enabled him to participate in the major decisions regarding medical support of the Allied Forces. From 1966 to 1967, he was the USMACV Surgeon and Senior Adviser to General Westmoreland. Later, 1968 to 1969, he returned to Vietnam and served initially as CG, 44th Medical Brigade, and Surgeon, USARYV, and sub- sequently, as Surgeon, USMACYV, and principal medical adviser to Gen- eral Abrams. Upon his return to CONUS, General Neel was nominated Deputy Surgeon General, Department of the Army, the position in which he has served since 1 October 1969. In addition to this study, General Neel is the author of some 33 articles which have been published in leading professional journals in this country and abroad. His present work constitutes a candidly expressed authentic overview of the Medical Department’s experiences in Vietnam which should be of considerable interest and benefit to all students of this period in our history. VERNE L. BOWERS Washington, D.C. Major General, USA 15 August 1972 The Adjutant General iv Preface General Westmoreland’s request that I prepare a monograph setting forth activities of the Medical Department in support of the U.S. Army in Vietnam, for the years 1965-1970, was most welcome since I had but recently returned from a second tour in Vietnam during which time I had held the positions of Surgeon, U.S. Army, Vietnam (USARV) and Sur- geon, U.S. Military Assistance Command, Vietnam (USMACV). The purpose of this monograph is to provide a meaningful overview of significant medical problems encountered and decisions made, of achievements and mistakes, and of lessons learned in Vietnam. The hope is that this study will provide a source of information for future planning, pending the writing of the definitive history of the Army Medical De- partment in Vietnam. Emphasis is placed on perspective rather than detail. In addition to describing the events that occurred, I have sought to explain why deci- sions were made and specific actions taken. Purely technical medical con- siderations are not within the scope of this monograph. An evaluation of the health of the command and the care provided to battle casualties is made within an operational context. The absence of more detail on the magnificent support provided by medical elements of the U.S. Air Force and U.S. Navy to U.S. Army medical operations is the result of the need for brevity rather than lack of appreciation. In planning the outline of this monograph, I gave consideration to the duties, experiences, and actions which make up the total of Medical Department support of the Army. I decided to concentrate on the major subdivisions of the medical service rather than deal with all aspects superficially. This study tells the story of the Army Medical Department in Viet- nam. Hopefully, this experience will provide a basis for those who must evaluate our current doctrine and organization and for those who will be responsible for planning the medical support of future operations. It is with no little pride that one can say that the facts give concrete evidence of the magnificent job done by the men and women who com- prise the Army Medical Department in Vietnam. In conclusion, I wish to acknowledge the efforts of the many contrib- utors who made this monograph possible. This study was, as can well be imagined, no one-man job. I am grateful to the members of the various directorates and offices of the Office of The Surgeon General who pro- vided me with material, and especially appreciative of the efforts of the Vv members of The Historical Unit, U.S. Army Medical Department, for their technical assistance in the preparation and editing of the manu- script. SPURGEON NEEL, M.D. Washington, D.C. Major General, U.S. Army 15 August 1972 Deputy Surgeon General Contents INTRODUCTION. ..ociciannuss samamnns s sunens s 48a Chapter I. THE MEDICAL COMMAND STRUCTURE... Medical Service During the Advisory Years. Command and Staff Relationships During the Ye ears of Military Commitment: 1965-67. ................ Nondivisional Command and Staff Relationships: 1967- II. HEALTH OF THE COMMAND............... Ratesand Trends. ............... ccc... Major Problems... ..; « covvsnssnnsnsssmununs san III. CARE OF THE WOUNDED................... Excellence of Medical Care. ....................... Nure of Words. «cv. ssussvssnnnins tmnmns serene Specific Advances. . soo: csvowsirannerismsnns ssums IV. HOSPITALIZATION AND EVACUATION. .... HospiloBizahion . « . ss. saxuvissasvnvssnmans snmnnns Brocton... . ..cvvs sassnns srasais smantiss senna Reduction and Reorgamization. ..................... V. MEDICAL SUPPLY uve. cccnnsnismmavs sonnmas Realignment of Medical Supply Activities. ............ Tht Depot SYSeMe vs susnnss rrnunss soenns snuwns Medical Equipment Maintenance Support. ............ VI. DIVISION AND BRIGADE MEDICAL SUP- Usages of Divisional Medical Assets. ............... Medical Support of Separate Infantry Brigades. . . . . . .. Trial Rett ofiizalion , ss uvus sonnnsssssnnss samemns 23 32 32 37 49 49 52 55 59 60 70 78 80 80 83 85 87 87 94 97 Chapter VII. AVIATION MEDICINE. ........ Flyer Fatigue. . .................. Care of the Flyer Program. . ........ IX. THE MILITARY BLOOD PROGRAM. ........ Evolution of the System. . .......... Initial Sources of Whole Blood. . . . . . . Agencies for Expansion of Blood Supply. ............. Relocation of the Central Blood Bank. . Group and Type-Specific Blood. . . . . . Transfusion Reactions. ............ Fresh Frozen Plasma. ............. Wastage of Blood. .............................. Technical Research and Innovations. . . Significant Problems. .............. The Donor System... ............. X. MEDICAL RESEARCH......... Initial Efforts in Southeast Asia. . . . . . Studies of the Medical Research Team. Special Projects. .................. Surgical Research. ................ XI. LABORATORY SUPPORT....... Evolution of the System............. The 9th Medical Laboratory. . . . . . .. Innovations. ..................... XII. CORPS SERVICES.............. Nursing Service. . ................ Dental Service. . ................. Veterinary Service. . ............... Army Medical Specialist Corps Services viii Page 99 100 102 108 108 111 113 114 114 116 117 121 122 122 123 124 124 126 126 127 127 128 131 135 136 136 136 137 139 142 142 146 150 158 Chapter XIII. MEDICAL ASSISTANCE TO VIETNAMESE CIVILIANS. i iiciminr sc vnmnmrrennmmns srnns Provincial Health Assistance Program. ............... Military Provincial Health Assistance Program. . . . . . .. Medical Civic Action Program. .................... Civilian War Casualty Program. ................... XIV. SUMMARY AND CONCLUSIONS............. Medical Command and Control System. .............. Health of the Command. ......................... Combat Casualties. . ............................ Hospitalization. ................................ Helicopter Boatttlon.... . «. « + covvussiivnnns smnnmns Medical Supply. ............................... Outpatients. ................. ccc... Batlalion SHIQEons. . «vos sinnvivivsnncs smmmnnes Impact of Policies. .............................. Lack of Responsiveness of the Army Authorization Docu- WORE SSYSIEI 15 « 20 57 00% 5 2 RR RUBE SAE EES FITOE NS § RESO 1 0054 i cs snttvimvnms nvmmunsssmmnnsn Civilian Implications. . .......................... GLOSSARY... o.oo INDEX . cit itiumissnnmnmesvnmunsensnnmmensnnces Tables No. 1. Hospital Admissions for All Causes, U.S. Army, in Three Wars: World War II, Korea, and Vietnam, by Year. Approximate Number of Man-Days Lost From Duty, by Cause, Among U.S. Army Personnel in Vietnam, 1967— . Selected Causes of Admissions to Hospital and Quarters Among Active-Duty U.S. Army Personnel in Vietnam, 1965-70. cs unne 1 sumunnss somennes sannns 3 sonny 11 . Incidence Rate of Diarrheal Disease Among U.S. Army Personnel in World War II and in Vietnam, by Year. . . Incidence Rate of Psychiatric Conditions, Army-Wide, 198370, sco vs0 4 550003 svmmmmn sv swmmmns sams s £48 Page 162 162 162 164 166 169 169 170 172 173 174 175 176 177 177 179 179 179 180 183 187 33 34 36 42 46 No. 10. 10. Percent of Deaths and Wounds According to Agent, U.S. Army, in Three Wars: World War II, Korea, and Vietnam . Location of Wounds in Hospitalized Casualties, by Per- cent, U.S. Army, in Three Wars: World War II, Korea, and Vietnam . Total Number of Patients Evacuated From Vietnam, U.S. Army, by Month, 1965-69........................ Number of Units of Blood Collected and Shipped, by Year, to the Central Blood Bank in Vietnam by the 406th Medical Laboratory, U.S. Army, Japan... ... Inspection of Food by the U.S. Army Veterinary Service in Vietnam, by Year, 1965-70 Charts . Medical Command and Staff Structure, U.S. Army, Vietnam, 24 February 1962-1 April 1965.......... . Medical Command and Staff Structure, U.S. Army, Vietnam, 1 November 1965-17 February 1966. . . . .. . Medical Command and Staff Structure, U.S. Army, Vietnam, 1 May 1966-10 August 1967............ Medical Command and Staff Structure, U.S. Army, Vietnam, 10 August 1967-1 March 1970. ......... . Medical Command and Staff Structure, U.S. Army, Vietnam, 1 March 1970. ........................ Admissions, by Year, to Hospital and Quarters for Ma- laria in Three Wars: World War II, Korea, and Viet- . Admissions to Hospital and Quarters for Malaria Among U.S. Army Personnel in Vietnam, 1965-69. ....... . Admissions, by Year, to Hospital and Quarters for Hepa- titis in Three Wars: World War II, Korea, and Viet- Admissions to Hospital and Quarters for Hepatitis Among U.S. Army Personnel in Vietnam, 1965-69. ....... Admissions to Hospital and Quarters for Diarrheal Dis- ease Among U.S. Army Personnel in Vietnam, 1965— Page 4 54 77 119 152 14 20 24 29 35 38 41 43 11. Admissions to Hospital and Quarters for Neuropsychia- tric Conditions Among U.S. Army Personnel in Viet- nam, 1965-69........................... ... 12. Units of Blood Available in South Vietnam, by Month, January 1965-December 1970.................... 13. Military Blood Program Agency Operational Scheme for Triservice Collecting-Processing of Whole Blood. . . . . . 14. A Field Medical Laboratory System in Vietnam... . .. Maps Nondivisional Medical Units, 31 December 1962... ... U.S. Army Hospitals in Vietnam, 31 December 1968. . Air Ambulance Units in Vietnam, 31 December 1968. . U.S. Army Hospitals in Vietnam, 1970.............. Whole Blood Supply and Distribution System, July 1969. Os ON Illustrations A Wounded American Soldier Receives Immediate Treat- Hospitals in Vietnam, 1967............................. 45th Surgical Hospital at Tay Ninh, 1967. ............... Use of Hoist in Vietnam, 1968. ......................... Preventive Medicine Unit Team Member Using Sprayer- Duster.......... An Overview of the New Central Blood Bank at Cam Ranh Bay, June 1969................................. A 2.5-Cubic Foot Freezer in Which Fresh Frozen Plasma Is Stored. ....... Veterinary Food Inspector Checking Ice for Chlorination and Potability........................................ U.S. Army Nurses Hold Sick Call at a Vietnamese Orphanage ........................................ Dental Clinic of the 85th Evacuation Hospital in Vietnam. . Cranes Unload Refrigerated Vans. ..................... A MEDCAP Mission in Vietnam. ...................... A Vietnamese Civilian Undergoing Treatment at a U.S. Army Hospital. .................................... Illustrations are from Department of Defense files. xi Page 45 115 118 138 62 72 79 120 5] 66 76 112 121 124 139 145 148 154 163 167 Introduction Full understanding of medical operations in Vietnam requires some appreciation of the nature of the country and of the war that has been waged there. The Republic of Vietnam lies entirely within the Tropics. Saigon is halfway around the world from Washington, D.C. There is a 12-hour difference in time between the two cities. The nearest off-shore U.S. hospital is almost 1,000 miles away at Clark Air Force Base in the Philippines. The nearest logistical support base is about 1,800 miles away in Okinawa. The nearest complete hospital center is in Japan, some 2,700 miles distant. Patients being evacuated to the United States must travel some 7,800 miles to reach Travis Air Force Base in California, or almost 9,000 miles to reach Andrews Air Force Base, near Washington, D.C. Because of these distances, even with modern air transport, the need for self-sufficiency in the zone of operations is greater than that normally required within a combat zone. This fact is reflected by a higher ratio of combat service support troops (including medical) to combat troops than is normally provided in more conventional situations. Vietnam is actually a combat zone combined with the advanced section of a com- munications zone. The distance of Vietnam from the logistical support base also has an adverse effect on the efficiency and morale of troops newly arrived in-country. Since 1954 Vietnam has been divided like Korea. North of the 17th parallel and Ben Hai River lies Communist North Vietnam and south is the free Republic of Vietnam. South Vietnam has a typically tropical climate of two seasons: hot and dry and hot and rainy. South Vietnam's continuously high temperature and humidity, its monsoon climate, and perennial dust-rain cycle have an obvious impact upon the types of dis- eases to be expected and upon the provision of medical care. The majority of tropical diseases are both endemic and epidemic in South Vietnam. The high ambient temperature and humidity adversely affect the efficiency and health of U.S. troops fighting in this area, and the medical personnel supporting them. These also make it difficult to preserve and maintain medical supplies and sophisticated medical equip- ment. South Vietnam’s terrain, with its waterways and jungles, impedes patient evacuation and supply distribution, even without the interference of combat operations. xiii The Republic of Vietnam is less than half the size of California and long and narrow like that state. It stretches some 700 miles from north to south, and is only 125 miles at its widest. It occupies the eastern and southern part of the Indochinese Peninsula in Southeast Asia, and borders the South China Sea and the Gulf of Siam. Near neighbors to the west are Laos, Cambodia, and Thailand. Several good ports along the eastern shore form the bases for logistical support of combat forces deployed inland and, in turn, affect the disposition of medical installations. The peninsular nature of Vietnam facilitates the employment of U.S. Navy hospital ships offshore in the South China Sea. The conflict in Vietnam is a limited war as well as a counterinsur- gency operation with the essential characteristics of both. There has been no ground or air confrontation between major powers. There has been no enemy aerial bombing of friendly troops, and artillery and rocket bombardment has been sporadic. The tour of duty in Vietnam is limited to 12 months, and forces in Vietnam enjoy a relatively high priority for all U.S. military resources. The Republic of Vietnam is a sovereign nation. U.S. forces are there at the invitation of the host government to help maintain this sovereignty. Economic, political, and sociological factors affect the con- duct of military operations. Vietnam, like most developing nations, suffers a paucity of medical resources. Through various medical civil assistance programs, the Army Medical Department has helped achieve national objectives in all facets of stability operations. Similarly, medical advice provided to the medical department of the Republic of Vietnam Armed Forces, has played a vital role in increasing the department’s competence, capability, and self-reliance. Guerrilla and terrorist operations throughout the country, inter- spersed with sporadic organized unit assaults against cities and mili- tary bases, characterize enemy tactics. There is no defined main line of resistance. The battle has been for popular support and stability, rather than for terrain, per se. Casualties occur anywhere at any time. There are no secure ground lines of communications outside of base areas. The conflict has involved highly mobile, small tactical units, and has not been a war of mass movement of major military formations. Search and destroy operations by small units from relatively secure base areas and for relatively short periods of time have been characteristic. There has been a high reliance on organic Army air mobility for the conduct and support of these operations. The Army Medical Department’s deployments and procedures have reflected these tactical realities. Treatment facilities located in base areas receive casualties by air from operating combat elements. Because there was no need to move frequently, it was practicable to construct semi- permanent medical facilities, thereby allowing the utilization of more xiv sophisticated equipment and providing a general upgrading of the level of medical care. At the beginning of 1965, the USMACV advisory effort was pre- dominant, almost to the exclusion of all other U.S. Army medical sup- port functions in Vietnam. There were some 20,000 U.S. troops in- country receiving medical support from two 100-bed hospitals (the U.S. Navy Hospital in Saigon and the U.S. Army’s 8th Field Hospital in Nha Trang), plus some miscellaneous small medical detachments providing air evacuation and dispensary, laboratory, dental, and veteri- nary services. The planning and implementing of medical support for the tactical and logistical buildup of Army forces in Vietnam have been challenging tasks. Many imponderables existed, mostly related to the nature of the country, the nature of the conflict, and the nature of the medical prob- lems to be met. Estimates and plans based upon previous experience had to be modified to fit the unique situations in Vietnam as valid in- formation was developed and a highly effective medical service created. Xv ——— MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM, 1965-1970 479-653 O - 73 - 2 CHAPTER I The Medical Command Structure Formal U.S. military assistance to the Republic of Vietnam may be traced to the signing of the Pentalateral Agreement in 1950, a multi- national Mutual Defense Assistance Treaty for Indochina. The American contribution to the defense of the Southeast Asian sovereignties was nom- inal for several years thereafter, as reflected by the fact that at no time during the next decade did U.S. military personnel in Vietnam number more than 1,000. Most of the U.S. support effort took the form of ma- teriel and supplies, distributed to the South Vietnamese government through MAAGV (Military Assistance Advisory Group, Vietnam), a small logistics and training organization. However, in November 1961, mounting support by North Vietnam of guerrilla activities in the South led President John F. Kennedy to conclude that, if the South Vietnamese democracy were to be preserved, a much larger commitment of U.S. military personnel in support of the RVNAF (Republic of Vietnam Armed Forces) would be required. The conseauences of the President’s decision were immediately mani- fest. By the end of 1961, the number of U.S. military personnel in Viet- nam had quadrupled. Slightly more than 4,000 men were assigned as military advisers to the RVNATF, to staff officers at MAAGYV headquar- ters, or to a rapidly increasing number of support units. With the arrival of additional Special Forces and logistical detachments in the first 2 months of 1962, the magnitude of the U.S. military role in Vietnam became clear. To provide centralized command and control for these growing combat advisory and support forces, USMACV (U.S. Military Assistance Com- mand, Vietnam), a joint command under CINCPAC (Commander in Chief, Pacific), was officially established on 8 February 1962. Named as the first COMUSMACYV (Commander, U.S. Military Assistance Com- mand, Vietnam) was Lieutenant General Paul D. Harkins, whose grade was indicative of the strength of the expanding American commitment. Closely related to the buildup of American combat, combat advisory, and support forces was the development of the U.S. medical service structure in Vietnam. Based on anticipated troop lists, initial medical sup- port requirements were set in December 1961, shortly after President Kennedy’s decision to increase the level of American support to the RVNAF. These requirements included one field hospital of 100-bed 4 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM capacity, with four attached medical detachments to provide specialty care but to be totally dependent on the hospital for administration and "logistics, and one helicopter ambulance detachment to provide evacuation capability to the treatment facility. Over-all planning and guidance for the deployment of all incoming units became the responsibility of CINCPAC under the direction of the Joint Chiefs of Staff and the Department of Defense. Logistical support responsibility was subsequently isolated and delegated to USARYIS (U.S. Army, Ryukyu Islands), a subordinate command of USARPAC (U.S. Army, Pacific). Logistical support of the medical units committed to Vietnam would become a major responsibility of the USARYIS surgeon’s headquarters. Medical Service During the Advisory Years The field hospital recommended for deployment in December 1961 was to become operational in April of the following year. In the interim, however, arriving Army units, primarily transportation companies, could not be left without any form of medical service. During January and February 1962, three small medical detachments, each attached to a transportation company, disembarked in South Vietnam. Each provided, on an area basis, limited dispensary and general medical care for the units to which they were attached, as well as for all other U.S. personnel in their area. To co-ordinate logistical and administrative support for the increasing number of U.S. Army personnel and units, USARYIS Support Group (Provisional) was established. On 24 February 1962, its medical section, comprised of one plans and operations officer and a chief clerk, both temporarily reassigned from the medical section of the 9th Logistical Command in Thailand, initiated medical activities in Vietnam. Through March, the medical section concentrated on assessing the capabilities of Army medical units in Vietnam, recommending to USARPAC through USARYIS headquarters that preventive medicine and veterinary food inspection detachments be sent from the United States to the theater of operations. Those requirements were subsequently corroborated by Major General Achilles L. Tynes, MC, USARPAC chief surgeon, and Colonel Thomas P. Caito, MSC, chief of his plans and operations division during a prolonged visit both made to Southeast Asia between 30 March and 1 May 1962. However, the medical section would not see the fruition of its efforts as a staff office of the USARYIS Support Group (Provisional) head- quarters. On 1 April 1962, the temporary USARYIS Support Group was redesignated USASGV (U.S. Army Support Group, Vietnam), and placed under the command and control of General Harkins as THE MEDICAL COMMAND STRUCTURE 5 COMUSMACYV. The mission of the USASGV medical section was now clarified: to advise the USASGV commander and his staff on matters pertaining to the medical, dental, and veterinary services of the command, and to supervise all technical aspects of those services. Less than 3 weeks later, on 18 April 1962, the 8th Field Hospital became operational at Nha Trang, assuming responsibility for the hos- pitalization of all authorized U.S. military personnel, dependents, and civilians living or stationed in Vietnam. A second responsibility allotted the 8th Field Hospital was that it act as a central medical supply point for all Army medical units in Vietnam, a duty for which the facility was ill-prepared and grossly understaffed. Concurrently, the hospital commander, Lieutenant Colonel Carl A. Fischer, MC, became also the USASGV surgeon, staff adviser to the Commanding Officer, USASGV, on all Army medical activities in Viet- nam. (Chart 1) As surgeon, Colonel Fischer also headed the USASGV medical section, now expanded to include one Medical Service Corps officer acting as chief of section and two enlisted men. Physically separated by some 200 miles from USASGV headquarters, Colonel Fischer made frequent trips from Nha Trang to Saigon to insure that all necessary action required of his medical section was accomplished. In addition, he had to utilize clerical personnel assigned to the 8th Field Hospital in performing those duties required of him as USASGV surgeon. Both arrangements proved unsatisfactory, prompting Colonel Fischer to re- quest a change in the table of distribution based on AR 40-1; a change which, if approved, would have placed a full-time surgeon in USASGV headquarters. He further reported that, as of 31 December 1962, one of the major problems he faced as hospital commander was that of insuffi- cient personnel in his headquarters section, leading to the absence of a “cohesive, balanced organization to accomplish the administrative and logistics burdens of attached units.” By the end of December, the number of detachments offering area medical coverage for U.S. forces, all obtaining their medical supplies through the 8th Field Hospital, had doubled. (Map 1) An even greater strain on the resources of that facility was created by attached units: two medical laboratories, three specialized surgical detachments, one seg- mented helicopter ambulance detachment, one dental detachment, one veterinary detachment, and one engineer detachment. While the veteri- nary detachment was headquartered in Saigon, all other units were totally dependent on the 8th Field Hospital for administration and logistics. The dual problems thus engendered—medical staffs too small to handle the administrative tasks demanded of them, and the physical separation of the USASGV surgeon from his medical section—would continue to plague the commanding officer of the 8th Field Hospital and his successors during the next 3 years. (1 CHART 1—MEDICAL COMMAND AND STAFF StrucTURE, U.S. ARMY, VIET- NAM, 24 FEBRUARY 1962-1 ApriL 1965 Joint Chs of Staff XXXX XXX CINCPAC (PAC COM) Office of the Surgeon XXXX . eeesssce . COMUSMACV (MACV HQ) Medical Section x stssessenaeerne } csecse USASCV (Army Comp) KXXXXXXXXXXXXXXXXX XXX XXX XXX Department USAMEDD of Army Office of the UsSskpac Chief Surgeon USARYIS Office of the Surgeon v . 0000000000000 0nsdecssesrcsnsnnne 8th Field Hospital Medical Units LEGEND xxxxxxx Operational control =mmmee Command less operational control w= mem Logistical support eeeses Co-ordination (1) Office of the Surgeon: MACV (2) Medical Section: USASCV * USASCV MACV Surgeon Surgeon Dental Surgeon Chief of Vet Section Officer Operations Admin Professional Prev Med Enlisted Branch Branch Services Br Officer Personnel Piao MEDCAP || School Dental Vet Prev Howp Opa, & Adv Tog Adv Advisor Med Adv Tng Div Advisor ’ Advisor 8 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Although the opening of a Navy dispensary in Saigon in 1963 re- moved that city, as well as IIT and IV CTZ’s (corps tactical zones) to the south, from the hospitalization responsibilities of the 8th Field Hospital, increasing numbers of casualties more than offset that relief. In the same year, USASGYV was again redesignated, becoming USASCV (U.S. Army Support Command, Vietnam). Now removed from his direct command, General Harkins as COMUSMACYV retained operational control over the lower headquarters. As the senior Army officer in Vietnam, however, he remained the Army component commander, while the Commanding General, USASCV, became deputy Army component commander. No benefits accrued to the USASCV medical section, however, and it re- mained understaffed and physically separated from the commanding officer of the 8th Field Hospital. The Army medical structure in Vietnam remained essentially un- changed in 1964. The USASCV surgeon’s medical section increased by one enlisted man; and while a dental surgeon, preventive medicine officer, and veterinarian were added to his staff, they too served in dual capacities and could contribute little to a reduction in the medical section’s workload. NOTES TO CHART 1 a Before the arrival of the 8th Field Hospital, administrative and logistical support for all Army medical units in Vietnam had been co-ordinated through the Office of the Surgeon, Headquarters, United States Military Assistance Command, Vietnam. bUSASCV was the acronym for the Army component headquarters in Vietnam from March 1963 through June 1965. Before 1963, that headquarters had been known as the USARYIS Support Group (Provisional) and, after 1 April 1962, as USASGV (United States Army Support Group, Vietnam). ¢The staff structure of the Office of the Surgeon, Headquarters, MACV, as of 31 December 1964. dThe staff structure of the USASCV Medical Section as of 31 December 1964. ¢The principal duty of the USASCV Dental Surgeon was Commanding Officer, 36th Medical Detachment (Dental Service), the command and control element for dental units. f The principal duty of the USASCV Veterinary Officer was Commanding Officer, 4th Medical Detachment (Veterinary I'ood Inspection), the command and control element for veterinary units. # The principal duty of the USASCV Preventive Medicine Officer was Commanding Officer, 20th Preventive Medicine Unit, the command and control element for preventive medicine units. hThe principal duty of the USASCV Surgeon was Commanding Officer, Sth Field Hospital, the senior medical organization and highest level headquarters for all nondivisional medical units in Vietnam. I The plans and operations officer acting as chief of section, as well as the enlisted personnel under him, had originally constituted the Medical Section of the 9th Logistical Command, Thailand, whence they had been reassigned for temporary duty to South Vietnam. Sources: (1) Medical Activities Report, Office of the Surgeon, Headquarters, Military Assist- ance Command, Vietnam, 1964. (2) Army Medical Service Activities Report, Medical Section, United States Army Support Command, Vietnam, 1964. (3) Army Medical Service Activities Report, Office of the Surgeon, Headquarters, United States Army, Vietnam, 1965. THE MEDICAL COMMAND STRUCTURE 9 NONDIVISIONAL MEDICAL UNITS 31 December 1962 25 0 100 MILES 25 0 100 KILOMETERS (approximate) ir 941th Med Det — 130th Med Det 8th Field Hospital 41st Med Det SN ) o} 44th Med Det Qui Nhon © 66th Med Det 36th Med Det 57th Med Det 7th Med Lab SOUTH 20th Med Lab VIETNAM VA 29th Engr Det 0 93d Med Det 129th Med Det 4th Med Det Nha Trang 0) Sist Med Det 134th Med Det Saigon- Tan Son Nhut Vung Tau FT Map 1 Command and Staff Relationships During the Years of Military Commitment: 1965-67 Two American destroyers were attacked by North Vietnamese PT-boats on 2 and 4 August 1964, prompting the Gulf of Tonkin resolu- tion. That action taken by Congress would lead to the direct commitment of the first major U.S. combat units in Vietnam. It would thrust General William C. Westmoreland, who had replaced General Harkins as 10 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM COMUSMACYV shortly after the consolidation of MAAGV and USMACYV headquarters in June 1964, into a position of international prominence; and it would be he who would supervise the massive buildup of U.S. forces in Vietnam over the next 4 years. Medical Command Versus Logistical Command As early as 1962, General Harkins had recognized the need for a centralized logistics organization in support of U.S. forces in South Vietnam. Again in 1964, COMUSMACYV had recommended that a logistical command be promptly introduced in-country. Later in the year, the organization of that command was authorized, with responsi- bility for over-all joint logistical planning to reside in USMACYV head- quarters. The decision stipulated that support should be conducted on an area basis for all common supply and service activities, which in practice meant that the Army was to provide common-item support within II, III, and IV CTZ, plus any portion of I Corps in which major Army forces were deployed. The doctrinal framework which justified the creation of a logistical command in Vietnam was COSTAR II, the second of two studies on combat service support of the Army. One of the outgrowths of the study was the directive that, when a field army was constituted, all logistical support was to be provided by FASCOM, a field army support command. Nondivisional medical service was placed under the Army support command. The juxtaposition of two events (the decision of the Joint Chiefs of Staff to establish a centralized logistical command in Vietnam and the Gulf of Tonkin aftermath) made it only a matter of time before the U.S. Army would assume responsibility in South Vietnam for the dis- tribution of supply items common to all military services, as well as for those used only by the Army. On 1 April 1965, Headquarters, 1st Logistical Command, a field army support command and control element, was activated. In accord- ance with the policy of centralized logistical direction, four geographic support areas (roughly corresponding to CTZ’s) were directly subordi- nated to that command. The 8th Field Hospital was removed from the direct command of USASCV headquarters and subordinated to the 1st Logistical Command. As senior medical officer in Vietnam, the hospital commander, Lieutenant Colonel (later Colonel) James W. Blunt, MC, now assumed a third hat: 1st Logistical Command surgeon and director of the command’s medical section. When Colonel Blunt activated the 1st Logistical Command medical section on 1 April, he was made responsible for providing the commander and his staff with necessary assistance and advice on all aspects of non- THE MEDICAL COMMAND STRUCTURE 11 divisional medical support, to include veterinary and dental service, and medical supply. That proved an impossible task, since he remained both USASCV surgeon and commanding officer of the 8th Field Hospital. Colonel Blunt’s dilemma was partially resolved with the interim appoint- ment of a more junior Medical Corps officer, Major (later Lieutenant Colonel) Stuart A. Chamblin, Jr., as the 1st Logistical Command surgeon on 12 May. However, far more important changes in the structure of the Army medical service in Vietnam were imminent and would, for a time, reduce if not eliminate the problems faced by preceding commanding officers of the field hospital. Consistent with current concepts, the USARPAC chief surgeon noted in his 1965 Annual Medical Activities Report: “Medical Service is an Army or area wide service and, as such, all medical support capability should be consolidated under one Medical Command.” Prompting that statement were the recognized criticality of professional medical per- sonnel, the unique characteristics of medical supply and maintenance, the constant demand for strong and effective preventive medicine and veterinary food inspection programs, and the requirement for medical support to be immediately responsive to the needs of the commander. A field hospital was completely unsuitable as a control element for a medical command encompassing units scattered through three CTZ’s. Conse- quently, the 58th Medical Battalion was assigned to the 1st Logistical Command on 29 May, assuming command and control over nondivi- sional Army medical units in Vietnam. The battalion’s commanding officer, Lieutenant Colonel (later Colonel) Edward S. Bres, Jr., MC, was simultaneously appointed 1st Logistical Command surgeon and director of its small organic medical planning staff. With the appointment of Colonel Bres as 1st Logistical Command surgeon, the commanding officer of the 8th Field Hospital once again wore only two hats. However, the need for a full-time surgeon in the Army component headquarters had not diminished, but rather had be- come more pressing. The Department of the Army finally concurred in the oft-repeated demands of earlier USASCV surgeons, and on 29 June, authorized a table of distribution change adding a full-time surgeon, an administrative officer, and an additional enlisted man to the USASCV medical section. Ten days later, Lieutenant Colonel (later Colonel) Ralph E. Conant, MC, became the USASCV surgeon. Assigned no duties other than surgeon, he retained that post when USASCV was redesig- nated USARV (U.S. Army, Vietnam), on 20 July 1965. The scope of the medical advisory effort at the field army level in- creased with the establishment of USARYV as the highest command and control headquarters for all U.S. Army units in Vietnam. Reorganized in structure and expanded in size, the USASCV medical section was renamed the Office of the Surgeon, Headquarters, USARV. Staff super- 12 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM vision of a medical service supporting Army logistical operations had ceased to be a responsibility of the medical section when the 1st Logistical Command’s medical section was activated. But on 20 July, that loss was more than offset with the assumption of staff responsibility for the health services of the entire Army medical structure in Vietnam, including unit, division, and army level medical service. Specifically, the USARV surgeon was given the mission of planning all USARV medical service, to be correlated at USARV headquarters with troop concentrations, logistical support areas, and the concept of tactical operations. Additional duties included preparing and co-ordinating broad medical policies, recommending assignments for medical personnel within USARV, main- taining medical records and statistics, and furnishing professional con- sultants to the command. In the meantime, the Ist Logistical Command surgeon was co- ordinating the deployment and day-to-day operations of nondivisional medical units in Vietnam, units increasing in numbers from 11 in April to 60 by early fall. Just as the 8th Field Hospital had earlier proved in- adequate as a command and control element, so now was Headquarters, 58th Medical Battalion, too small to handle the increasing volume of logistical, administrative, and support functions demanded by subordi- nate headquarters. On 18 August, Lieutenant Colonel Conant was re- placed as USARV surgeon by Colonel Samuel C. Gallup, MC. On 25 October, the recently promoted Colonel Conant in turn replaced Colonel Bres as 1st Logistical Command surgeon. The reason for the replacement of Colonel Bres was soon apparent, for with the activation of the 43d Medical Group on 1 November, the 58th Medical Battalion ceased to be the senior army level medical unit in Vietnam. (Chart 2) Colonel Conant was the commanding officer of that medical group. Although a subordinate medical headquarters, the 58th Medical Battalion continued to exercise major command and control responsibil- ities through 17 March 1966. The 43d Medical Group assumed the non- divisional medical service mission in IT CTZ, and also exercised command and operational control over all nondivisional medical maintenance, laboratory, and helicopter units in Vietnam. The 58th Medical Battalion remained the command and control element for nondivisional units in III and IV CTZ’s, and for all preventive medicine, dental, and veterinary units, until the 68th Medical Group became operational on 18 March 1966. Command by the Medical Brigade In December 1965, Lieutenant General Leonard D. Heaton, The Surgeon General, and General Westmoreland decided to send a medical brigade to Vietnam. Agreement had not been reached, however, on the THE MEDICAL COMMAND STRUCTURE 13 level at which the brigade should be assigned. A month earlier, The Surgeon General visited Southeast Asia and, at that time, had con- cluded that the medical brigade should be made a major subordinate command of USARV headquarters, just as were the aviation and military police brigades and the engineer command. Shortly thereafter, Colonel (later Major General) Spurgeon Neel, MC, USMACV surgeon, had prepared a memorandum for General Westmoreland recommending that the medical brigade could most effectively support Army personnel in Vietnam if placed under the direct supervision of the USARV surgeon. Pointing out that medical service is an integrated function consisting of treatment, evacuation, and supply, Colonel Neel maintained that optimal medical service could only be achieved if directed solely by professional medical personnel. The interposition of an intermediate, nonmedical headquarters between responsible commanders and their medical re- sources could only reduce the quality of medical care available to troops. During the same interval, the USARPAC chief surgeon, Brigadier Gen- eral (later Major General) Byron L. Steger, MC, had visited Vietnam and strongly recommended the release of medical service from logistical command and control. The designated commanding officer of the medical brigade, Colonel (later Major General) James A. Wier, MC, nonetheless found that, upon his arrival in January, no decision as to the placement of his command had been made. Under the COSTAR II concept, medical service was visualized as a logistical service and, as such, belonged under FASCOM, the Ist Logistical Command. The FASCOM commanding general, Major General Charles W. Eifler, was unconvinced of the need for a medical brigade, preferring instead that medical groups be placed under the operational control of the commanding officers of each of his three area support commands. In that manner, General Eifler believed, all logistical support would be more responsive to the needs of the com- manders of the two Field Force headquarters, and the mission of FASCOM best accomplished. Since existing doctrine lent support to the position of General Eifler, Colonel Wier was made director of Medical Service and Supply on the General Staff of the FASCOM commanding general on 26 January 1966. Colonel Conant, who had previously occupied that position, was to remain 1st Logistical Command surgeon until the arrival of the medical brigade. In a March briefing attended by Major General (later Lieu- tenant General) John Norton, Deputy Commanding General, USARV, and General Eifler, Colonel Wier made a final attempt to have the med- ical brigade assigned directly to USARV headquarters, but to no avail. He succeeded only in persuading all concerned that the senior medical officer in Vietnam should be the USARYV surgeon at the Army com- CHART 2 Mebica. CoMMAND AND STAFF STRUCTURE, U.S. ARMY, VIET- NAM, 1 NovEMBER 1965-17 FEBRUARY 1966 Joint Chs Department of Staff of Army USAMEDD % I : CINCPAC XXXXXXKXXXXXXXXXKXXXX Ofc of the (PAC COM) | SARPAC Gh Surgeon x J v Xx 1 . Ofc of the COMUSMACV Ofc of the mn Surgeon (MACV HQ) LISARYIS Surgeon (2) | Oleofth USARV J ———— Surgeon : 1 LEGEND (3) Med Di- 1st Log rectorate Command xxxxxxx Operational control r - — Qommand less operational control 43rd Med 58th Med == == Logistical support Group Battalion esses Co-ordination I b 1 1 1 1 . 406 Mob Air Amb 32 Med 36 KJ 4 JA 20 LA Med Lab Company Depot Den Vet Prev Med | Meet II CTz III CTZ 1V CTZ Units Units Units (1) Office of the Surgeon: MACV ¢ MACYV Surgeon Deputy Surg XO Operations Admin Professional Division Branch Services Div Plans, Opns | & Tng Div Dental Adv p= MEDCAP/ | MILHAP . Vet Ady [wm Hosp Admin Advisor Mil Med Prev Med ik | Sch Adv Officer RF/PF Sanitary Advisor Engineer |_| FWMAF Nursing = [J] Opns Off Sci NCO Office of the Surgeon: USARV'® (2) USARV | . I Surgeon g ] Dental Veterinary Stf Off Stf Off XO Admin Supply Div Branch h Plans and Prev Med Prof Svc Opns Div Division Division (3) Medical Directorate: 1st Log Command ! Medical ! I Director | Dental Prev Med Surgeon Officer XO Admin | Med Supply Officer Officer Med Regulat- Med Plans & ing Officer Opns Officer 16 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM ponent headquarters rather than the commanding officer of the medical brigade. Thus, when the advance party of the 44th Medical Brigade, acti- vated at Fort Sam Houston, Tex., on New Year’s Day 1966, arrived in Vietnam on 18 March, it was assigned to the 1st Logistical Command. A Medical Brigade (Provisional) was established, consolidating in a single element command and control responsibility for medical units not organic to divisions and separate brigades—responsibilities formerly divided between the 43d and 68th Medical Groups. As director of the NOTES TO CHART 2 “As is indicated above, the 58th Medical Battalion, senior Army-level medical unit in Vietnam from 30 May 1965 to 31 October 1965, retained considerable command and control jurisdiction after the 43d Medical Group became operational, although it was technically a subordinate unit of that group. Y The 406th Mobile Medical Laboratory, based in Japan, was reorganized on 24 September 1963 to include a mobile laboratory unit attached to USASGYV. Envisioned as a Pacific Command-wide laboratory service for all U.S. military medical facilities, the 406th Mobile Medical Laboratory replaced and absorbed the personnel and equipment of the 7th Medical Laboratory, previously operative in Vietnam. Throughout the Vietnam confiict, the 406th Mobile Medical Laboratory remained under the command of USARJ (United States Army, Japan). While operating in Vietnam, however, it was attached to and operationally controlled by various in-country medical headquarters. ¢ Operational control of the 36th Medical Detachment (Dental Service), 4th Medical Detach- ment (Veterinary Food Inspection), and 20th Preventive Medicine Unit was retained by the 1st Logistical Command Surgeon. 4 The staff structure of the Office of the Surgeon, Headquarters, MACV, as of 31 December 1965. The consolidation of MAAGV and MACV Headquarters led to an expansion in the functions of the Office of the Surgeon, and culminated in the staff organization depicted above. The MACV Surgeon’s Office changed little in subsequent years. Throughout the Vietnam conflict, Army medical staffs and headquarters were directed to co-ordinate their activities with the MACV Surgeon’s Office, although the latter was not an element in the command and control chain for Army medical Units. © The staff structure of the USARV Surgeon's Office as of 31 December 1965. The organizational structure was patterned after the reorganized USASCV Medical Section of 9-20 July 1965. fOn 1 November 1965, a full-time USARV Dental Surgeon, with no additional duties, was appointed. The commanding officer of the 36th Medical Detachment, who had previously performed that advisory function as an additional duty, continued to wear a second hat as the 1st Logistical Command Dental Surgeon. «The commanding officer of the 4th Medical Detachment was also Veterinary Staff Officer in the Office of the Surgeon, USARV Headquarters, until that advisory function was delegated to lower headquarters, the 44th Medical Brigade, in 1966. h Through 20 November 1965, the commanding officer of the 20th Preventive Medicine Unit served also as Preventive Medicine Officer on the staff of the USARV Surgeon. Thereafter, that position constituted a full-time assignment. i The staff structure of the 1st Logistical Command Medical Directorate as of 31 December 1965. Emerging duplication in medical staff functions is reflected in the similarity between the organizations of the USARV Surgeon's Office and the Medical Directorate. J Before 26 January 1966, the Medical Director was also the 1st Logistical Command Surgeon. Both were additional duties performed by the commanding officer of the 43d Medical Group, who retained his second position as 1st Logistical Command Surgeon following the appointment of a full-time Medical Director on 26 January. Sources: (1) Medical Activities Report, Office of the Surgeon, Headquarters, Military Assist- ance Command, Vietnam, 1965. (2) Army Medical Service Activities Report, Office of the Surgeon, Headquarters, United States Army, Vietnam, 1965, 1966. (3) Army Medical Service Activities Report, Medical Section, Headquarters, 1st Logistical Command, 1965. (4) Army Medical Service Activities Reports, Headquarters, 43d Medical Group, 1965 and 1966. (5) Army Medical Service Activities Reports, Headquarters, 58th Medical Battalion, 1965 and 1966. THE MEDICAL COMMAND STRUCTURE 17 FASCOM medical section and designated commanding officer of the incoming brigade, Colonel Wier had paved the way for the assimilation of the Logistical Command’s medical directorate personnel and func- tions into the Medical Brigade (Provisional). The medical directorate was, at that time, charged with an inclusive mission: to develop, co-ordinate, and supervise medical plans and opera- tions, medical supply and maintenance policies, medical statistics and records, professional medical and dental activities, preventive medicine, and medical regulating activities for all nondivisonal medical units in Vietnam. Between 18 March and 1 May, when the 44th Medical Brigade became operational, the responsibility for the accomplishment of these functions was shifted from the directorate to the brigade. The number of personnel staffing the FASCOM medical section gradually dimin- ished; some transferred to the Medical Brigade (Provisional), others rotated. By 1 May, the only personnel left in the medical directorate were the director and a FASCOM staff medical section consisting of two plans officers, one supply and maintenance officer, one medical noncommis- sioned officer, and two enlisted men. Five months later, the medical section had withered even further, and was thereafter maintained at Headquarters, 1st Logistical Command, for liaison purposes only. During its 6-week span, the Medical Brigade (Provisional) had served as a medium for transferring direct command and control of medical units from the 1st Logistical Command to the 44th Medical Brigade. From 1 May 1966 through 9 August 1967, when the most rapid buildup of U.S. combat forces took place in Vietnam, the 44th Medical Brigade remained subordinate to the 1st Logistical Command. As combat forces expanded, medical units and personnel grew proportionately; by 31 December 1966, units assigned to the medical brigade totaled 121, while assigned personnel increased from 3,187 on 1 May to 7,830 by the end of the year. Units and individuals under the centralized control of the 44th Med- ical Brigade operated on a direct support/general support basis. Those providing countrywide or general support services, such as medical lab- oratories, supply depots, and preventive medicine units, were retained under the direct command of Headquarters, 44th Medical Brigade. Com- manders of these general support facilities frequently held two posts, act- ing as staff officers at brigade headquarters. They were occasionally given a third hat as well, maintaining an office at USARV headquarters as staff advisers to the USARV surgeon. Other units, particularly evacuation and treatment facilities, pro- vided area or direct support, and as such would be subordinated to one of the medical groups. Groups were in turn assigned geographic areas of responsibility approximately equivalent to doctrinal Army corps areas, 479-653 O - 78 - 3 18 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM and attached to one of three area support commands of the 1st Logistical Command for administration and logistics. Thus, when the 55th Medical Group became operational in June 1966, it was attached to the Qui Nhon Area Support Command, assuming control over nondivisional medical units in IT CTZ North. The 43d Medical Group, previously responsible for medical service throughout IT CTZ, retained that wider responsibility only for air evacuation. For all other aspects of nondivi- sional medical care, the 43d Medical Group was responsible only for IT CTZ South, supported in its mission by the Nha Trang (later Cam Ranh Bay) Area Support Command. Headquarters, 68th Medical Group, remained the command and control element for units in III and IV CTzZ, and was, along with Headquarters, 44th Medical Brigade, and all gen- eral support units, attached to the Saigon Area Support Command for administration and logistics. (Chart 3) In his assigned area, the group commander would act as the support command surgeon, providing first-echelon medical care for nondivisional and nonaviation units, plus evacuation and second-echelon medical treat- ment for all U.S. Army and other authorized personnel. Medical regu- lating within the CTZ would be controlled from his group headquarters, with all hospitalization and air ambulance units kept directly under group command. In most cases, however, a separate medical battalion headquarters would be used as the command element for ground ambu- lance, clearing, and dispensary units. Had all medical command and control been vertically integrated, that system of area medical service might have been most efficient. How- ever, the separation of administrative and logistical support from com- mand, in conjunction with the existence of an intermediate, nonmedical headquarters between medical practitioners in the field and consultants in the USARYV surgeon’s office, created duplicative, overlapping, and confusing channels of communication. Administrative support was often confused with command responsibility, with actions of the former type following a communications channel from the support command directly to Headquarters, 1st Logistical Command, completely bypassing Head- quarters, 44th Medical Brigade. The resultant lack of responsiveness to administrative problems on the part of the Commanding Officer, 44th Medical Brigade, an officer on the same command level as the command- ing officers of each area support command, was inevitable, although difficult to explain to the Commanding General, 1st Logistical Command. Similarly, the inability of hospital and medical group commanders to accomplish required personnel changes in their commands limited the effectiveness of medical service. Professional consultants assigned to the USARYV surgeon’s office, following visits to treatment facilities, made recommendations directly to the USARV surgeon or brigade personnel THE MEDICAL COMMAND STRUCTURE 19 officer. Medical officers, on that basis, were subsequently transferred among installations and support areas, frequently without the foreknowl- edge of affected hospital and medical group commanders, Duplication of Effort: Headquarters, 44th Medical Brigade, Versus the Office of the Surgeon, Headquarters, USARV Much, if not all of that confusion, could have been eliminated through a concise delineation of the responsibilities of Headquarters, 44th Medi- cal Brigade, vis-a-vis the USARYV surgeon’s office. In theory, the former should have been responsible for the day-to-day operations of all non- divisional medical services in Vietnam; the latter, for long-range plans and operations. In reality, those functions could not be so easily segregated. In addition to those responsibilities earlier transferred from the 1st Logistical Command medical directorate to the medical brigade, the duties of the brigade commander included all in-country communica- tions among nondivisional medical units; the evaluation and dissemina- tion of medical intelligence; and provision for the security of all medical forces assigned to the 1st Logistical Command. The mission of the USARV surgeon, originally less broad with respect to the operations of nondivisional medical service than that of the Ist Logistical Command surgeon, rapidly outpaced that of the com- manding officer of the 44th Medical Brigade. On 10 June 1966, Colonel Wier became USARYV surgeon, and command of the brigade was trans- ferred to Colonel Ray L. Miller, MC. Exactly 5 months later, Colonel Wier received his first star. Although, when serving as brigade com- mander, he had expressed the desire to reduce if not eliminate the USARYV surgeon’s office, Brigadier General Wier found it necessary to double the size of his office staff over the next year. As U.S. Army forces and their organic medical units expanded, so, of course, did the work- load of the surgeon assigned to headquarters of the Army component. However, part of the growth in the USARV surgeon’s office was the result of an increasing volume of paperwork, principally planning, accomplished at the Army level. Much of that planning was demanded of General Wier by G-3, Assistant Chief of Staff for Plans and Opera- tions, Headquarters, USARV. Because of the timelag involved, General Wier found co-ordination with Headquarters, 44th Medical Brigade, difficult and was therefore unwillingly forced to increase the staff of his plans and operations division. Other responsibilities such as collecting and compiling medical statistics were added to his office during the year, and could not be delegated to lower headquarters. Professional activities and consultants had to remain at the Army level for, in addition to visit- CHART 3—MEepIicAl. COMMAND AND STAFF STRUCTURE, U.S. ARMY, VIETNAM, 1 MAY 1966-10 AucusTt 1967 Joint Chs Department of Staff of Army USAMEDD x I 3 ( anaras ) XXXXXXXXXXXXXXXKXXXXXXXOXXXXX XXX xxxxxxxx| USARPAC Sa oe x —« Ofc of the COMUSMACV Ofc of the Surgeon (MACV HQ) USARYIS Surgeon Seeeeeecatttetiittttatttcittttttttiiiittttttttttnnans ®0ccvcccscsccce BOT R GEER (1) Ofc of the USARV —— — a Surgeon tal” 2 1 (2)2 Med Di- 1st Log : rectorate Command SessTassniy 1 (3)[ HQ 44th 44th Med Med Bde Brigade LEGEND 1 1 1 43rd Med 55th Med 68th Med xxxxxxx Operational control Group Group Group C . 1 | I = Command less operational control Med Units Med Units Med Units w= ===] o0gistical support II CTZ S II CTZN ITI, IV CTZ ¢+ ees ee Co-ordination . I 1 1 1 27 Mil 32 Med 932 Med Det | IM od Lib Hist Det Depot AI (Den) 1 | 4 Med Det nr 20 Prev JB (Vet) Med Unit (1) Office of the Surgeon: TUSARV (3) Headquarters 44th Medical Brigade ; . Brigade Chief of Stf 2) Commander 2 ACofS G-1 p+: DCS (P&A) Medical Directorate Vet 1 Dental : Ist Logistical Command # Officer DBC Surg . h ACofS G4 * Medical Chap- I Prev Med Supply * Director lain Med Off 3 : XO i++] USARV Surg Dietary Staff Stf Adv Nurse Deputy Surg FASCOM Sec = I 1 1 1 1 | Plans Off | Det Adj - S_1 S-3 S—4 | Med NCO HQ 5 ¥ B Enl Pers | — J i Pers & |_| Plans Supply | J Admin & Pol Div Pers Opns& Gen & M Mgt i Comm U Sup M . Med Med b= Admin Reg Sup & Intel oy Med ers a r Stat Pers Den Prev Med Rec Prof Plans & Admin Nursing Avani Div Div | | Med Div Stat Div Svc Div | | Opns Div Office Div 22 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM ing hospitals, they provided consultant services for organic medical units in divisions outside the purview of the 44th Medical Brigade. The confusion in command and control, support, and co-ordination that ensued was documented in a position paper prepared by General Wier in June 1967. Noting that the USARYV surgeon was not only the senior medical officer, but was also assisted by the most competent medi- cal consultants in Vietnam, General Wier argued for the placement of the 44th Medical Brigade directly under Headquarters, USARV. To do so would make the highest level of medical skill directly and immedi- ately available to all medical units; a level of skill far beyond that avail- able to the Commanding General, 1st Logistical Command, under the existing organization. Advantages resulting from the removal of the medical brigade and subordinate units from the intermediate logistics headquarters would be numerous: reinforcement of the medical service of tactical units could be more rapidly effected, and personnel economies could be realized through the realignment of duplicative staffs in higher and lower medical headquarters and through the elimination of the Ist NQTES TO CHART 3 2 Deployment of medical groups as of 1 July 1966. When the 68th Medical Group became operational on 18 February 1966, it became the higher headquarters for, and assumed the former command and control responsibilities of, the 58th Medical Battalion. The 55th Medical Group became operational on 1 July 1966, assuming control over nondivisional medical units in the northern portion of II CTZ. The 43d Medical Group remained the command and control element for units in the southern portion of II CTZ. It acted in the same capacity for the 6th Convalescent Center, operational at Cam Ranh Bay since 16 May 1966, although doctrine specified that the facility be assigned directly to Headquarters, 44th Medical Brigade. All Medical Groups were furt®®r attached for administration and logistics tp the headquarters of the various area support commands, subordinate commands of the 1st Logistical Command. On 1 August 1966, Headquarters, 9th Medical Laboratory became operational in Saigon. Thereafter, it acted as the control element for all medical laboratories in Vietnam, including the 406th Medical Mobile Laboratory. © Attached for administration and logistics. 4Upon becoming operational in Saigon on 27 December 1965, the 932d Medical Detachment (AI) became the command and control element for dental units in Vietnam. ¢The staff structure of the USARV Surgeon's Office as of 31 December 1966. Until 9 March 1967, the Chief Nurse, USARV Surgeon’s Office, also acted as Staff Nurse, Headquarters, 44th Medical Brigade. From 9 March to 27 September, the latter position was occupied on a full-time basis by an ANC officer. 8 The staff structure of the 1st Logistical Command Medical Directorate as of 1 October 1966. hThe primary duty of the 1st Logistical Command Medical Director was Commanding Officer, 44th Medical Brigade. i The staff structure of Headquarters, 44th Medical Brigade, as of 31 December 1966. In general, the organization differed in structure from that of the Medical Brigade (Provisional) only in the addition of two officers to the Brigade Commander’s staff: (1) The Dietary Staff Advisor; and (2) the Staff Nurse. JOn 6 June 1966, the Brigade Staff Veterinarian was appointed to additional duty as Veterinary Consultant to the USARV Surgeon. kThe primary duty of the 44th Medical Brigade Dental Surgeon was commanding officer of the 932d Medical Detachment (Dental Service). Sources: (1) Army Medical Service Activities Reports, Office of the Surgeon, Headquarters, United States Army, Vietnam, 1965, 1966, and 1967. (2) Army Medical Service Activities Report, Headquarters, 44th Medical Brigade, 1966. (3) Interview, Brigadier General James A. Wier, MC, USARYV Surgeon, and Captain Darrell G. McPherson, MSC, 17 June 1967. THE MEDICAL COMMAND STRUCTURE 23 Logistical Command medical directorate. Perhaps most importantly, the centralized control of all Army medical assets in Vietnam would permit the most efficient use of critical, scarce resources. Their optimal utiliza- tion would be assured by vesting in the senior medical officer in Viet- nam, the USARV surgeon, full command and control responsibility. With the exception of G-1, Assistant Chief of Staff for Personnel, all members of the USARV General Staff concurred in General Wier’s proposal. The lone demurral argued that placing the medical brigade directly under USARV headquarters would cause the latter to become a support command, rather than the command and control headquar- ters for a true field army. General Wier’s paper was returned without action, and before the proposal could be resubmitted, he returned to the United States, replaced as USARV surgeon by Brigadier General (later Major General) Glenn J. Collins, MC. The effort to elevate the 44th Medical Brigade to the field-army level of command did not subside, and events of the first 2 weeks of General Collins’ tour as USARYV surgeon were to conspire to make that effort successful. As the result of decisions made elsewhere, space ceil- ings were placed on USARYV in July 1967, bringing about a total re- evaluation of the Army medical service in Vietnam. After a careful examination of the over-all Army medical support structure, the Office of the Surgeon concluded that spaces could be deleted from the division medical service. To do so, however, would make it mandatory that the USARYV surgeon have complete and direct control over all medical resources. Otherwise, the immediate reinforcement of divisional medical units could not be guaranteed. On 2 August 1967, a final realignment study including these quali- fications was presented by General Collins to the USARV General Staff. More explicit than the June proposal, it listed in detail both the advan- tages of assigning the 44th Medical Brigade directly to USARYV, as well as the disadvantages of leaving the brigade directly under the 1st Logistical Command. Two points were, for the first time, emphasized: the reduction in delays in medical planning and medical statistical reporting, and in implementing the recommendations of professional consultants; and the greater ease in the management of medical per- sonnel to be realized by assigning the brigade directly to USARV head- quarters. Nondivisional Command and Staff Relationships: 1967-71 The need could no longer be denied. On 10 August 1967, the 44th Medical Brigade was released from the 1st Logistical Command and reassigned directly to USARV as a major subordinate unit. (Chart 4) The efforts of the last 2 years were rewarded; the arguments of Cuart 4—MEepicaAL COMMAND AND STAFF STRUCTURE, U.S. ARMY, VIETNAM, 10 AucusT 1967-1 Marcu 1970 Joint Chs Department of Staff of Army USAMEDD x 1 . Within) XXXXXXXXXXXXXXXXXXXXX XX XXXXXXXXKX USARPAC eof sie % rere reeereerommeerneed Ofc of the COMUSMACV Ofc of the Surgeon (MACV HQ) USARYIS Surgeon Seeeesceceetccttccs Kietecerncnarenncsnnrecans BRB STIT BE EHE SHE SN 9.00 SHOE CHEST Cy Ofc &f the (1) Surgeon USARV — i —— I | HQ 44th 44th Med | * LEGEND (2) Med Bde Brigade xxxxxxx Operational control igs TI Rd TALS Command less operational control Group Group Group Group == === Logistical support I I 1 I seeeee Co-ordination Med Units Med Units Med Units Med Units II CTZ S II CTZN 1CTZ III, IV CTZ i 1 I 1 9 Med 32 Med 932 Med 522 Med 5 Lab Depot Det (Den) Det (Vet) I 20 Prev 172 Prev Med Unit Med Unit (1) Office of the Surgeon: TUSARV ¢ Chief of Stf ACofS G-1 [eee DCS (P&A) ®ee+ | USARYV Surg Deputy Surg XO Dental v Chief Admin Surgeon eterinanan Nurse Office Pers Prev Med Rec & Prof Plans & Med Mat Div | | Med Div Stat Div Sve Div | |Opns Div Div (2) Headquarters 44th Medical Brigade © 1 == Bde CG { g Vet Off 1 Den Surg DCG Prev Chap I Med Off Dietary x0 Chief Stf Adv Nurse — st |H s3 |[ s+¢ h[Adi] [per co |_| Officer Plans Med i Pers & Opns Supply - Enl [| S-9 Fac & Pers Const Mpr Con & Gen Sup ™ ctv pers 1] MA Re {| ghee I Morale & Aviation Bde MUST] 1 Welfare ¥ Officer ABXXX xx] 222 PSC | 26 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM General Heaton, General Steger, General Wier, General Collins, and Colonel Neel, validated. The Army medical service in Vietnam became in effect what it would become in later years in name—a unified medical command. The Medical Brigade as a Major Subordinate Command of USARV Headquarters General Collins assumed the dual role of Surgeon, USARV, and Commanding General, 44th Medical Brigade. Although technically ex- cluded in the former capacity from operational control over nondivisional medical units, he was nonetheless able to exercise full command and con- trol responsibilities in his other position as brigade commander. As USARV surgeon, General Collins and his staff were charged with five general responsibilities: to advise the USARV commander on all matters regarding the health of the command; exercise technical super- vision over all medical activities of the command; plan to assure the availability of adequate medical support in the command; control the assignment and use of medical personnel in Vietnam; and manage medi- cal supply and maintenance functions. As applied to nondivisional medi- cal service, these were interpreted as responsibilities for medium- and long-range planning, the development of theater-wide medical planning factors, and the monitoring of co-ordination between the 44th Medical Brigade and supported units. Meanwhile, Headquarters, 44th Medical Brigade, assumed respon- sibility for programs not originally envisioned for a field medical unit, in- NOTES TO CHART 4 2 The maximum deployment of medical groups in Vietnam, a situation existing from 23 October 1967, when the 67th Medical Group became operational, to the 15 June 1969 deactivation of the 55th Medical Group. Originally headquartered in III CTZ, the 67th Medical Group relocated in I CTZ early in 1968. b The 522d Medical Detachment (AF) became operational on 10 April 1968, assuming control over all veterinary TOE units in Vietnam. ¢The 172d Preventive Medicine Unit became operational under reduced strength on 1 August 1968. It was not subordinated to the 20th Preventive Medicine Unit, but rather assigned directly to Headquarters, 44th Medical Brigade. Both the 172d and 20th Preventive Medicine Units acted as control elements for preventive medicine detachments in Vietnam, the former for those operative in I and II N CTZ, the latter for units in II S, III, and IV CTZ. 4The staff structure of the USARV Surgeon’s Office as of 31 December 1969. ¢The staff structure of Headquarters, 44th Medical Brigade as of 31 December 1968. fThe Commanding General of the 44th Medical Brigade was also USARV Surgeon. 8 The 44th Medical Brigade Veterinary Officer was also USARV Veterinarian. hThe 44th Medical Brigade Dietary Staff Advisor performed additional duty as Dietetic Consultant in the USARYV Surgeon’s Office. i The 44th Medical Brigade Dental Surgeon was also USARV Dental Surgeon. i The 44th Medical Brigade Preventive Medicine Officer was also USARV Preventive Medicine Officer. kThe 44th Medical Brigade Chief Nurse was also Chief Nurse, USARV Surgeon’s Office. Sources: (1) Army Medical Service Activities Reports, Office of the Surgeon, Headquarters, United States Army, Vietnam, 1965, 1967, and 1969. (2) Army Medical Service Activities Report, Headquarters, 44th Medical Brigade, 1968. THE MEDICAL COMMAND STRUCTURE 27 cluding an awards program, command maintenance inspections, and supervision of special services activities. Other responsibilities of the brigade commander and his staff were more limited than those of the USARYV surgeon, including in-country medical regulating and the short- term planning of day-to-day operations involving army level medical support. The similarity in functions performed by these two medical staffs produced both advantages and disadvantages. Personnel economies were realized, and the degree of co-ordination between higher and lower head- quarters enhanced, but considerable confusion remained as to the pre- cise staff functions to be performed at each level, especially with respect to operational responsibilites. In addition to the surgeon /brigade commander, the dental surgeon, chief nurse, veterinary officer, preventive medicine officer, entomologist, dietitian, and aviation staff officer sat on both staffs, eliminating several duplicate slots. Further, personnel consultants on the USARV surgeon’s staff now had direct access to medical treatment facilities of the brigade, contributing to improved relations between surgeons and medical com- manders at all levels. The greater ease of co-ordination which these staff- ing arrangements permitted was heightened by the shift in location of brigade headquarters from Tan Son Nhut to Long Binh late in Septem- ber 1967. The proximity of the two headquarters added materially to the freedom of communications between the two staffs. As General Neel, successor to General Collins as USARV surgeon /brigade commander, emphasized, good communications were essential to the success of army level medical service in Vietnam. All forms of co-ordination between the two staffs were not enhanced by the assignment of the medical brigade directly to USARV head- quarters, however. In an attempt to delineate the proper role of S-3, Plans and Operations, the USARV Organization and Functions Manual was amended in December 1968, and the name of the USARV surgeon’s Plans and Operations Division changed to the Plans, Programs, and Analysis Division. That abortive attempt to more precisely describe the division’s functions created more confusion than order, and it reverted to the original designation the following year. In short, under the existing medical structure in Vietnam, no better description of proper staff func- tions could be made on the simple statement: the brigade staff were the operators; the surgeon’s staff, the advisers and long-range planners. Establishment of the U.S. Army Medical Command, Vietnam Duplicative staff functions, the last major area of deficiency in the medical command and control structure in Vietnam, were eliminated in 1970 with the creation of USAMEDCOMYV (U.S. Army Medical Com- 28 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM mand, Vietnam) (Provisional). The previous year had been one of major reorganization, consolidation, and realignment of 44th Medical Brigade units. Headquarters, 55th Medical Group, had been deactivated on 15 June. The 43d Medical Group then assumed command and con- trol over all 55th Medical Group units in II CTZ, but was itself sched- uled for deactivation in the spring of 1970. When Headquarters, 43d Medical Group, was reduced to zero strength, the 67th Medical Group, which had become operational in October 1967 and had assumed com- mand and control over nondivisonal units in I CTZ, became the com- mand and control element for medical units in IT CTZ as well. Through- out, the 68th Medical Group exercised responsibility for nondivisional medical service in III and IV CTZ. Reorganization and consolidation of medical staffs proceeded in tan- dem with that of field units. A review of functions performed by the USARYV surgeon’s office and the 44th Medical Brigade headquarters suggested that, if the two staffs were combined, duplication and overlap could be eliminated. Accordingly, Brigadier General David E. Thomas, MC, USARV surgeon /brigade commander, appointed a study group to determine the feasibility of such a move. A lone admonition guided their study: that the prospective consolidation of staffs and functions result in no loss in the efficiency of medical service in Vietnam. A basic organization and function for the unified medical command was derived from the finding of the study group. The 44th Medical Brigade would be eliminated, with all command and control responsibili- ties absorbed by the medical command. The USARV surgeon would assume the role of Commanding General, USAMEDCOMYV. Similarly, the Deputy Commander, USAMEDCOMYV, would serve as the USARV deputy surgeon. Manpower spaces would be eliminated in the offices of the USAMEDCOMYV dental surgeon and veterinarian, officers who had formerly maintained staffs in both medical headquarters. In total, the study revealed that manpower could be reduced by 17 percent with no loss in functional efficiency through the proposed consolidation of medi- cal staffs. Based on these projected results, the study further recom- mended that, in the future, the dual function concept of the surgeon as commander of the major surbordinate medical unit be retained, and considered on all levels as a method of reducing manpower requirements and achieving the best utilization of all scarce medical resources. On 1 March 1970, Headquarters, 44th Medical Brigade, was consoli- dated with the USARYV surgeon’s office, forming the USAMEDCOMV (Provisional). (Chart 5) That command continues to provide field-army- level medical service throughout Vietnam. Most of the co-ordination and logistics problems associated with the Army medical structure in Viet- nam have been eliminated, and benefits have been achieved through a CHART 5—MEpIcAL COMMAND AND STAFF STRUCTURE, U.S. ARMY, VIETNAM, Joint Chs of Staff x x CINCPAC (PAT COM) x x Ofc of the Surgeon COMUSMACV (MACV HQ) x eec0cee X secon xX eecccsccccced XXXXX XXX XXX XX XXX XXX X. 1 March 1970 Department USAMEDD of Army 1 : Ofc of the USsRPAC Ch Surgeon USARYIS Ofc of the Surgeon ae. es sn od LEGEND : USARV : 1 : Freeeeereeess] Medical Command (1) [fr— 67th Med 68th Med Group Group I 1 Med Units Med Units 1, II CTZ 111, IV CTZ 1 1 1 32 Med 932 Med 9 Med Labs Depot Det (Den) | | 1 1 522 Med 172 Prev 20 Prev Det (Vet) Med Unit Med Unit v xxxxxxx Operational control Command less operational control p === == Logistical support Co-ordination (1) Headquarters Medical Command (Provisional) © CG/USARV I Surgeon 1 Veteri- 1 Dental narian DCG/Deputy Surgeon USARYV Surg 1 1G Chief of Stf Adjutant XO Info Off I ACC fS ACC fS AC fS : . o o 0 ACofS Pers & Plans, In- pom Supply & _ Prof Sves Prev Med Admin tel & Opns Maint Svcs Division Division Rgr & Distr Plans Gen Sup & Medical Prev Med Division Division = Svcs Div Consultant Consultant Pers Mgt Opns |_| Med Sup rs Surgical Prev Med Division Division Division Consultant Officer Morale & Intel & |_| Med Maint NP Sanitary Welfare Scty Div Division Consultant Engineer HQ Det Med Req, Const Rn Nursing Company Rec & Rep Officer Consultant Chaplain Aviation pt Dietetic Stf Off Consultant Commo Chief THE MEDICAL COMMAND STRUCTURE 31 reorganization that has resulted in a medical command structure curi- ously similar to that which prevailed before the buildup of U.S. combat forces. Duplication of efforts in the functional areas of command, includ- ing dental and veterinary control, administration, and plans and oper- ations, has been eliminated. Manpower requirements have been reduced without degrading the efficiency of medical operations. More importantly, the responsiveness and flexibility of the command to changes in medical support requirements have improved, perhaps the ultimate test of the value of Army medical service in the theater of operations. NOTES TO CHART 5 aThe deployment of Medical Groups in Vietnam has continued despite the reduction of zero personnel strength and equipment status of the 43d Medical Group on 7 February 1970. b Support areas in Vietnam are now referred to as Military Regions (MR) rather than Corps Tactical Zones (CTZ). The geographic regions thus specified are similar to, although not identical with, the CTZ’s of earlier years. c¢The staff structure of Headquarters, Medical Command (Provisional) as of 1 March 1970. Sources: (1) Army Medical Service Activities Reports, Office of the Surgeon, Headquarters, United States Army, Vietnam, 1965 and 1969. (2) Operational Report, Lessons Learned of the United States Army Medical Command, Vietnam (Provisional) for Period Ending 30 April 1970, Headquarters, United States Army Medical Command, Vietnam (Provisional), 15 May 1970. CHAPTER II Health of the Command Rates and Trends In Vietnam, as in Korea and in the Asiatic and Pacific theaters in World War II, the cumulative effect of disease was the greatest drain on the strength of the American combat and support effort. Disease admissions accounted for just over two of every three (69 percent) hos- pital admissions in Vietnam in the period 1965-69; battle injuries and wounds, in contrast, were responsible for approximately one of six admis- sions during this period. (Table 1) But the average hospital stay and thus the time lost from duty resulting from combat injury was considerably longer than that resulting from disease. In 1970, however, as a result of the diminution of the American combat role, disease and nonbattle injury accounted for more than half the man-days lost to the Army in that theater. (Table 2) While indicative of the theater’s single greatest cause of morbidity, disease rates for Vietnam revealed encouraging trends when compared to rates for previous conflicts. The average annual disease admission rate for Vietnam (351 per 1,000 per year) was approximately one-third of that for the China-Burma-India and Southwest Pacific theaters in World War II (844 per 1,000 per year and 890 per 1,000 per year, respectively), and more than 40 percent less than the rate for the Korean War (611 per 1,000 per year). (See Table 1.)* One of the most striking achievements of military medicine in Viet- nam was the rapid and effective establishment of a preventive medicine program that blunted the impact of disease on combat operations. In World War II, preventive medicine programs in the Far East did not begin to make inroads upon disease incidence until 1945, a year of transi- tion from war to peace. In Korea the delay was less, but still considerable. In Vietnam, however, effective disease control programs were introduced in 1965, and these were successfully maintained throughout the stress of the troop buildup. (See Table 1.) In addition to minimizing the incidence of disease in American troops, the medical effort in Vietnam had the ancillary benefit in the late 1960’s *Rates are expressed as cases per annum per 1,000 average strength, throughout this chapter. HEALTH OF THE COMMAND 33 TABLE 1.—HosSPITAL ADMISSIONS FOR ALL Causes, U.S. Army, IN THREE Wars: WorLp War II, Korea, AND VIETNAM, BY YEAR [Rate expressed as number of admissions per annum per 1,000 average strength) Non- | Battle Disease as War Year All battle | injury Dis- percent of causes | injury and ease all causes wounds World War II China-Burma-India. ... 1942 1,130 81 3 | 1,046 92 1943 1,081 84 6 991 92 1944 1, 191 96 18 1,077 90 1945 745 80 4 661 90 Southwest Pacific. . .... 1942 1,035 178 25 832 80 1943 1,229 171 12 [1,046 84 1944 1,013 139 34 840 83 1945 990 99 48 843 85 Korea................ 11950 1, 526 242 460 824 61 1951 897 151 170 576 64 1952 592 102 57 433 75 Vietnam. . coo: onvvss me 1965 484 67 62 353 73 1966 547 76 75 396 72 1967 515 69 84 362 70 1968 523 70 120 333 64 1969 459 63 87 309 67 1 July-December only. Sources: (1) World War II: Morbidity and Mortality in the United States Army, 1940-1945. Preliminary Tables Based on Periodic Summary Reports, Office of the Surgeon General, U.S. Army. (2) Korea: Korea, A Summary of Medical Experience, July 1950-December 1952. Reprinted from Health of the Army, January, February, and March 1953, Office of the Surgeon General, U.S. Army. (3) Vietnam: Health of the Army, May 1966, May 1967, May 1968, May 1969, May 1970, Office of the Surgeon General, U.S. Army. of making predictable the parameters of various disease problems at particular points in time. The curves depicting the monthly rates per 1,000 per year of those diseases having greatest impact on military oper- ations reveal that, as the Medical Department effort became established and routinized, the annual rates fell, month by month, very closely to- gether. Thus, the 1968 and 1969 curves for malaria, for example, were almost superimposed upon each other. (Chart 6) Not only was disease being controlled but, if preventive measures were properly implemented, its incidence could be forecast with increasing accuracy, and it therefore became a variable for which the field commander could account in planning combat operations. 479-653 O - 73 - 4 34 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM TABLE 2.—APPROXIMATE NUMBER OF MaN-Days Lost From Dury, By CAUSE, AMONG U.S. ARMY PERSONNEL IN VIETNAM, 1967-70 [Preliminary estimates based on sample tabulations of individual medical records] Cause 1967 1968 1969 1970 Malaria. . ....covueneeninnnennnns 228, 100 215, 400 183, 050 167, 950 Acute respiratory infection. ........ 66, 800 83, 181 63, 530 70, 800 Skin diseases (including derma- tophytosis).............ouinnnn. 66, 400 64, 832 50, 790 80, 140 Neuropsychiatric conditions. . ...... 70, 100 106, 743 125, 280 175, 510 Viral hepatitis. .............oonnnn 80, 700 116, 981 86, 460 85, 840 Diarrheal diseases. ................ 55, 500 60, 132 48, 980 45, 100 Venereal disease (excluding CRO! CABCEY «vv 4 noi i 3 450% § 0 WIFE & § WR ¥ 915 7, 500 6, 840 3,130 3,700 Fever of undetermined origin. ...... 205, 700 289, 700 201, 500 205, 500 Disease total... ............ 780, 800 943, 809 762, 720 834, 540 Battle injury and wounds. ......... 1, 505,200| 2,522,820 | 1,992, 580| 1,044, 750 Other injury. ........covvevinneens 347, 100 415, 140 374, 030 309, 670 1 CRO: Carded for record only. Source: Health of the Command, report submitted to the Deputy Surgeon General, March 1971. Concentration upon prevention did not preclude the aggressive de- velopment of new treatment regimens for old and known problems. In 1965, the average time lost from duty for a patient ill with Plasmodium vivax malaria was 21 days, and for the Plasmodium falciparum malaria patient, 5 weeks. By 1969, P. vivax patients were being returned to duty in 5 to 8 days, and P. falciparum patients in 17 to 19 days. Similarly, in 1966, average time lost from duty for the patient with infectious hepatitis was 49 days; in 1970, it was 35 days. Diseases of major military import for which the incidence in Vietnam exceeded the incidence in the Army as a whole include malaria, viral hepatitis, diarrheal diseases, diseases of the skin, FUO (fever of unde- termined origin), and venereal disease. Venereal disease in Vietnam was most often gonorrhea or other infections of the urinary canal reported under this rubric on clinical grounds alone. It was treated on an out- patient basis and was not a major cause of lost duty time. The other diseases can be divided into two rather general groups: those, such as hepatitis, which affected relatively few men but incapaci- tated them for long periods; and those, like most diarrheal and skin diseases endemic to Vietnam, which incapacitated large numbers of men, HEALTH OF THE COMMAND 35 CHART 6—ADMISSIONS, BY YEAR, To HOSPITAL AND QUARTERS FOR MALARIA IN THREE WARS : WorLD War 11, KOREA, AND VIETNAM [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 200 180 % 160 7 / A 140 7 1 \ 120 \ | ow A WORLD WAR II \ 100 80 7 * * * tN SWPA, WORLD WAR II ° ° 40 toss T oq 3. VIETNAM » ° "eq Soa 20 KOREA 0 WORLD WAR II 1942 1943 1944 1945 KOREA 1950 1951 1952 VIETNAM 1965 1966 1967 1968 1969 Sources: (1) World War II: Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through the Respiratory and Alimentary Tracts. Washington: U.S. Government Printing Office, 1958. (2) Korea: Korea, A Summary of Medical Experience, July 1950-December 1952. Reprinted from Health of the Army, January, February, and March 1953. Office of the Surgeon General, United States Army. (3) Vietnam: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. 36 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM but for relatively short periods. Malaria, and especially the drug-resistant P. falciparum strain, widespread and incapacitating for relatively long periods, combined the least desirable features of each of these categories and was consequently the greatest medicomilitary disease problem in Vietnam. (Table 3) TABLE 3.—SELECTED CAUSES OF ADMISSIONS TO HOSPITAL AND QUARTERS AMmonc Active-Duty U.S. ARMY PERSONNEL IN VIETNAM, 1965-70 [Rate expressed as number of admissions per annum per 1,000 average strength] Cause 1965 | 1966 | 1967 | 1968| 1969| 1970 Wounded in action.................. 61.6 | 74.8| 84.1| 120.4| 87.6| 52.9 Injury (except wounded in action).... 67.2 | 75.7| 69.1| 70.0| 63.9| 59.9 Malaria. .sws sommes mers eames mov 48.5 | 39.0| 30.7| 24.7| 20.8| 22.1 Acute respiratory infections........... 47.1 | 32.5| 33.4| 34.0] 31.0| 38.8 Skin diseases (includes dermatophy- BOIS). weve vee e ee 33.1 | 28.4 | 28.3| 23.2] 18.9| 32.9 Neuropsychiatric conditions. . ........ 11.7 | 122.3 | 10.5| 13.3 | 15.8 | 25.1 Viral hepatitis. «cco ssnmv rs ommrrmnnsy 5.7 4.0 7.0 8.6 6. 4 7.2 Venereal disease (includes CRO 1)... | 277.4 |281.5 {240.5 | 195.8 | 199.5 |222.9 Venereal disease (excludes CRO 1)....| 3.6 3.8 2.6 2.2 1.0 1.4 Fever of undetermined origin......... 42.8 | 57.2 | 56.2 | 56.7 | 57.7 | 72.3 1 CRO: Carded for record only. Source: Health of the Army, May 1966, May 1967, May 1968, May 1969, May 1970, Office of the Surgeon General, U.S. Army. Other diseases were of grave concern to the Medical Department because of their widespread presence in the civilian population with the concomitant threat to American troops or because of their relatively exotic nature. In the first of these categories fell such conditions as plague, tuberculosis, cholera, and rabies. In the second were found such disease problems as melioidosis, Japanese B encephalitis, and amebiasis. These diseases, although constantly monitored for preventive purposes, had no material effect on U.S. fighting strength. Statistics on hospital admissions are not an accurate guide to the ex- tent of high-incidence, short-duration diseases, for often these conditions were treated on an outpatient basis. In 1968, for example, the Ninth In- fantry Division surgeon reported that, after 5 days in the rice paddies of the Mekong Delta region, a battalion’s strength was at one time reduced as much as a third by skin disease; though not fully fit for duty, most of these men were treated as outpatients. Similarly, statistics on diarrheal disease are commonly considered to reflect a small but unknown fraction of noneffectiveness caused by that problem. HEALTH OF THE COMMAND 37 A parallel problem is posed by FUO because of the tendency in the field to report such miscellaneous nonfebrile conditions as headache and backache within this category. One informed observer contends that between one-quarter and one-third of the disease reported as FUO was not in fact febrile illness. Statistics on malaria and infectious hepatitis are firmer because of the more precise nature of the categories and be- cause of the long-term impact of the disease upon the individual patient, although studies reveal that some malaria has been reported as FUO. Experience showed that the acclimatization process had a significant effect on the impact of the high-incidence, short-duration disease prob- lems in Vietnam. Speaking at the 1970 Pacific Command Conference on War Surgery, Brigadier General George J. Hayes, MC, stated: - . . [t]here is a time reference with respect to diarrheal and upper respira- tory disease and fevers of unknown origin. . . . The combination of change in circadian rhythm, climate, and early acquired diarrhea, most certainly of viral origin, lead to about a six week acclimatization period for the troops. After this time the incidence of such disorders in acclimatized troops de- creases to a negligible level. Because of the 12-month rotation policy, unacclimatized troops con- tinually arriving in Vietnam tended to keep the rates for these diseases high. Acclimatization was not only a physical problem but a psychological and cultural one as well, as indicated by the substantial rates of neuro- psychiatric ineffectiveness in the theater, especially during the latter part of the 1965-70 period. Not all replacements, upon entering Vietnam and being assigned to a unit, were able to negotiate the period of psycho- logical adjustment successfully, despite the salutary effect of the 1-year rotation policy. In addition, for the individual soldier, adjustment to the Vietnam environment also involved coming to grips with the use of illicit drugs among his peers. The extent of this problem, the result of which is partially reflected in rising neuropsychiatric rates, is only now being explored. Major Problems Malaria. In Vietnam, the average annual rate of admission to hospital and quarters for malaria (26.7 per 1,000 per year) was about one-third of that for the Southwest Pacific theater (70.3 per 1,000 per year) and one-quarter of that for the China-Burma-India theater (101 per 1,000 per year) in World War II. (See Chart 6, Table 1.) Vietnam rates, however, were higher than those for the Korean War (11.2 per 1,000 per year), principally because P. falciparum malaria was encountered in- frequently during 1950-53, and because primaquine, having just been 38 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM introduced into general use, had not yet induced the development of a drug-resistant strain of the parasite. Over-all rates do not reflect the crippling effect of malaria on Amer- ican strength at the outset of the Vietnam effort. In December 1965, the over-all Army rate in Vietnam reached a peak of 98.4 per 1,000 per year; during that period, rates for certain units operating in the Ia Drang valley were as high as 600 per 1,000 per year, and at least two maneuver battalions were rendered ineffective by malaria. Malaria rates among military personnel in Vietnam were cyclical, reaching their low in February or March and their high in October or November. Rates correlate with climatic conditions, region of operation, and degree of contact with the enemy. (Chart 7) Studies done from 1965 to mid-1967 showed that, in the central highlands, enemy soldiers provided a reservoir for infection by the malaria parasite, especially the P. falciparum strain. The progressive gains of the antimalaria program can be measured by the difference between the peak and bottom monthly rates in each year of the American presence. The smaller the difference, the more effective the program has been in curbing malaria. In 1965, the differ- CHART 7—ApMIssioNs To HosPITAL AND QUARTERS FOR MALARIA AMONG U.S. ARMY PERSONNEL IN VIETNAM, 1965-69 [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 80 \ 75 / 60 \ 7 45 v le. 7 30 $e ° °® . KT . Lo 1968 tr 2 rg? 0 JAN FEB MAR | APR | MAY JUN JuL AUG | SEP ocT Nov | DEC Source: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. HEALTH OF THE COMMAND 39 ence between these two rates was 97.1; in 1969, it was 20.7. Success was also indicated by the down trend, since 1967, in the absolute number of malaria cases, and by the low level at which deaths from malaria have been held: Year Cases Deaths 1965. .............. 1,972 16 1966. . cs ssivissim. 6, 662 14 YOBT . . ini tm mon ns ius 9, 124 11 1968. .............. 8,616 15 1969. .............. 7, 322 10 1970... ...c000m00 5 ue 6,718 12 Much of the success in the fight against malaria was the result of the ongoing preventive medicine program and of findings of Army re- searchers in the field and the laboratory. Advances also were made in the treatment of the disease once it had been incurred, advances which lowered the relapse rate and returned the soldier to duty more quickly. In mid-1966, a multiple treatment regimen consisting of quinine, pyrimethamine, and dapsone was instituted for the initial attack of P. falciparum. Before the addition of dapsone to this regimen, relapse rates averaged 7 to 8 percent; after the change, they were lowered to 2 to 3 percent. Studies done in 1969 and 1970 at the 6th Convalescent Center, however, indicated that, among patients who received this regi- men orally, the relapse rate had increased to about 10 percent. For those re-treated with quinine orally, the relapse rate was 67 percent; with intravenous quinine, 11 percent. These observations suggest that the P. falciparum malaria parasite acquires substantial resistance to quinine, a phenomenon that demands further study. Plasmodium vivax malaria was experienced very rarely in American troops until mid-1967. Since then, largely because of breakdowns in malaria discipline, it has become an increasingly large factor in the problem with this disease in Vietnam. P. vivax infection has been easily treated with a short course of chloroquine followed by primaquine. A further problem with this strain, however, arose with its increasing ap- pearance in the United States in Vietnam returnees, an experience which paralleled that of the American forces in Korea. In 1965, 62 cases of malaria were treated in Army facilities in the United States. In 1970, 2,222 such cases were treated, and this figure is a minimum, neglecting cases that arose in returnees after separation from the service. Eighty percent of these stateside cases of malaria were of the P. vivax variety. This graphically pointed to a failure in the terminal 40 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM prophylaxis program, which, as a result, has received further command emphasis during 1970: Year Cases 1965. ccs 62 1966 _____ 303 1967 ce 2,021 1968... comms 1,598 1969... commie 1, 969 1970... comm mmm 2,222 Hepatitis As with malaria, the average annual infectious hepatitis rate in Viet- nam (6.9 per 1,000 per year) was lower than comparable rates for World War II (SWPA, 27.1 per 1,000 per year; CBI, 9.8 per 1,000 per year), but unlike malaria, Vietnam rates for infectious hepatitis were also lower than those for Korea (7.9 per 1,000 per year). (See Table 1; Chart 8). The hepatitis rate in Vietnam reached a peak in August 1968; CHART 8—ADMISSIONS, BY YEAR, TO HOSPITAL AND QUARTERS FOR Hepatitis IN THREE WARS: WorLD WAR II; KOREA, AND VIETNAM [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 20 15 £2 ~ CBI, : WORLD WAR II 10 ON Na, ” ~8- ° ® ° KOREA >, ° 5 R 2? 4 °, ° 1 ® ® VIETNAM : WORLD WAR II 1942 1943 1944 1945 KOREA 1950 1951 1952 VIETNAM 1965 1966 1967 1968 1969 Sources: (1) World War II: Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washington: U.S. Government Printing Office, 1958. (2) Korea: Korea, A Summary of Medical Experience, July 1950-December 1952. Reprinted from Health of the Army, January, February, and March 1953. Office of the Surgeon General, United States Army. (3) Vietnam: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. HEALTH OF THE COMMAND 41 CHART 9—ApMIssIONs TO HospiTaL AND QUARTERS FOR HEPATITIS AMONG U.S. ARMY PERSONNEL IN VIETNAM, 1965-69 [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 20 10 WA Y 5 nN FH AA L NAA 1965 1966 1967 1968 1969 Source: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. the low rate for the theater, achieved in July 1965, has not been ap- proached since that time. (Chart 9) Unlike statistics for most other dis- ease entities in Vietnam, hepatitis incidence has not shown a downward and stabilizing trend over a period of time. Largely caused by failures in mess and field sanitation and by consumption of nonpotable water and ice available through the local economy, this disease was most commonly acquired by soldiers in their fourth through ninth month in Vietnam. The incidence of hepatitis co-varied with the occurrence of combat opera- tions and with the degree of troop interaction with the civilian populace. Although no specific treatment was available, most patients recovered completely from viral hepatitis with adequate rest and diet. A study at the 6th Convalescent Center reconfirmed Korean War findings that bed rest was not essential after the patient had recovered from the acute phase of this illness. Recently, added attention has been paid to the serum hepatitis prob- lem. Its true extent among American soldiers is unknown because it is masked by over-all hepatitis statistics, but those who ran the greatest risk were men receiving multiple transfusions after battle injury, and those injecting illicit drugs intravenously. Diarrheal Diseases The incidence of that fraction of diarrheal disease severe enough to require hospitalization or assignment to quarters showed a steady down- ward trend between 1965 and 1970. In 1965, the average theater-wide annual rate for this type of disease was 69 per 1,000 per year; in 1969, it was 35 per 1,000 per year. Also during this period, the difference 42 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM between the annual high and low rates was significantly reduced, indicat- ing an improvement in control during periods of peak disease incidence. In 1965, this difference was 55.4; in 1969, it was 18.7. A comparison with World War II experience gives Vietnam diar- rheal disease rates added significance. With respect to the China-Burma- India theater, it was reported that «. . . except for an occasional winter month, monthly rates for diarrheas and dysenteries were never under 100 per 1,000 per year until the fall of 1945.” For both the China- Burma-India and Southwest Pacific theaters, average annual rates, when viewed over a period of time, did not reveal a downward trend as did those for Vietnam ; furthermore, the Vietnam rate was a fraction of the rates for these areas. (Table 4) Accurate comparisons with the Korean experience cannot be made because of differences in the bases for sta- tistics in the two conflicts. Incidence of diarrheal disease peaked in May or June, correspond- ing with the monsoon season, and sometimes reached a secondary peak in October. (Chart 10) Affected most severely were unacclimatized troops and troops under combat conditions. For the latter, disease often stemmed from feces-laden soil being washed into inadequately protected water supplies in the field. Any one of a host of viral, bacterial, or parasitic agents caused diar- rhea in Vietnam; an exact etiology could not be identified in most instances. When specific agents were identified, excellent therapy was readily available. The average hospital stay for a patient with a diarrheal problem was 5%2 days. TapLe 4.—INcDENCE RATE OF DIARRHEAL DISEASE AMONG U.S. ArRMy PERSONNEL IN WORLD WAR II AND IN VIETNAM, BY YEAR [Rate expressed as number of cases per annum per 1,000 average strength] World War II Vietnam China-Burma- Southwest India Pacific Year Year Rate Rate Rate 1942... oii 123 59 1965... . vis vain v5 wry 69 1048. oo s wivis » wins wine o 146 70 1966. . « vo » wii # § Hit 48 19%. ...0nisnmmss muy 181 55 1967... ccvviennnnn 49 1045... « cove vx mi v4 638 4 4 93 74 VOB... 4 wie 3 min» # women 43 1969. . isvwisnvasaws 35 Sources: (1) World War II: Morbidity and Mortality in the United States Army, 1940-45. Preliminary Table Based on Periodic Summary Reports, Office of the Surgeon General, U.S. Army. (2) Vietnam: Health of the Army, May 1966, May 1967, May 1968, May 1969, May 1970, Office of the Surgeon General, U.S. Army. HEALTH OF THE COMMAND 43 CHART 10—AbDMIssIONS TO HospiTAL AND QUARTERS FOR DIARRHEAL Disease Among U.S. ARMY PERSONNEL IN VIETNAM, 1965-69 [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 105 90 75 60 45 30 15 0 1 1 1 1 1 1 | 1 1 ] z om © x > z = o a = > oO < a < = > > w oO o w = io s < s a 2 z ® o z a Source: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. It is notable that cholera, the most feared of diarrheal diseases, has not been a military problem in Vietnam, though it is endemic in the civilian population. Immunization against typhoid fever, however, has not been so effective; 25 Army cases have occurred in the theater, 13 of these in 1970. Diseases of the Skin Rates of incidence of skin disease severe enough to require hospital- ization or admission to quarters in Vietnam varied around the 30 per 1,000 per year level until 1968, when the institution of a prophylactic program resulted in a dramatic drop to the 20 per 1,000 per year level. (See Table 3.) Figures for 1970, however, indicate a resurgence of this problem to heights comparable to those of 1965. This rise is, as yet, unexplained. No adequate statistics exist for the comparison of dermatological problems in Vietnam with those of World War II and Korea. As pre- viously noted, hospital statistics provide minimum figures only in this 44 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM area of disease; dermatological problems have been severely debilitating in units operating in flooded areas of Vietnam. The three major skin disease problems in Vietnam have been super- ficial fungal infection (dermatophytosis), bacterial infection, and im- mersion foot. Disease is probably due to the interaction of four factors: changes brought about in the resistance of the skin to infection because of prolonged exposure to contaminated water; damage to the skin by trauma and friction generated by wearing boots and socks; presence of the etiological organisms in the watery environment; and increased tem- perature of the tropical environment. Susceptibility to dermatological diseases increased with time in combat, peaking at the 10th month, although some individuals had inherent immunity. Black troops proved to be less susceptible than white troops. The keynote in dealing with the militarily important dermatological diseases in Vietnam was prevention. Immersion foot was treated through the use of a drying-out period, and the others through the therapeutic use of griseofulvin-V, broadscope antibiotics, and a variety of topical treatments. Melioidosis Melioidosis, one of the more exotic medical problems encountered by U.S. troops in Vietnam, is an infectious disease caused by Pseudo- monas pseudomalli, a common bacterium of Southeast Asia that has been cultured from soil, market fruits and vegetables, well water, and surface water. The source of the infection is not fully known, nor has man-to-man transference been observed. In humans, melioidosis is manifest in one of three ways: by acute lung infection, by overwhelming systemic infection, or by localized abscess. The unfamiliarity of American physicians with this disease and their concomitant failure to diagnose and treat it properly in all but the most severe cases are shown in the low rate and high fatality incidence in 1966: Year Cases Deaths O83: cs csamirimmeny 6 0 1966. .............. 29 8 1967... t. 50 3 1968... vu ssomisss 56 1 1969. ccivnniennnion 46 1 YOT0. «+ cvie iw 8 50 43 1 Although multiple antibiotics were initially used to treat melioidosis, it has become clear over time that tetracycline alone was the drug of choice. Since 1967, most patients have been treated and returned to duty in Vietnam. Patients evacuated from Vietnam or found to have HEALTH OF THE COMMAND 45 the disease after departing were referred to Valley Forge General Hos- pital, Phoenixville, Pa., or Fitzsimons General Hospital, Denver, Colo., both designated by The Surgeon General as melioidosis treatment centers. Neuropsychiatric Problems Psychosis and neurosis. Until 1968, the neuropsychiatric disease rate in Vietnam remainded roughly stable and parallel with that for the rest of the Army. In that year, however, Army-wide rates began to increase, and rates in Vietnam increased more precipitously than in any other location where substantial numbers of American troops were serving. (Table 5, Chart 11) Rising rates showed increases in all areas of psychiatric illness: psychosis, psychoneurosis, character and behavior disorders, for example. CHART 11—ApMIssioNs To HospPiTaL AND QUARTERS FOR NEUROPSYCHI- ATrRIC CONDITIONS (Psychotic, PSYCHONEUROTIC, AND CHARACTER AND Benavior Disorpers) Amonc U.S. ArRMY PERSONNEL IN VIETNAM, 1965-69 [Rate expressed as number of admissions per annum per 1,000 average strength] Rate 15 A A A AM nN UJ "Y 1965 1966 1967 1968 1969 Source: Health of the Army, May 1966, May 1967, May 1968, May 1969, and May 1970. Office of the Surgeon General, United States Army. The extent of the problem is evident from several statistical indices. Rates for admission to hospital and quarters for neuropsychiatric cases in Vietnam more than doubled between 1965 (11.7 per 1,000 per year) and 1970 (25.1 per 1,000 per year). (See Table 3.) In terms of esti- mated man-days lost, neuropsychiatric conditions were the second lead- ing disease problem in the theater in 1970; the 175,510 figure for that year is more than twice as high as the estimate for 1967 (70,000), re- flecting a steady increase over the 1967-70 period. (See Table 2.) Statistics in this area are not comparable with those for World War IT and Korea because of differences in diagnostic standards and cate- gories, but it is notable that, unlike the case for World War II, in Viet- TasLe 5.—INcDENCE RATE oF PsycmiaTric Conprrions, Army-WibE, 1965-70 [Rate expressed as number of cases per annum per 1,000 average strength] T otal psychiatric conditions Psychosis Psychoneurosis Year Army- Army- Army- wide |CONUS|USAREUR|RVN|| wide USAREUR| RVN|| wide | CONUS|USAREUR |RVN 1965... . 0 vs svi sa mwie om 9.1 9.1 7.7 .8 || 1.4 1.6 0.7| 1.6 1.6 1.5 1.0 2.3 1966. . ons snus sine sss 10. 3 10.8 7.3 |11.6 1.7 2.1 0.8 1.4 1.9 2.0 1.0 2.5 1967. iii 9.7 9.5 82| 9.8 1.6 1.8 0.9| 1.7 1.7 1.9 1.0 1.3 1968; ; ovis 2 5 mie « 3 iw 3 wove 10.3 9.9 7.9 112.7 1.8 1.9 0.9| 1.8 1:9 1.9 }.2 2.2 1969. . ons vs min v3 mim v ve 5 11.3 10. 4 7.8 [15.1 2.6 2.4 1.6 3.4 1.7 1.6 1.5 1.9 1970... 15. 4 12.5 9.7 (24.0 i 3.2 2.4] 3.8 2.3 1.9 1.8 3.3 Character and behavior disorders Other psychiatric conditions Year Army-wide CONUS USAREUR Army-wide | CONUS USAREUR RVN 1965... : 00003 wun «2 wie A 2.3 2.0 2.2 3.1 3.8 4.0 3.8 3.8 1966. ....covvvvienn 2.5 2.4 2.2 2.8 4.2 4.3 3.3 4.9 1967... .ccovviiiied 2.4 2.1 2.2 2.9 4.0 3.7 4.1 3.9 1968... .onvecamessmnnsd 2.3 1.8 1.8 3.7 4.3 4.3 4.0 5.0 1969... .0050 0000 cr wninsd 2.4 1.8 1.6 4.2 4.6 4.6 3.1 5.6 19701... . inns nnmihs 3.7 1.7 1.9 8.4 6.1 5.7 3.6 8.5 1 January-September only. Source: Morbidity Report, RCS MED-78. Sb WVNLIIA NI AWYV 'S'Q FHL 40 1d0ddNS TVOIAIN HEALTH OF THE COMMAND 47 nam the incidence of neuropsychiatric admissions did not co-vary with the incidence of combat injury. Rather, neuropsychiatric rates rose de- spite the diminishing combat role in that country in 1969 and 1970. Several hypotheses have been offered to explain these rising rates in the Army in general and in Vietnam in particular. It has been sug- gested, for example, that increased drug abuse has been reflected in increased rates of psychosis, rates which include toxic ( drug-induced) psychosis. For Vietnam, it has also been suggested that identity with another peer group, such as one based upon race, political affiliation, or drug use, at the unit level has threatened the integrity of the squad as the sole reference point for the soldier in combat. This tendency in turn resulted in rising neuropsychiatric rates among individuals who, presented with alternatives, lack the certainty in the stress of combat that confidence in the squad gave the World War II infantryman. These and other hypotheses are currently under study. In providing psychiatric support for combat troops, the practice in Vietnam was to offer aid as close to the unit as possible, relying upon the social worker and enlisted clinical specialist, and upon three basic tools: rest, sedation, and supportive psychotherapy. Guidelines indicated that hospitalization was to be avoided except when the patient was dangerous to himself or others or mentally ill. Hospitalization for simple drunken- ness, for sociopathological individuals, or for administrative conven- ience was forbidden by regulation. This adds significance to the rising statistics cited previously. Drug abuse. One of the unique problems that faced the Medical De- partment in Vietnam was the drug milieu into which the American soldier was immersed, both on and off duty, upon arrival in the theater. The growth of illicit drug use within the Army kept pace with that in the larger society, but the ready availability of marijuana, barbiturates, amphetamines, heroin, opium, and other substances in Vietnam, at a lower price for a less adulterated product than that available in the United States, exacerbated the problem. Comprehensive statistics are not available, but preliminary work based upon sample surveys of soldiers entering and leaving the combat zone indicates that illegal drug use is widespread, especially among younger, lower ranking enlisted men, and that many individuals started using drugs while in Vietnam. One study, done in 1969 at the Cam Ranh Bay replacement depot by Captain Morris Stanton, MC, reported that, of a population of 994 outgoing enlisted men, 53.2 percent had tried marijuana sometime in their lives, 21.5 percent for the first time in Vietnam. The same study reported that the use of opium among the soldiers sampled nearly tripled during their stay in Vietnam, rising from 6.3 percent to 17.4 percent. 48 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Growing command awareness of the nature and extent of the drug problem in Vietnam led to a search for a flexible, nonpunitive response that would encourage drug users to seek professional help in solving their problems, thus aiding them and, at the same time, serve the Army’s interest in conserving the fighting strength. This search resulted in a two- fold program in Vietnam. At the first level the program was educational, bringing information about the problem to key commissioned and non- commissioned officers so that they could deal intelligently with it, and provide believable advice about drug abuse to the troops in Vietnam. The latter task was the more difficult because conflicting information available in all sectors of American society about the dangers of mari- juana and the linking of its use with other drug problems led to a state of incredulity among American troops. This credibility gap was partially overcome through the use of ex-addicts in information programs, through the realistic redirection of the efforts of the Armed Forces Radio, and through an attempt to dispense factual data personally through medical channels. But informational activities were directed at men who had not yet become deeply involved with drugs. For others less fortunate, the experi- mental institution of an amnesty program in the 4th Infantry Division in 1968 attracted wide attention as a promising attempt to deal with the problem. The program provided that a soldier who voluntarily presented himself as a drug user to his commanding officer, chaplain, or unit sur- geon, would not be punished merely for admitting to the use of drugs, if this use had not previously come to the attention of the command. The drug user who voluntarily sought assistance was aided through limited hospitalization to determine the nature and extent of his addiction; through extensive psychiatric and other counseling, including group therapy when possible; and through assignment of a “buddy” to give him positive reinforcement in his effort to give up drugs. During the period of counseling and rehabilitation, the patient continued, as much as possible, to perform full military duties. The 4th Infantry Division’s program was adopted throughout the Army in December 1970. CHAPTER III Care of the Wounded* Excellence of Medical Care Factors in Low Morbidity and Mortality The excellence of care of the wounded in Vietnam was the result of a combination of factors: rapid evacuation of the casualty, ready avail- ability of whole blood, well-established forward hospitals, advanced sur- gical techniques, and improved medical management. From the standpoint of methods used to wound—mines, high- velocity missiles, and boobytraps—as well as the locale in which many were injured—in paddy fields or along waterways where human and animal excreta were common—Vietnam was quite a “dirty” war. Yet helicopters were able to evacuate most casualties to medical facilities before a serious wound could become worse. There were practically no conditions under which the injured was denied timely evacuation; weather, terrain, time of day, enemy contact, all were surmounted by the capabilities of the air ambulances and the skill of their crews. The use of whole blood, occasionally even before the arrival of an air ambulance, contributed to the low mortality rate in Vietnam by better preparing the wounded for evacuation. Blood packaged in styro- foam containers which permitted storage for 48 to 72 hours in the field could be placed in the forward area in anticipation of casualties. This was a marked increase in the utilization of whole blood, since virtually none was used at the division level in World War II. Stocks of blood, drawn from PACOM (Pacific Command) in the early years and later *This chapter, involved with statistical analysis of World War II, Korea, and Vietnam as indices of the quality of care of the wounded, is subject to all the handi- caps of comparison. Reporting procedures have changed over the last 25 years, and the most recent reports included more individuals through the increased scope and efficiency of the data collecting system; moreover, some information gathered for Vietnam had no true counterpart in the previous conflicts. Yet another problem is semantics: “hospitals” is different from “all medical treatment facilities,” which presents the danger of “comparing” what is actually two different populations. Con- cern with these problems is highly justified, and any reader must view comparisons merely as illustration of trends, not as absolute fact. While the figures will change as more complete information becomes available, the basic fact which they illuminate will not—the care of the wounded in Vietnam has been superior to that given in combat anywhere at anytime. 479-653 O - 73 - 5 50 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM largely from CONUS (continental United States), were always sufficient. The relative stability of forward hospitals in Vietnam made possible the use of sophisticated equipment. Air conditioning to counter the ex- treme heat, dust, and humidity allowed better control of the environment of the wounded before, during, and after surgery, and was necessary for the proper functioning of the highly sensitive equipment. Commenting on hospital apparatus, the USARV neurosurgical consultant, Lieutenant Colonel Robert C. Leaver, MC, stated, “The traditional equipment seen in neurosurgical centers throughout the United States is available, i.e., respirators, Stryker frames, and hypothermia units. Other than the physi- cal deficiencies of a hospital in a combat area, there is little that would distinguish our neurosurgical wards from those in hospitals in America.” Surgical technique as practiced in Vietnam was certainly as advanced as the state of the art in general, and perhaps more so in the realm of trauma. Contrary to traditional procedure, surgeons in Vietnam redis- covered that wounds (except cranial and facial, and some hand in- juries) responded better to a delayed closure which permitted necessary drainage. Management of severe liver injury was a real therapeutic chal- lenge since massive transfusion, control of relatively inaccessible bleeding, and removal of large portions of liver substance were often required. Surgeons performed complex operations daily and routinely in all hos- pitals, not just selected ones in the rear. Vascular surgery, sporadic in Korea, was commonplace in Vietnam, and surgeons became so adept that not only thoracic but also general and orthopedic surgeons routinely performed repairs. The high level of skill was maintained despite the turnover of medical officers. Since surgeons arriving in Vietnam were not adequately pre- pared by their background in civil trauma to treat combat casualties, they were attached to experienced teams for orientation and learned technique in the operating room. Improved medical management of the casualty contributed to the quality care. Surgery itself had become a part of the continuing process of resuscitation and a weapon in the struggle against shock. The team approach, in which surgeons of a variety of specialties operated together, also proved highly effective; a “team” for head injuries, for example, included a neurosurgeon, ophthalmologist, oral surgeon, otolaryngologist, and plastic surgeon. If the casualty had multiple injuries, more than one surgical team operated simultaneously. Survival Statistics Between January 1965 and December 1970, 133,447 wounded were admitted to medical treatment facilities in Vietnam; 97,659 of these were admitted to hospitals. The hospital mortality rate for this period was 2.6 CARE OF THE WOUNDED 51 A WOUNDED AMERICAN SOLDIER RECEIVES IMMEDIATE TREATMENT upon arrival at a MUST field hospital in Vietnam. percent, compared to 4.5 percent in World War II and 2.5 percent in Korea. The very slight increase in hospital mortality in Vietnam over that in Korea was a result of rapid helicopter evacuation which brought into the hospital mortally wounded patients who, with earlier, slower means of evacuation, would have died en route and would have been recorded as KIA (killed in action). Assuming that most of those patients who died within the first 24 hours in hospitals belong in this class, the rate would be much closer to 1 percent. Actually, it is further testimony to the high quality of medical care provided in Vietnam where even though mortally wounded casualties arrived at Army hospitals, the mortality rate was only marginally greater than in Korea. Perhaps a better index of the effectiveness of medical treatment was the ratio of deaths to deaths plus surviving wounded (or “deaths as a percent of hits”). For World War II, it was 29.3 percent; Korea, 26.3 percent; and Vietnam, 19.0 percent. The ratio of KIA to WIA (wounded in action) was as follows: World War II, 1:3.1; Korea, 1:4.1; Vietnam, 1:56. 52 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Patient Care Indices Since the task of the combat physician is to salvage as much limb or function as possible, and the goal of the Medical Department is the salvage of lives, it is proper that the accomplishments of the Medical Department mission in Vietnam be measured in terms of lives recovered rather than numbers lost. The bed occupancy rate in Vietnam ran approximately 60 percent, and that in offshore facilities about 50 percent, which allowed ample flex- ibility to respond to fluctuating casualty rates and remain capable of providing optimum medical care. The average length of stay per case for patients in Vietnam was considerably below that of both earlier conflicts: Days World War II... 80 Korean War .... 75 Vietnam*. ...... 63 *Through July 1967. This reduction of approximately 20 percent reflected the advances in wound management and patient care. Of the 194,716 wounded in Vietnam (January 1965-December 1970), 61,269 (31 percent) were treated and returned to duty immedi- ately. Of those admitted to treatment facilities, the distribution was as follows: 42.1 percent returned to duty in RVN 7.6 percent returned to duty in PACOM 33.4 percent returned to duty in CONUS 2.7 percent-still hospitalized, 31 December 1970 14.2 percent other dispositions (died; transferred to Veterans’ Administration hospital; discharged; and so forth) Two to three percent of the hospitalized wounded in Vietnam had significant vascular injuries, and the amputation rate for those with major arterial injury was about 13 percent. This rate was approximately the same as that for Korea, and markedly less than the 49 percent rate for World War II. The approach was for maximum conservation of stump length which, in conjunction with developments in prosthetic manu- facture, decreased morbidity and length of hospitalization among ortho- pedic patients. Nature of Wounds The lethality of modern weapons directly affected the work of the medical personnel who attempted to undo the damage. While one must CARE OF THE WOUNDED 53 be wary of dubbing things “new,” certainly the problems which medical Y g things y the'p personnel in Vietnam encountered were more complicated than before. Mechanics of Wounding High-velocity, lightweight rounds from M16/AK47-type weapons have greater kinetic energy and leave larger temporary and permanent cavities and more severe tissue damage than do low-velocity projectiles, and their easy deflection by foliage resulted in tumbling and spinning and the generation of even larger entrance wounds. Moreover, blood vessels not in the direct path of the missile were affected. The bullet usually disintegrated and was rarely found whole even when an exit wound was absent. These rapid fire weapons increased the chances of multiple wounding, which complicated resuscitation and treatment. The claymore mine received its first field trials by both sides in Vietnam. The intensity of peppering and velocity of the fragments often resulted in deep penetration in a number of sites. The extensive use of mines and boobytraps in Vietnam created a serious medical problem: the proximity of the blast caused severe local destruction, and tremendous amounts of dirt, debris, and secondary missiles were hurled into the wound. Massive contamination challenged the surgeon to choose between radical excision of potentially salvageable tissue and a more conservative approach which might leave a source of infection. Causative Agents The data on the physical agents which caused wounds and deaths reflect the nature of the combat. Much higher proportions of the casual- ties were caused by small arms fire, and by boobytraps and mines, than in Korea or World War II, and much lower percentages were caused by artillery and other explosive projectile fragments. This relationship gen- erally was more pronounced among the fatalities than among the wounded. (Table 6) Statistics compiled at different times in the Vietnam conflict mirrored the shift in combat from the defensive to the offensive. In 1965, U.S. forces were most concerned with establishing and defending their bases, and only in 1966 did they launch operations to check the enemy offen- sive. By 1968, troops were usually engaging the enemy in his defensive positions. Wounding from small arms fire decreased from 42.7 percent in June 1966 to 16 percent in June 1970, while the percentage from fragments (including mines and boobytraps) rose from 49.6 percent in 1966 to 80 percent in 1970. 54 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM TaBLE 6.—PERCENT OF DEATHS AND WOUNDS ACCORDING TO AGENT, U.S. ARMY, IN THREE WARS: WORLD WAR II, KOREA, AND VIETNAM Deaths Wounds Agent World | Korea | Viet- | World | Korea | Viet- War II nam ! | War II nam ! Small arms. ive ss ems 32 33 51 20 27 16 Fragments...........coneess 53 59 36 62 61 65 Booby traps, mines........... 3 4 11 4 4 15 Punjistakes. ........oooeennefeneneeadoneneforeiiihniifan 2 Other. ....oveneeieanennn. 12 4 2 14 | 8 | 2 1 January 1965—June 1970. Source: Statistical Data on Army Troops Wounded in Vietnam, January 1965-June 1970, Medical Statistics Agency, Office of the Surgeon General, U.S. Army. Anatomical Location of Wounds The rapid fire weapons of the enemy resulted in a significant increase over World War II and Korea in the percentages of multiple wounds among the distribution of wounds by site. (Table 7) Small arms fire caused approximately two-thirds of the wounds of the head and neck, and three-fourths of the trunk wounds; fragments accounted for the remainder. Fragments and small arms contributed fairly equally to wounds of the extremities. The distribution of fatal wounds by location differed from that for total wounds since some areas were much more likely to involve mortal Tae 7.—LocaTion oF Wounps IN HospiTALIZED CASUALTIES, BY Percent, U.S. Army, IN THRee Wars: WorLp WAR II, KOREA, AND VIETNAM Anatomical location World War II Korea Viétnam 1 Head and neck. .................. 17 17 14 Thorax. ....ovouemeneenenenennanns 7 7 7 ADAOIREN. oo 53 ive #5 win 02% ®w0n 5 vines» 8 7 5 Upper extremities. ................. 25 30 18 Lower extremities. ................. 40 37 36 Other Sites. ....vvovnerneenennnnn 3 2 220 1 For a 24-month period. 2 Including multiple wounds. Source: Statistical Data on Army Troops Wounded in Vietnam, January 1965— June 1970, Medical Statistics Agency, Office of the Surgeon General, U.S. Army. CARE OF THE WOUNDED 35 injuries than others. Thus the 14 percent of the wounds located in the head and neck region accounted for 39 percent of the fatalities. This was followed by 19.3 percent fatal wounds in the thorax; 17.9 percent, abdo- men; 16.1 percent, multiple sites; 6.8 percent, lower extremities; and 0.9 percent, upper extremities. Twenty to thirty percent of the penetrating head wounds brought in from the field in Vietnam were classed as “expectant” cases, and little could have been done for them; however, the mortality rate for the others was rather low because of early evacua- tion, extensive use of blood, and the presence of fully trained neuro- surgeons in the combat zone. Most of the abdominal fatalities were from extensive liver destruction or multiple organ involvement. Certainly the data on relative lethality of wounds and the distribution by causative agent showed the advantage of wearing properly designed body armor. Had helmets been worn, they would have proved very effective against fragments, although little could be done in the event of a direct hit by a small arms round. To quote Lieutenant Colonel (later Colonel) William M. Hammon, MC: “If our combat troops . . . were to wear the helmet, we believe that about 1/4 fewer significant combat casualties would need to be admitted to a neurosurgical center here in Vietnam.” Flak vests did prove effective against three-fourths of the fragments which struck the thorax, thereby increasing the percentage of gunshot wounds to other areas of the body to 75 percent of chest wounds. Troops in static positions, or in air or ground vehicles, usually wore both helmets and flak vests, but soldiers on the move found the body armor too heavy and too hot. Some commanders (and some individuals regardless of the command decision) decided to forego the protection rather than accept the reduction in mission capability and the increase in heat casualties. Specific Advances The continuous thrust of the U.S. Army Medical Department in combat surgery is on the development of better procedures and ancillary techniques for the care of the wounded. In Vietnam, concern centered on the areas of anesthesia, blood and plasma expanders, treatment of burns, wound healing, shock, and surgical routine. Anesthesia Most surgery in Vietnam hospitals was done under a general anesthetic, usually thiopental induction and maintenance with halothane, nitrous oxide, and oxygen. Most anesthesiologists favored halothane, with its rapid action, ease of administration, nonflammability and applicability 56 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM to all cases; also, it did not produce nausea and did not mask critical drops in blood volume. Local anesthetics were used only for very minor wounds and a few delayed primary closures. Employment of spinal anesthesia was very limited. The emphasis continued on development of safe, simplified methods of portable inhalation anesthesia. New concepts for assisting the breathing of the critically injured were also developed to meet Vietnam requirements. Prolonged mechanical support was necessary in some cases to minimize oxygen deficiency, and while respirators were ordinarily used, the possibility existed that harm- ful bacteria might be introduced since proper sterilization was not always feasible under combat conditions. New respiratory assistance devices, eliminating or reducing that potentiality, were tested. Blood and Plasma Expanders Frequently transfusions of whole blood were initiated long before the casualty reached a facility with the capacity for cross-matching blood, and in these cases, type O low titer blood was used. As a rule, any patient who had received four or more units of type O low titer was continued on this type, while those with less than four were matched at the hospital. Massive transfusions (one surviving patient had received 92 units), although lifesaving, presented problems of their own. A tendency toward bleeding appeared after multiple transfusions, but it was found that fresh frozen plasma or, if possible, freshly drawn blood could control the con- dition. Also, the patient whose body temperature dropped as a result of extensive transfusion became a serious problem. Two evacuation hos- pitals utilized microwave ovens to warm the whole unit of blood in seconds to counter this condition. Burns The most unfortunate aspect of the burn injuries incurred in Vietnam was that more than half were accidental and therefore preventable. Burns associated with enemy fire, while fewer in number, accounted for almost 70 percent of the fatalities because of their severity and associated wounds. A factor in the high mortality was that most combat burns occurred in an enclosed space, such as an armored personnel carrier or a bunker, and were, therefore, complicated by inhalation injuries. Burn cases were stabilized in-country and then evacuated to the 106th General Hospital in Japan, where a special burn unit had been estab- lished. Of the burns treated by the 106th, 27 percent returned to duty, 66 percent were evacuated to the burn unit at Brooke Army Medical Center, Fort Sam Houston, Tex., and 7 percent died. CARE OF THE WOUNDED 57 Sulfamylon ointment was employed to prevent infection. If evacua- tion to Japan was delayed more than 48 hours, treatment was initiated in Vietnam. Since the standard treatment of phosphorus burns with copper sulfate solution was found to be toxic in itself, their management became even more difficult and debridement of the wound grew more important. Wound Healing The Surgical Research Team, WRAIR (Walter Reed Army Institute of Research), tested in Vietnam several experimental items developed to aid wound healing. An antibiotic preparation, packaged as an aerosol, was distributed to aidmen in various tactical units. Immediate use on an open wound acted to retard bacteria growth, and resulted in decreased morbidity, Tissue adhesives which had low toxicity, degraded relatively rapidly, and spread well proved valuable in surgery on the lung, kidneys, and liver. The Surgical Research Team utilized them with excellent results as early as 1968. Shock Shock was a killer which was checked somewhat by the rapid evacua- tion system and the whole blood available to the wounded in Vietnam. Yet even so, mortality rates were increased by a postoperative pulmonary complication known as shock lung or wet lung where the lung or thorax had been traumatized. By the time the condition could be detected by X-ray, it was usually too advanced to respond to treatment. However, after extensive investigation, Colonel James P. Geiger, MC, surgical con- sultant from June 1969 to June 1970, identified the mechanics of the problem and demonstrated that the complication could be forestalled by the use of diuretics in those likely to be so afflicted. This treatment signifi- cantly reduced the morbidity and mortality in the syndrome. Surgical Routine An outstanding feature of medical service in Vietnam was the quality and extent of care given in the battle area. Any type of medical or surgi- cal specialist was available in the combat zone. For example, by the spring of 1968, there were 10 neurosurgeons at five Army hospitals, supervised by a board-certified neurosurgeon. Sophisticated operations were handled as a matter of routine. Lapa- rotomies were done “on suspicion” (which proved positive in about 25 percent of the cases) in a zone where heretofore there was a degree of reluctance to operate even when abdominal penetration was certain. Primary repairs were performed on veins which had simply been ligated in earlier conflicts, and fasciotomy, cutting the tissue sheathing the 58 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM muscles and reducing pressure on the muscles, was not uncommon. In a few instances, limb salvage was possible by constructing an extra ana- tomic bypass, tunneling a graft through a new route around the area, until the wound healed and a permanent vascular graft could be inserted. The expert surgeon, supported by a skilled medical team and well- equipped facilities, provided a quality of care superior to that in any previous conflict. CHAPTER IV Hospitalization and Evacuation The peculiar nature of counterinsurgency operations in Vietnam re- quired modification of the usual concepts of hospital usage in a combat area. There was no “front” in the tradition of World War II. The Army checkered the countryside with base camps. Although any one of these might become a battlefield, the base camp was relatively secure unless it was under attack. Semipermanent, air-conditioned, fully equipped hospitals were constructed at a number of these camps. In contrast to World War II and the Korean War, the hospital did not follow the advancing army in direct support of tactical operations. All Army hos- pitals in Vietnam, including the MUST (Medical Unit, Self-contained, Transportable) units, were fixed installations with area support missions. Since there was no secure road network in the combat area of Vietnam, surface evacuation of the wounded was almost impossible. Use of the five separate companies and five detachments of ground ambulances sent to Vietnam was limited largely to such functions at base camps as transportation between the landing strip and the hospital or the routine transfer of patients between neighboring hospitals when roads were secure. Air evacuation of the injured became routine. Getting the casualty and the physician together as soon as possible is the keystone of the practice of combat medicine. The helicopter achieved this goal as never before. Of equal importance was that the Medical Department was getting the two together in a hospital environment equipped to meet almost any situation. The degree of sophistication of medical equipment and facilities everywhere in Vietnam permitted Army physicians to make full use of their training and capability. As a result, the care that was available in Army hospitals in Vietnam was far better than any that had ever been generally available for combat support. The technical development of the helicopter ambulance, a primitive version of which had been used to a limited extent in the Korean War, the growth of a solid body of doctrine on air evacuation procedures, and the skill, ingenuity, and courage of the aircraft crewmen and medical aidmen who put theory into practice in a hostile and dangerous environment made possible the hospitalization and evacuation system that evolved in Vietnam. The system worked effectively because it was compatible with the characteristics of warfare in that country. 60 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Hospitalization Until April 1965, the 8th Field Hospital at Nha Trang with a 100- bed capacity was the only U.S. Army hospital in Vietnam. Housed in fixed semipermanent quarters, the 8th Field was fitted with a combina- tion of field and “stateside” equipment and operated in a manner similar to a station hospital. Attached to it were four medical detachments which provided specialty care but were totally dependent on the hospital for administrative and logistical support. In October 1963, the Navy opened a dispensary in Saigon which removed that city, as well as III and IV CTZ’s to the south, from the hospitalization responsibility of the 8th Field Hospital. It remained re- sponsible only for the large area encompassed by II CTZ. Because of the limited number of Army hospital beds in Vietnam to support the buildup of U.S. combat forces in 1965, a variable 15- to 30-day evacuation policy was established by the Surgeon, USMACV. By mid-1966, the number of beds had increased sufficiently to permit a change to a 30-day policy. Patients who could be treated and returned to duty within 30 days were retained in Vietnam; patients requiring hospitalization for a longer period were evacuated out-of-country as soon as their medical condition permitted. In the development of the medical troop list, the length of the evacua- tion policy did not weigh as heavily as the patient treatment capability required in-country. Among the factors which affected the normal book planning of allocations were the lack of data on the number and types of foreseeable casualties in counterinsurgency operations, the insecure ground lines of communication, and the wide separation of secure base areas. No single factor had as great an influence in determining the number of hospital beds required as the policy approved by USMACV to keep 40 percent of the operational beds available to support un- expected surges in the casualty flow resulting from hostile actions. The occupancy rate exceeded 60 percent on two occasions: during May 1967 when it briefly approached 67 percent, and for a 24-hour period during the Tet Offensive in February 1968, when it again increased to more than 65 percent. Between April 1965 when the 3d Field Hospital arrived in Saigon and December of that year, two surgical hospitals, two evacuation hos- pitals, and several numbered field hospital units, which were initially co- located with the 8th Field Hospital in Nha Trang and the 3d Field Hospital in Saigon, were deployed to Vietnam. By the end of 1965, the total number of hospital beds in-country had increased to 1,627. Throughout 1965, separate clearing companies were at times used interchangeably with hospitals. Augmented by specialty teams, platoons HOSPITALIZATION AND EVACUATION 61 of these companies often preceded or supplanted hospitals, providing limited care within an area until more adequately staffed and equipped units arrived. Field-army-level clearing units were also used to augment hospitals and provide additional bed space. Dispensaries sometimes sup- plemented the resources of major hospitals and at other times provided outpatient service in remote areas. The deployment of additional hospitals to Vietnam continued throughout 1966 and 1967. During 1966 and 1967, four surgical hos- pitals, six evacuation hospitals, and another hospital unit of a field hos- pital arrived in-country. The 6th Convalescent Center was established at Cam Ranh Bay. The buildup of medical units was completed in 1968 with the arrival of one surgical hospital, three evacuation hospitals, and additional field hospital units, as well as 11 Reserve and National Guard medical units. The 312th Evacuation Hospital, the largest Reserve medical unit sent to Vietnam, arrived in September 1968, and occupied a facility the 2d Surgical Hospital had operated at Chu Lai. By December 1968, there were 5,283 Army hospital beds in Vietnam at facilities located through- out the four corps tactical zones. (Map 2) With the exception of the 2d Surgical Hospital which moved from An Khe to Chu Lai on 8 May 1967 to support Task Force OreGoN, the movement of hospitals was minimal before 1968. The problems en- countered by the 22d Surgical Hospital in its move from Da Nang to Phu Bai were illustrative of the difficulties of moving medical facilities in the Vietnamese environment. The hospital was moved by LST (land- ing ship, tank) from Saigon to Da Nang. Enemy activity closed the road between Da Nang and Phu Bai, stranding the unit for several days while it awaited air transportation. The number of sorties required to complete the movement resulted in an even further delay. The policy which called for minimal movement of hospitals was modified somewhat in 1968 and, to a greater extent, in 1969. The 22d Surgical Hospital and other medical units were sent to Phu Bai. The 18th Surgical Hospital was moved to Quang Tri, to Camp Evans, and back to Quang Tri. The 17th Field Hospital departed Saigon to operate in An Khe. The 27th Surgical Hospital was sent to Chu Lai after it came in-country, while the 95th Evacuation Hospital functioned in two dif- ferent parts of Da Nang. The 29th Evacuation Hospital was established at Binh Thuy to support operations in the Delta, but was later deactivated and its facilities taken over by the 3d Surgical Hospital after it had moved from Dong Tam. The 91st Evacuation Hospital went to Chu Lai after the unit had built a facility near Tuy Hoa. The 85th Evacuation Hospital departed Qui Nhon for Phu Bai. 62 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM U.S. ARMY HOSPITALS IN VIETNAM 31 December 1968 2S 0 IOOMILES 25 0 100 KILOMETERS (approximate) _- Pp 18th Surgical Camp oO Evans 22d Surgical Phu i WE 85th Evacuation 95th Evacuation 312th Evacuation doe — 27m Surgical i an 17th Field 71st Evacuation Khe ple ° Quiot 3lith Field Nhon 67th Evacuation Io Tuy Hoa OE 91st Evacuation Nha $ 8th Field 2d Surgical J— 6th Convalescent Center 12th Evacuation 1 7th Surgical 24th Evacuation 93d Evacuation 741th Field 3d Field 36th Evacuation Can Tho 3d Surgical z 29th Evacuation Map 2 Among other moves, the 2d Surgical Hospital remained temporarily at Chu Lai, then selected personnel deployed to Phu Bai to operate a 100-bed U.S. Army hospital (provisional) in facilities previously op- erated by the Marines. The provisional hospital was opened to retain the real estate and provide continued medical coverage in Phu Bai until a larger hospital could be constructed. When the 85th Evacuation Hospital took over in Phu Bai, the 2d Surgical Hospital moved to Lai Khe. HOSPITALIZATION AND EVACUATION 63 To a certain extent these moves were made to support increased Army combat activity in I CTZ and elsewhere, but they were not in support of tactical operations in the tradition of World War II and the Korean War. Except for the interim use of MUST equipment or existent build- ings, the moves were made into semipermanent construction and were far more deliberate and complicated than the movement of tent-housed hospitals in previous conflicts. To a far greater extent shifts in 1968 and 1969 were the result of the deactivation of units and the consolidation of areas of support. Construction The construction of a modern hospital is a lengthy and complicated process. Line officers, medical staff planners, and hospital commanders soon found that many time-consuming, frustrating problems had to be resolved before construction could start. Real estate was generally acquired in large sections for military use and then parceled out to the units needing it. Negotiations for a hospital site were often protracted. For example, the need for an evacuation hos- pital in the Pleiku area was recognized long before the area was secure enough to permit construction. Meanwhile, the original allocation of land for this use had been lost, and new negotiations were opened with the commander of the Vietnamese II Corps and the U.S. Air Force. It was some time before an agreement for suitable land was again reached and the contractor could begin work on the 71st Evacuation Hospital. Hospitals were built in a wide variety of configurations, and con- struction was accomplished in almost as many ways as there were hos- pitals. Some structures, for example, the 91st Evacuation Hospital at Tuy Hoa, were built almost entirely by medical personnel with some technical advice from the Corps of Engineers. Some were started by contractors and finished by the Corps of Engineers. Medical personnel did some phase of the construction work in almost all the hospitals, but some work by contractors or engineers was needed in almost all cases to put in wiring, electrical fixtures, and heavy equipment. In October 1965, the USARYV surgeon and engineer established a policy for space utilization and prepared guidelines to govern hospital construction. This policy was disseminated in a USARV regulation which stated that patient wards, operating suites, and X-ray facilities were to be located in air-conditioned semipermanent structures. The use of these structures for medical purposes was to take precedence over that for troop billets, recreational areas, and administrative sections. The improvement of existing medical facilities as well as the con- struction of new units continued to receive much attention during 1966 and 1967. Strict controls were placed on construction, and the position 64 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM HospitaLs IN VIETNAM, 1967 of base development co-ordinator was established at USARV head- quarters. The base development co-ordinator was to evaluate the condi- tion of hospitals and other medical treatment facilities, determine construction requirements, establish priorities, and limit or stop construc- tion projects if duplication of effort was disclosed. Hospital construction was assigned a priority second only to the requirements of tactical units and communication centers. The construction of dispensaries and dental clinics was given a lower priority. Adequate control had been established over the construction of army-level (separate) dispensaries, general dispensaries, and dental clinics, but control over the construction of unit dispensaries was ini- tially inadequate. Some units constructed elaborate facilities, often located adjacent to another dispensary or hospital. Controlling these actions was difficult because of the maze of channels through which re- quests for construction were forwarded and approved. After appoint- ment of the base development co-ordinator, these wasteful and un- economical practices were greatly reduced. Climate and weather created special problems in site selection and preparation. Buildings flooded during the monsoon rains, requiring ex- tensive dike building and ditch digging to preclude a recurrence. Roads had to be hard-surfaced to be passable during the wet season. Grounds had to be seeded with grass to keep the dust down during the dry season. HOSPITALIZATION AND EVACUATION 65 Heavy-duty construction equipment itself had to be specially prepared to withstand the dust, mud, humidity, and intense heat. Electrical power was limited in the cities and lacking in the country- side. Generators were installed to provide the vast quantities of current needed for lighting, air-conditioning units, and the electrically powered equipment of a modern hospital. Water was equally limited. Wells were dug or water piped in to furnish the running water needed for bathing, laundry, sterilization of equipment, and operation of flush toilets. Equip- ment was installed to make the water potable. Through the concerted effort of contractors, the Corps of Engineers, and medical personnel, these handicaps were overcome and a series of superb hospitals capable of providing the finest care in every branch of medicine and surgery was established in Vietnam. After returning from Vietnam in 1968, General Collins commented, “Our hospitals in Vietnam are not evacuation hospitals, surgical hospitals, or field hos- pitals. They are more than that and consequently require sophisticated equipment . . . . We are all interested in providing the best care pos- sible. At present we have some items of equipment in Vietnam that equal what you have at Walter Reed.” Special Units MUST-equipped surgical hospitals were operated for several years in Vietnam with mixed success. These units consisted of three basic ele- ments, each of which could be airlifted and dispatched by truck or heli- copter. The expandable surgical element was a self-contained, rigid-panel shelter with accordion sides. The air-inflatable ward element was a double-walled fabric shelter providing a free-space area for ward facili- ties. The utility element or power package contained a multifuel gas turbine engine which supplied electric power for air-conditioning, refrig- eration, air heating and circulation, water heating and pumping, air pressure for the inflatable elements, and compressed air or suction. In addition, other expandables were used for central materiel supply, labora- tory, X-ray, pharmacy, dental, and kitchen facilities. By 20 October 1966, personnel and MUST equipment of the 45th Surgical Hospital had all arrived in-country. Work was begun on ground preparation and construction of quarters and a mess a few miles west of Tay Ninh. The utility packs and operating room and central materiel expandables had been moved next to the site when it was hit by mortars on 4 November and its commander, Major Gary P. Wratten, MC, was killed. Two days later the hospital was ordered to become operational as soon as possible to support Operation ATTLEBORO, then in progress northeast of Tay Ninh. An emergency surgical capability and a 20- 479-653 O - 73 - 6 66 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM 45TH SurcicaL HospiTtAL AT Tay Ninu, 1967 patient holding capacity was completed on 8 November. The rest of the hospital was ready to open on 11 November when three more mortar attacks delayed operations until 13 November, when the hospital re- ceived its first casualties. Lieutenant Colonel (later Colonel) Thomas G. Nelson, MC, MUST professional consultant to The Surgeon General, reported in 1967 that, during the early period of its operation, the 45th Surgical Hospital operated as a true forward surgical hospital; that is, patients were not held for followup surgery or prolonged treatment. Commenting on the relationship between helicopter evacuation and the employment of a forward surgical hospital, he continued: As was true of other hospitals in Vietnam, patients were moved directly from the battlefield either to a clearing station or a nearby hospital . . . . Most patients arrived at the hospital within 10 minutes of pickup, and some of these were in such critical condition, usually from internal bleeding or respiratory problems, that further evacuation even by helicopter would likely have been fatal . . . . Patients were moved from the helicopter pad directly into the preoperative and resuscitation shelter where they were met by the surgical team on-call and the registrar section to initiate resuscitation and medical records. Patients were nearly always admitted in groups of from three to ten, and surgical priorities were established as blood administration and other stabilizing measures were employed and X-ray and laboratory determinations obtained. HOSPITALIZATION AND EVACUATION 67 The performance of the 45th Surgical Hospital led to the accelerated deployment of MUST equipment for three additional surgical hospitals in 1967: the 3d, 18th, and 22d. In 1968, the 95th Evacuation Hospital was temporarily supplemented with some MUST equipment until the construction of a fixed facility was completed. The 2d Surgical Hospital arrived in Vietnam in 1965 and had a long history of distinguished serv- ice before becoming the last unit to be equipped with MUST in Jan- uary 1969. Meanwhile the Marine Corps was also using MUST equipment. All medical facilities were vulnerable to enemy attack. On 4 and 11 November 1966, the 45th Surgical Hospital was subjected to mortar attacks. The 3d Surgical Hospital underwent a 15-minute mortar bar- rage on 24 July 1967, with direct hits on the bachelor officers’ quarters and the MUST maintenance hut. Near misses caused extensive damage to practically all inflatable elements. No patients were wounded, al- though 18 members of the hospital staff received minor wounds. During 1968, the 3d Surgical Hospital underwent 13 attacks which resulted in damage to the hospital area. On 5 and 6 March the hospital suffered extensive damage from mortar and recoilless rifle fire. The headquarters and chapel were completely flattened; the dental clinic, X-ray, labora- tory, medical library, medical supply building, and nurses’ quarters were all damaged. The intensive care ward and postoperative ward were heavily damaged or destroyed. During this 2-day period, no patients were wounded, although three staff members received minor fragment wounds. Repairs were completed quickly and the hospital remained operational throughout. Until mid-1968, most field-army-level medical facilities, including MUST units, were not mobile. The 45th and 3d Surgical Hospitals remained stationary after the initial emplacement of MUST equipment. Billets, messhalls, and storage areas were constructed to support the units. Revetments were raised around all inflatable MUST components to make them less vulnerable during attacks. Difficulties in relocating the 18th and 22d Surgical Hospitals earlier in 1968 demonstrated the need to retain mobility. Thus, late in 1968, the USARV surgeon insti- tuted a policy that two MUST surgical hospitals would retain all equip- ment necessary to be completely mobile and that drills would be held frequently to keep hospital personnel trained to displace, move, and emplace their hospitals rapidly. The 2d and 18th Surgical Hospitals were designated as “mobile” MUST’s. While MUST equipment was an important addition to the inventory of Medical Department assets, it was not used in accordance with doc- trine. Its “transportable” attribute was not exploited. Because hospitals supported operations from fixed locations, emphasis was placed on the 68 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM selection of a hospital site in a reasonably secure area. Proximity to tac- tical operations was a consideration only in the sense that the hospital had to be within reasonable air-evacuation time and distance. Hospitals had to be moved only when major tactical forces shifted to open new areas of operations, such as, for example, the large-scale buildup of U.S. Army forces in I CTZ during 1968. MUST equipment was a link in such hospital relocations. Pending the construction of fixed facilities in new areas, MUST hospitals provided the controlled environment and the other resources needed for high-quality patient care. As air-conditioned fixed hospitals were completed, the need for MUST equipment dimin- ished. In late 1969, the MUST equipment was withdrawn from the 3d, 18th, and 22d Surgical Hospitals, leaving only two hospitals so equipped. The 3d and 18th Surgical Hospitals were re-established in semipermanent facilities and the 22d Surgical Hospital redeployed to the continental United States. The 2d and 45th Hospitals were closed out in 1970. The convalescent center. During the visit of The Surgeon General, Lieutenant General Leonard D. Heaton, to Vietnam in early November 1965, General Westmoreland strongly recommended that a convalescent center be established in Vietnam as soon as possible. Malaria was increas- ing among U.S. forces, and too many patients suffering from malaria or hepatitis were being evacuated out of the country because they could not be hospitalized and returned to duty within the USARV 30-day evacua- tion policy. General Heaton accepted this recommendation and directed that a convalescent center be established. The 6th Convalescent Center was activated on 29 November 1965, deployed to Vietnam during March and April 1966, and received its first patients on 15 May. The center was located at Cam Ranh Bay, adjacent to the South China Sea. Its mission was to provide convalescent care for medical and surgical patients, including combat wounded. After a year of operation, approximately 7,500 patients had been admitted to the center from all areas of the country. The patient census averaged more than a thousand a month, with malaria constituting 50 to 65 percent of all admissions. Other admissions included hepatitis patients and those requiring longer periods of postoperative care than 30 days. Approxi- mately 96 percent of all admissions were returned to duty—during an average month, the equivalent of one to two battalions. Prisoner-of-war hospitalization. During 1965, POW (prisoner-of- war) patients captured by U.S. forces were treated in U.S. medical facili- ties in the area where they were apprehended. Because of an increase in the number of prisoners, this policy was changed in early 1966. Special medical facilities for the care of prisoners of war, operated by two clear- ing companies, were constructed at Long Binh and Phu Thanh (near Qui Nhon). Initial major surgery and postoperative care continued to be HOSPITALIZATION AND EVACUATION 69 provided by an Army hospital before the POW patient was moved to a clearing facility. This system created a number of problems. It reduced the number of beds available for U.S. soldiers, mixed prisoners of war with U.S. patients, and required a large number of guards. To alleviate these problems, both clearing facilities were expanded by semipermanent construction into 250-bed hospitals with complete surgical resources. During 1968, the POW patient load increased from an average of 250 to approximately 400. After several Reserve and National Guard hospitals arrived in October, the 74th Field Hospital assumed the POW mission of the 50th Clearing Company at Long Binh, and the 311th Field Hospital replaced the 542d Clearing Company at Phu Thanh. During the first half of 1969, the patient load remained fairly con- stant. Average length of stay for wounded POW patients was 4 to 5 months, and each hospital had a 70- to 80-percent average bed occu- pancy. After hospitalization, patients were transferred to POW com- pounds operated by the Vietnamese Army. Upon the redeployment of the reserve hospitals to CONUS during the second half of 1969, the POW hospital mission was reassigned to the 17th Field Hospital and the 24th Evacuation Hospital. A decrease in combat activity reduced the average patient load in each hospital to approximately 100. Because the ARVN (Army Republic of Vietnam) had the largest POW medical workload and the ultimate responsibility for the prisoners’ continued confinement, USARYV proposed that ARVN administer the entire POW hospitaliza- tion program. U.S. Army hospitals would continue to accept and treat prisoners of war captured in their respective geographic areas until their medical condition permitted transfer to an ARVN hospital. In addition, the United States agreed to assist ARVN in reducing the reconstructive and rehabilitative surgical backlog of patients in ARVN hospitals. This concept was implemented in September 1969. Offshore Support The patient evacuation policy for Vietnam was established as a 15- day minimum or a 30-day optimum. Under this policy, it was possible to return to duty in Vietnam nearly 40 percent of those injured through hostile action and 70 percent of other surgical patients. Out-of-country evacuation was by aircraft to Clark Air Force Base in the Philippines; from there evacuees were subsequently routed either to the continental United States, to Tripler General Hospital in Hawaii, to the U.S. Armv Hospital, Ryukyu Islands, or to Japan. In the summer of 1966, direct evacuation by jet aircraft of patients from Vietnam to the continental United States via one stop in Japan was inaugurated. Patients received in the continental United States were mostly ac- commodated in general hospitals nearest their homes, but some were 70 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM regulated to class I hospitals even nearer their homes when these hospitals had beds available and the professional capability of treating their injuries. As the entire Republic of Vietnam had been designated a combat zone, fixed hospitals that give long-term care to patients and are normally found in a communications zone were not present. If all the injured or sick who could not be returned to duty in Vietnam within the established 15- to 30-day evacuation policy had been evacuated to the continental United States, it would have created a great drain of experienced man- power from the combat zone. To give this fixed-bed capability, the equiv- alent of about 31, general hospitals were established in Japan to receive and care for patients who could be expected to return to duty within 60 days. Evacuation In-Country Highly mobile and widely deployed forces must have a highly mobile and flexible medical evacuation system immediately responsive to their needs. The helicopter ambulance provided this flexibility and responsive- ness in Vietnam. At the peak of combat operations in 1968, aeromedical support was provided by 116 air ambulances. These helicopters could transport six to nine patients at a time, depending upon the number of litter cases. Medical evacuation flights averaged only about 35 minutes each, a feat which often meant the difference between life and death for hundreds of patients. The more seriously wounded usually reached a hospital within 1 to 2 hours after they were injured. Of the wounded who reached medical facilities, about 97.5 percent survived. The helicopter brought modern medical capabilities closer to the frontline than ever before. Furthermore, combined with a medical radio network, the helicopter provided greater flexibility in regulating patients. Preliminary evaluation of the injury and the condition of the patient was made while in flight, and the use of the radio network permitted redirecting the patient to the nearest hospital suited to his needs. If a hospital developed a surgical backlog, the combination of helicopter and radio facilitated regulating patients according to available operating facilities, rather than available beds. This combination was the core of the Army medical management system in Vietnam. The buildup of air ambulance units. The buildup of air ambulance units paralleled the commitment of U.S. combat forces to Vietnam. The first air ambulance unit sent to Vietnam, the 57th Medical Detachment (Helicopter Ambulance), later nicknamed “The Originals,” arrived in 1962 to support the 8th Field Hospital at Nha Trang. The unit was authorized five HU-1A aircraft, which were replaced by an improved model, the “B” version, in March 1963. Initially, two aircraft were HOSPITALIZATION AND EVACUATION 71 stationed at Qui Nhon and three in Nha Trang. As fighting increased around Saigon and in the Delta, the helicopters were shifted from place to place in response. The 82d Medical Detachment (Helicopter Ambu- lance) became operational in IV CTZ (the Delta), in November 1964. The buildup of units continued at an accelerated pace in 1965. The 283d Medical Detachment (Air Ambulance) arrived in August 1965, followed by the 498th Medical Company (Air Ambulance) in Sep- tember. The 254th Medical Detachment (Air Ambulance) arrived in Vietnam before the end of the year but did not become operational until February 1966 because a backlog at the port delayed the arrival of the unit’s equipment. The four detachments, each authorized six helicopters under a new table of organization and equipment, supported III and IV CTZ’s. The 498th Medical Company, which was authorized 25 aircraft, supported II CTZ. During 1967, the 45th Medical Company (Air Ambulance) and four additional air ambulance detachments arrived in Vietnam. The units were shifted from location to location to provide the most effective area coverage in response to tactical operations. In 1968, four additional detachments were sent to Vietnam, completing the buildup of aeromedi- cal evacuation units. One unit, the 50th Medical Detachment, which was assigned to the 101st Airborne Division in mid-1968, became the nucleus of the division’s air ambulance platoon. By 1969, there were 116 field-army-level helicopter ambulances in Vietnam. These were assigned to two companies and 11 separate detachments. (Map 3) Air Force aeromedical evacuation support. The Army and the U.S. Air Force evacuation systems complemented each other, each carefully continuing the movement of wounded or sick until they reached a final- destination medical facility. Based on experience gained in World War II and the Korean War, the U.S. Air Force initially used returning assault or cargo aircraft for casualty evacuation. The system worked well during the early stages of the Vietnam War, because the number of sick and wounded was rela- tively low. As troop strength increased and combat operations became more intense, the system grew progressively less satisfactory. The require- ments for evacuation often coincided with the most urgent needs for re- supply, although not always at the same location. The old system was therefore abandoned in favor of a new one in which aircraft were regularly used specifically for evacuation purposes. The 903d Aeromedical Evacuation Squadron scheduled the first regular in-country evacuation flights in 1967. By late 1969, the number of regular scheduled flights had increased to 188. The assault aircraft initially used for aeromedical evacuation were supplemented, in early 1968, by C118 cargo aircraft specifically modified for evacuation missions. The average 72 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM AIR AMBULANCE UNITS IN VIETNAM 31 December 1968 25 0 100 KILOMETERS (approximate) 237th MDHA = Ne C foe © Sm MDHA Me 236th MDHA Phu Bai© Da Nang \ 54th MDHA I ail o Chu Lai 283d MDHA 498th Med Co (AA) Qui Nhon© I y,—" MDHA Tuy Hoa O a 254th MDHA hI O Nha Trang 159th MDHA 45th Med Co (AA) 57th MDHA 247th MDHA Map 3 number of patients moved increased from 5,813 per month between July 1967 and January 1968, to 9,098 from March to June 1968. During the Tet Offensive in February 1968, more than 10,000 patients were evacu- ated by the Air Force. “Dust-off.” Those Army medical evacuation helicopter units not or- ganic to divisions came to be called Dust-off, after the radio call sign of HOSPITALIZATION AND EVACUATION 73 the most famous of the early pilots, Major Charles L. Kelly, MSC, who was killed in action on 1 July 1964. Several scores of these flying “medics” flew their unarmed helicopters into hostile areas, risking their own lives to save those of others. In a 2-year period, 39 crew members were killed and 210 wounded in aeromedical evacuation missions. The combination of the helicopter ambulance and a medical radio network was the basis of the effective medical regulating system that evolved in Vietnam. During the first phase of U.S. troop commitment to Vietnam in early 1965, there was only one hospital in support of each CTZ and therefore no alternative to the destination of a casualty. As the number of hospitals and the number of casualties increased, however, the need for a regulating system became imperative. The first system in the IIT and IV CTZ’s was set up with Air Force Radar Tan Son Nhut, Paris control. Dust-off helicopters inbound called Paris control which had a direct-line field telephone “hot line” to the MRO (medical regulating office) and the 3d Field Hospital. The three major treatment facilities available were the 3d Field Hospital, the 93d Evacuation Hospital, and the 3d Surgical Hospital, the last named then located at Bien Hoa. The MRO confirmed or changed the destination chosen by the pilot as the medical situation indicated. After Headquarters, 44th Medical Brigade, arrived in Vietnam in 1966, the brigade MRO became responsible for all in-country regulating of patients. Medical groups controlled the movement of patients from tactical areas to hospitals within their own group areas. Further move- ment of patients from one group area to another was co-ordinated by medical group MRO’s with the brigade MRO, who maintained over-all control to insure proper usage of all medical facilities. Telephone communications were abysmally poor and radio commu- nications not much better during this period. When heavy fighting pro- duced a large number of casualties and medical regulating was most urgently needed, operational radio traffic was also heaviest. Moreover, since short-range radios were used, requests for evacuation had to be routed from divisional medical battalions to backup hospitals by way of the Dust-off radio network or through the supporting field army medical group. This cumbersome method caused delays and sometimes resulted in garbled transmissions. On an experimental basis, the 55th Medical Group at Qui Nhon borrowed single-sideband long-range radios from the 498th Medical Company (Air Ambulance). Originally placed in the air ambulance company for long-range transmissions to its aircraft on evacuation mis- sions, these radios had been little used because of the relatively short dis- tance of most flights and the extensive maintenance they required. Their use for medical regulating proved highly successful, and an additional 54 74 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM sets were ultimately acquired to expand the communications network throughout the medical brigade. Medical regulating started on the battlefield. Medical groups placed regulators (senior noncommissioned officers) in areas of troop concentra- tion or at the site of a combat operation. In co-operation with the local medical unit, the regulator radioed requests for evacuation to the sup- porting Dust-off unit. The transmission was monitored by the MRO at his medical group headquarters. In the absence of a field medical regulator, a request for air evacua- tion was normally made by the medical aidman at the site of the casualty. The request, which included such information as the number of patients by type, the exact location by map grid co-ordinates, data on enemy movements, and the radio frequency of the requesting unit, was trans- mitted over the Dust-off radio network to the supporting air ambulance unit. Frequently the call was received by.an air ambulance already in flight which could be diverted from a less urgent mission. If not, a standby crew at a field site or at the unit headquarters scrambled to make the pickup. After proper identification of the ground force with the casualty, the Dust-off helicopter generally made a high-speed or tight-circle approach into the area. Time spent on the ground in a normal operation was usually between 30 seconds and 1 minute, depending on the number of casualties. The casualty was given emergency treatment by the medical aidman on board as soon as the aircraft was out of the combat area. The patient was flown directly to the medical treatment facility best able to give the care required. This might or might not be the one nearest the site of injury. The decision as to the proper destination hospital was based on several factors. Distance was less important than time; the objective was to reduce the time between injury and definitive treatment to the minimum. Information based on the preliminary in-flight evalua- tion of the injury and the condition of the patient, knowledge of existing surgical backlogs, and the over-all casualty situation were other consider- ations. If the aircraft commander questioned the destination selected by the medical regulator because of his knowledge of the patient’s condition, a physician was consulted by radio while the patient was still in transit before the decision became final. The inbound medical aircraft com- mander informed the receiving hospital by radio of his estimated time of arrival, the nature of the casualties on board, and any special reception arrangements that might be required. Thus, the receiving hospital was able to have everything in order to receive casualties and begin definitive surgical care. Helicopter evacuation techniques and requirements varied by geo- graphic area, type of combat operation, and type of equipment available, and changed from year to year as experience modified and refined pro- HOSPITALIZATION AND EVACUATION 75 cedures. Since the air ambulance was unarmed, gunship support was requested if the ground reported contact with the enemy in the vicinity of the pickup site, or if the rescue was a hoist operation. In “hot” areas, the crew of the evacuation aircraft consisted of a pilot, copilot, crew chief, medical aidman, and a man armed with an automatic rifle. In quieter areas, the rifleman was left behind in favor of increased patient capacity. On hoist operations in mountainous and jungle terrain, before the more powerful “H” model aircraft was introduced, the crew consisted only of a pilot, copilot, and hoist operator. On these missions, fuel load was also generally reduced in favor of greater lift capability. Night missions were quite common, often comprising 15 to 20 percent of the total missions in some areas. Helicopter rescue operations were aided by new equipment designed especially for use in jungle terrain or in combat areas where it was too dangerous for a helicopter to land. The hoist consisted of a winch and cable on a boom which was moved out from the aircraft when it arrived over the rescue site. At the end of the cable was a ring and hook to which a Stokes litter, rigid litter, or forest penetrator could be attached. The cable could be lowered at the rate of 150 feet per minute and re- tracted at the rate of 120 feet per minute. The forest penetrator, a spring- loaded device which could penetrate dense foliage, opened to provide seats on which a casualty could be strapped. It was preferred over the litter by the crews for hoist rescues because it was less likely to become entangled in the trees. Hoist operations significantly increased the danger for Dust-off crews. Hovering above the jungle or a mountain side as it lowered its cable, the helicopter became a ‘sitting duck” for enemy troops in the area. In 1968, 35 aircraft were hit by hostile fire while on hoist missions. The number increased to 39 in 1969. Nonetheless, the hoist was used exten- sively and to great advantage in Vietnam. Its use permitted the rescue of 1,735 casualties in 1968 and 2,516 casualties in 1969, who otherwise could not have been retrieved. The primary mission of the Army helicopter ambulance was the in- country aeromedical evacuation of patients. The number of patients evacuated by aeromedical evacuation helicopters rose from 13,004 in 1965, to 67,910 in 1966, to 85,804 in 1967, and peaked at 206,229 in 1969. These figures included members of the ARVN, Vietnamese civil- ians, and Free World forces as well as U.S. patients. Each time a patient was moved by helicopter, the move was entered in the tally. Thus, if a patient was taken to a surgical hospital by helicopter and later transported from there to an evacuation hospital by helicopter, this would count as two patients evacuated. Army air ambulances completed more 76 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM than 104,112 aeromedical evacuation missions while flying approximately 78,- 652 combat hours in 1969. In addition to this primary mission, Army helicopters were also used to trans- port professional personnel, medical sup- plies, and blood to medical facilities. Supplemented by scheduled Air Force flights, and from time to time by larger { * helicopters, they were also used to trans- F port patients between hospitals for con- sultations or to free beds in areas where increased casualties were anticipated. Usk oF Hoist IN VIETNAM, 1968 Out-of-Country The Air Force provided all out-of- country aeromedical evacuation. Initially, out-of-country medical regu- lating was controlled at the FEJMRO (Far East Medical Regulating Office) at Camp Zama, Japan, through a representative functioning at the Office of the Surgeon, USMACV. To handle the increased volume of traffic, a branch of the FEJMRO was established in Vietnam and Major (later Lieutenant Colonel) Robert M. Latham, MSC, reported as Chief, FEJMRO (USMACV), in July 1966. FEJMRO allotted bed space in hospitals in the Pacific area for FEJMRO (USMACV) use, and issued “bed credits” on a 24-hour basis. This information was relayed to Vietnam via Clark Air Force Base in the Philippines because communications between Japan and Vietnam were chronically poor. Late in 1966, a direct system for transmitting information between the two offices was adopted. The procedures for regulating out-of-country evacuations were fur- ther improved in November 1967. Under these new procedures, medical group regulating officers submitted consolidated requests for evacuation to the medical brigade MRO who then sent a single request to FEJMRO (USMACV). In turn, information concerning destination hospitals was sent back down the line. The new system enabled hospitals in Vietnam to follow up on patients and permitted medical facilities to close out clinical records. It also provided information more promptly on the total number of evacuees to casualty staging facilities, the Military Airlift Command, and offshore hospitals. Routine calls were handled within a 36-hour period, and urgent evacuation requests were processed within an hour if an aircraft was available. Since substantial U.S. forces were committed to Vietnam in 1965, the relative continuity of combat was as much a factor in building up HOSPITALIZATION AND EVACUATION 77 patient loads as was the severity of fighting. Under such conditions, pa- tient evacuation was therefore accelerated to provide for contingencies. The 9th Aeromedical Evacuation Squadron, for example, increased its flight schedule from two weekly departures from Tan Son Nhut to daily flights with additional sites for departure at Da Nang and Qui Nhon. The number of evacuations out-of-country increased from 10,164 in 1965 to 35,916 in 1969. (Table 8) TaBLe 8. —ToraL NuMBER OF PATIENTS EvacuaTED FROM VIETNAM, U.S. Army, BY Month, 1965-69 Month 1965 1966 1967 1968 1969 January. ................. 164 832 1,469 2,417 3,224 February........... PU 227 1, 330 1, 851 3,376 3, 099 March. « cove es sma 06 5m 6 5 2 226 1, 062 2,178 2,471 4, 166 Aplus: musa vi nme isan 252 853 1,780 2,782 3,210 MAY: sia. vision nn ivem 1 5 scwrm o 5 ws 300 1,298 2, 367 3,952 4,334 June..................... 480 1,256 2,072 2,701 3,951 July... 471 766 1, 595 2, 569 2,879 August. oo owes sues smn dss 821 957 1,521 2, 700 3, 308 September. :..: vos som 50s 999 942 1,431 3,401 2, 187 October. ................. 1,978 983 1,851 2, 856 1, 890 November. ............... 2, 361 1, 331 2,435 2,790 1,789 December................. 1, 885 996 2,152 3,176 1,879 Total....:s00:nnmix 10, 164 12, 606 22,702 35, 391 35,916 Source: Army Medical Service Activities Report, MACV, 1965; Army Medical Service Activities Reports, 44th Medical Brigade, 1966, 1967, 1968, 1969. Initially, out-of-country evacuation was by aircraft to Clark Air Force Base; from there evacuees were routed either to the continental United States; to Tripler General Hospital in Hawaii, to the U.S. Army Hos- pital, Ryukyu Islands, or to Japan. In the summer of 1966, to reduce the drain of experienced manpower from the combat zone, the equivalent of about 37, general hospitals was established in Japan to receive and care for patients who could be returned to duty within a 60-day period. C—141 Starlifter jets, which were used to transport troops to Vietnam, were quickly reconfigured to evacuate patients to Japan. The C—-141 could carry 80 litter, 121 ambulatory, or a combination of 36 litter and 54 ambulatory patients. After a 6-hour flight to Japan where those patients to be retained disembarked, patients bound for the continental United States boarded and the aircraft continued either to Andrews Air Force Base, Washington, D.C. (18 hours via Elmendorf Air Force Base, Alaska) or to Travis Air Force Base, Calif., by a direct 10-hour flight. 78 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Throughout the chain of evacuation, the well-being of the patient was of overriding concern. At all points along the chain, a qualified flight surgeon was on hand to determine if the evacuation should be continued. If necessary, a physician accompanied a severely wounded or critically ill patient. At all times, the finest medical care was given to the wounded or sick soldier as he progressed through the aeromedical evacuation system. oo Reduction and Reorganization The de-escalation of combat activities in Vietnam during 1969 and 1970 was paralleled by a reduction in the number of hospitals and air ambulance units. During 1969, three Reserve hospitals returned to the continental United States. The 7th and 22d Surgical Hospitals and the 29th and 36th Evacuation Hospitals were inactivated. The number of beds in operation decreased from 5,189 to 3,473 by the end of the year. During 1970, the 8th Field, the 2d Surgical, the 45th Surgical, and the 12th Evacuation Hospitals were redeployed or inactivated. (Map 4) The 254th Medical Detachment (Helicopter Ambulance) was inacti- vated in November. A new structure for administering the medical units still in-country was authorized. Early in 1970, outlying dispensaries and clinics were placed under the command and control of the hospital in the closest geographic proximity. This change resulted in the inactivation of the headquarters elements of two medical battalions. The two medical bat- talions in-country were reorganized and given command and control of all medical evacuation helicopter, field ambulance, and bus ambulance resources. One medical evacuation battalion was assigned to each of the two medical groups that remained in Vietnam. HOSPITALIZATION AND EVACUATION 79 U.S. ARMY HOSPITALS IN VIETNAM 1970 25 0 100 MILES 25 © 100 KILOMETERS (approximate) —- \ 18th Surgical Quango Tel 85th Evacuation ——" Phu Bai® Sr 95th Evacuation Da Nard Ye— I 2% Evacuation o 27th Surgical Chu Lai 71st Evacuation 17th Field > ere 6Tih Evacuation Khe Qui©, Nhon - Io Com Ranh Op 6th Convalescent Center Bay XXX m okong Binh 24th Evacuation Binh Thuy ° 93d Evacuation 3d Field Map 4 CHAPTER V Medical Supply Realignment of Medical Supply Activities Medical Materiel Management in Overseas Commands: 1962-66 After the reorganization of the Department of the Army headquarters in 1962, supply activities in overseas commands were consolidated within supply agencies organized on a functional basis. Medical supply was in- corporated within the functional systems although in each instance the command surgeon objected to the change, contending that there would be a serious deterioration in support to medical facilities and medical units. Under the new system, supply management activities for USARPAC were centralized at the Inventory Control Point in Hawaii. The In- ventory Control Point was responsible for controlling of all requisitioning of supplies within the command and for the centralized maintenance of records on the status of supplies for the Eighth U.S. Army in Korea as well as for U.S. Army units in Japan, Hawaii, and Okinawa. Medical Materiel Support of the Troop Buildup The disadvantages in treating medical materiel as just another cate- gory of supply items were quickly and unequivocally exposed in 1965 when Army medical materiel units were faced with an expanded support mission—the buildup of U.S. Army troops in Vietnam. One of the most significant supply problems at the onset of the buildup was a lack of adequate medical supply personnel in the theater as well as the lack of continuity in key positions resulting from the 12-month Vietnam tour of duty. The 8th Field Hospital at Nha Trang was responsible for medical supply distribution to the medical units in Vietnam. This unit was aug- mented by a small staff which was not adequate to provide the necessary control over the tremendous requirements being generated practically overnight. This situation was compounded by the protracted delay in deployment of the 32d (Field Army) Medical Depot which, although “ready” in July 1965, was not deployed until late October. One supply detachment had been deployed in July and another shortly thereafter, MEDICAL SUPPLY 81 but these detachments did not have a sufficient depth to manage supply activities in a theater of operations the size of Vietnam. With the escalation of U.S. efforts in Vietnam, greater dependence was placed upon the Ryukyu Islands as the offshore base to support units in Vietnam. A supply detachment was deployed to Okinawa in August, and in November 1965, the 70th Medical Depot was deployed to aug- ment and expand the operation of the medical depot in Okinawa. The Surgeon General, handicapped by insufficient strength and con- trol of medical supply, co-ordinated with CINCPAC to establish a system of automatic shipments of medical materiel to Vietnam. These shipments, initiated in July 1965, were based upon schedules developed to support forces which were deployed from the continental United States to Viet- nam. The materiel shipped consisted primarily of medical resupply sets and later, after their development, included optical resupply sets. The automatic supply support system continued for a period of approximately 10 months, with peakloads of resupply occurring from November 1965 through January 1966. This system, although only a temporary measure, was not so successful as anticipated. Delays in shipment from CONUS ports and in off-loading procedures at Vietnam facilities and the splitting of the medical resupply sets into various shipments on board vessels were the major difficulties experienced. Investigation of Malfunctions in the Medical Supply System By mid-1965, the Army medical materiel supply system was close to a complete breakdown because of the lack of qualified medical logis- tics personnel in Vietnam, the shortcomings of the medical resupply system related previously, and the inability of a centralized supply man- agement activity in Hawaii to meet the medical materiel demands in Vietnam. In November 1965, the Vice Chief of Staff directed The Sur- geon General to investigate and recommend appropriate measures to resolve these difficulties and end the shortages occurring in Vietnam and other subordinate commands within USARPAC. A representative of The Surgeon General investigated and found that the Inventory Control Point, USARPAC, could not provide pertinent data on the medical supply situation within USARPAC. Consequently, requisitioning objec- tives were being computed without the full knowledge of subordinate command conditions, environment, or professional requirements. In fact, to insure adequacy of objectives, subordinate commands had to review their records constantly and thus engage in duplication of effort. The investigation revealed that the Inventory Control Point provided little assistance to the subordinate commands or to the surgeons who were re- sponsible for the health of troops in those subordinate commands. The report indicated that the medical commodity group was not large enough 479-653 O - 73 - 7 82 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM to require management within a centralized and functionalized system; however, it was important enough to require extraordinary management under the direction of the subordinate command surgeons to support peacetime and wartime operations. The status of medical supply in each of the subordinate commands disclosed large numbers of medical items with zero balances (complete lack of stock). This situation necessitated submitting large numbers of high priority requisitions to CONUS to obtain vitally needed stocks rapidly. The report further indicated that the rapid buildup of troop strength in Vietnam had placed a serious drain on available medical materiel stocks in the DSA (Defense Supply Agency) system. For example, of the 6,000 to 7,000 medical items on hand, DSA was out of stock on about 1,500 items and these were articles needed in the field to administer first aid. Delays in shipments and out-of-stock conditions became more serious as the buildup progressed. In Okinawa, the offshore support base, for example, zero balances rose from 16 percent in December 1964, to 28 percent in March 1965. Unfortunately, The Surgeon General was not fully informed of the deficiencies until complaints were received from Vietnam and other USARPAC areas. While the inadequacies and malfunctioning of the supply system were being investigated, a concept study advocating a bold, new approach to the problem of the administrative support of a theater army, entitled “TASTA-70 (The Administrative Support-Theater Army 1965-70),” was under study in the Office of the Chief of Staff. Commenting on the study, The Surgeon General recommended that the Army Medical De- partment be given control over medical depots and medical inventory control activities. Approved by the Chief of Staff, The Surgeon General’s recommendation was incorporated in the TASTA-70 concept and pro- vided the basis for the realignment of medical supply activities under the command surgeons in overseas commands which began in the summer of 1966. The Surgeon General’s Plan During the summer of 1966, the medical supply system supporting military activities in Vietnam was realigned by shifting the responsibility for determining requisition objectives for stocked medical items and for ordering replenishment supplies from the Inventory Control Point to the U.S. Army Medical Depot in the Ryukyu Islands. This depot, in turn, ordered replenishment supplies directly from the Defense Personnel Support Center through the USAMMA (U.S. Army Medical Materiel Agency), Phoenixville, Pa. MEDICAL SUPPLY 83 The effect of this realignment was the routing of all requisitions for medical materiel from subordinate commands within USARPAC to the USAMMA, where the order was recorded and reviewed before it was transmitted to the Defense Personnel Support Center, the agency of the Defense Supply Agency which handled medical materiel. Thus, USAMMA was able to maintain control and “followup” on each requi- sition to insure that the requesting agency was kept fully informed on the status of its order and, when necessary, to expedite the delivery of urgently needed items. USAMMA also prepared and maintained a catalog of nonstandard items for the Pacific area. This catalog facilitated requisitioning of items that were not in the standard supply system and permitted the accumulation of data on worldwide usage of nonstandard items to determine the need for type classification actions. In 1967, the medical supply section within USARPAC, the Materiel Management Agency, was transferred to the Chief Surgeon, USARPAC, thus completing the shift of all medical supply activities in the Pacific command to medical channels. After this transfer, the Chief Surgeon, USARPAC, was responsible for directing all medical supply functions within the command. In each subordinate command, medical supply responsibilities were assigned to medical commanders and surgeons; for example, in Vietnam, the Surgeon, USARV, was responsible for medical supply functions to include the operations of the 32d Medical Depot, and the operation of the U.S. Army Medical Depot, Ryukyu Islands, was a responsibility of the U.S. Army Medical Center, Ryukyu Islands. Sim- ilarly, the U.S. Army Medical Command, Japan, directed the functions of the 504th Medical Depot; the 6th Medical Depot in Korea was as- signed as a function of the Surgeon, Eighth U.S. Army; and medical sup- ply activities in Hawaii were incorporated within the structure of Tripler Army Medical Center. The Depot System As a result of this assignment of medical materiel mangement the Okinawa depot expanded in size and responsibilities. The depot ulti- mately supported U.S. Army units in Vietnam and Thailand ; the Armed Forces of Vietnam, Thailand, and Laos; and AID (Agency for Inter- national Development) activities in Southeast Asia, while also supply- ing military customers on the Ryukyu Islands. The amount of depot sales to customers rose from $28.5 million in fiscal year 1967 to $64 mil- lion in fiscal year 1968 and peaked at $71.5 million in fiscal year 1969. The depot satisfied over 85 percent of the demands for stocked items dur- ing fiscal year 1968. The depot also provided optical and medical equip- ment maintenance support to all areas which it supplied. In Vietnam, the 32d Medical Depot, which had deployed in October 1965 and which received its medical materiel support from the Okinawa 84 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM depot, provided medical materiel for units of the U.S. Army and the Armed Forces of Korea, the Philippines, Australia, and New Zealand, operating in Vietnam. During fiscal year 1968, for example, the 32d Medical Depot issued about $30 million of medical materiel in Vietnam and filled more than 85 percent of all requisitions submitted by medical units. Shipments of medical supplies increased from 482 short tons per month in the first quarter of fiscal year 1968 to 932 short tons per month in the third quarter. The depot’s functions included the fabrication of single-vision spectacles—in fiscal year 1970 alone the depot produced 170,279 pairs—and the maintenance and repair of medical equipment of supported units throughout Vietnam. The depot operated through five locations (four advance depots and a base depot at Cam Ranh Bay). Despite chronic shortages of personnel and equipment, the 32d Med- ical Depot continued to fulfill its mission in a superb manner. By 1970, the medical supply support had reached an operational plateau as med- ical units and facilities received a routine replenishment of medical supplies. The Army Medical Depot, Ryukyu Islands, also continued to provide replenishment supplies to the Vietnamese Armed Forces, and military assistance supplies for Thailand and Laos forces, and for AID activities in Vietnam, Thailand, and Laos. Medical supplies valued at $71.5 million were distributed through this depot during the fiscal year. Mechanization of Medical Materiel Recordkeeping The improvement of medical support in Vietnam was based on the excellent support rendered to the 32d Medical Depot by the U.S. Army Medical Depot, Okinawa, and in-country procedural, organizational, and facility improvement. The depot installed the NCR (National Cash Register Co.) 500 computer system to mechanize stock control and in- ventory management at the base depot in Cam Ranh Bay and at two advance depots in Long Binh and Qui Nhon in 1967. By 1968, it was apparent that the NCR 500 computers were not adequate to provide the data necessary for decision making, plot supply trends, forecast trouble areas, or program financial inventory data. The depot therefore de- veloped its own programs, borrowed computer time on an IBM (Inter- national Business Machines) 360 computer system in Saigon, and pro- duced the information necessary to operate effectively in an environment that was rapidly becoming increasingly management and cost conscious. By the fall of 1968, the 32d Medical Depot produced the first theater stock status report. The report was developed by converting data from the NCR 500 computer system to cards which were processed in the IBM 360 system. By the spring of 1969, additional advances had been made in the automation of medical materiel recordkeeping. These ad- vances included the preparation of theater excess reports, financial inven- MEDICAL SUPPLY 85 tory feeder data, due in and due out reconciliation reports, order and shipping time studies, and interdepot redistribution of assets studies. In light of these achievements, plans were made and submitted for compara- ble support in 1969, and a data automation requirement to automate medical materiel management in Vietnam was approved by the Depart- ment of the Army in February 1969. Transportation and Communication Problems The reliable transmission of requisitions or supply information was a continuing problem within Vietnam and to a lesser degree between Viet- nam and Okinawa. The primary modes of communication were trans- ceiver, mail, and telephone. The transceiver was used between advance depots and the base depot whenever possible and mail was the alternative. Policy changes were sent to the advance depots by transceiver or mail and high-priority requisitions were telephoned to the base depot. To prevent losses of requisitions transceivered between depots, which was not uncommon, batch control techniques were established and proved highly successful. Transporting supplies within the depot system presented difficulties at times. The road network was poor and often interdicted by the enemy. Under these circumstances, the helicopter was used to pick up supplies from designated supply points and to deliver high-priority requisitions. Bulk quantities of resupply were packed in Conex containers and airlifted by Chinook helicopters. Improvement of Storage Facilities Lack of adequate and sufficient storage space for medical supplies was a chronic problem in Vietnam. The acquisition of additional storage space continually lagged behind actual needs. The redistribution of troops compounded matters and storage requirements for medical sup- plies were frequently overlooked in planning programs. During the carly part of the war, there was an acute lack of sufficient covered stor- age space for the protection of delicate or perishable medical supplies; it was not unusual to find medical supplies being stored in temperatures above 100° F. although boxes were plainly marked not to be stored in temperatures exceeding 80 degrees. Through the vigorous efforts of the 32d Depot, these inadequacies were gradually overcome, and facilities for the proper storage of medical supplies were constructed. Medical Equipment Maintenance Support The deployment of medical units and hospitals to Vietnam during 1965 and 1966 precipitated various problems in medical equipment maintenance support. The 32d Medical Depot base platoon general and 86 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM direct support facility, which was located at Nha Trang, operated out of temporary buildings with inadequate storage and shop space. Hos- pitals within Vietnam had little or no maintenance capability and were thus dependent upon the base depot for support. Although the 32d Medical Depot had deployed to Vietnam with a prescribed load of re- pair parts, the supply proved inadequate because of the early approval of many complex and highly specialized items of medical equipment for use in-country. A majority of these items were nonstandard and con- sequently required nonstandard repair parts which were not included in the original load. During late 1966 and early 1967, the depot in- corporated many standard and nonstandard items into a depot mainte- nance float for direct exchange by units using them; this action made repair parts available to medical facilities within the depot system. With the establishment of backup maintenance support at the U.S. Army Medical Depot, Okinawa, a number of problems were solved. For example, it was no longer necessary to send 100 MA X-ray tubes to CONUS for repair, a step which involved considerable delay in get- ting the equipment back into the depot system. By 1968, tremendous improvements had been made in medical maintenance support and capability. The base depot maintenance sec- tion was moved to Cam Ranh Bay and new facilities were programmed for construction. Repair parts management was transferred from main- tenance repair personnel to inventory managers, thus enabling the re- pairmen to devote more time to the actual repair of equipment. In addition, medical equipment assistance teams, composed of highly skilled technicians, responded to the needs of medical facilities for periodic technical assistance and on-site repair. CHAPTER VI Division and Brigade Medical Support Two impressive aspects of medical operations in support of combat units in Vietnam were the versatility of the classic system and the far- reaching modifications of the system that evolved from the Vietnamese experience. Doctrine prescribed the structure and type of medical support for combat units sent to Vietnam. A medical battalion of four companies, each with three platoons, supported each division. A single medical com- pany supported each separate brigade. The medical platoon of three sec- tions supported units of infantry and tank battalions or armored cavalry squadrons. Under the fluid conditions of warfare in Vietnam, the employ- ment and deployment of combat units determined the utilization of their supporting medical units, and no two medical battalions were used alike. The action accounts that follow are representative of these varied usages. Usages of Divisional Medical Assets Ist Cavalry Division (Airmobile) In September 1965, the 1st Cavalry Division (Airmobile), supported by the 15th Medical Battalion (Airmobile), arrived at the Central High- lands bases of Qui Nhon and An Khe lying southeast of Pleiku. In Oc- tober the North Vietnamese Army began a major operation in the Central Highlands, opening its campaign with an attack on the Plei Me Special Forces camp 25 miles southwest of Pleiku. The 1st Brigade, 1st Cavalry Division (Airmobile), was moved into the area south and west of Pleiku to block any further enemy advance and to stand in readiness as a reaction force. On 27 October, the 1st Cavalry Division (Airmobile) was directed to seek out and destroy the enemy force in western Pleiku province. Thus began the month-long campaign known as the Battle of the Ia Drang Valley. The great effectiveness of the airmobile division was demonstrated in its first combat trial. The Ia Drang campaign also proved the worth of the airmobile medi- cal support battalion. An innovation, the airmobile medical battalion differed structurally in several ways from the conventional medical bat- talion. The most important difference was that it included an air ambu- lance platoon of 12 helicopters and an aircraft maintenance section. 88 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Doctrinally, the division of responsibility between air ambulances organic to a division and Army-level, or Dust-off helicopters, was clear cut. Divisional air ambulances evacuated patients in the division’s area of operations from the site of wounding to one of the division’s four clearing stations. Dust-off helicopters evacuated patients from the divi- sional clearing station to an Army hospital. In practice, the line of de- marcation was often blurred. During lulls in combat, divisional aircraft flew patients from the clearing station to a hospital, while during peak periods of combat, Army-level helicopters supplemented divisional air- craft and evacuated casualties from the frontline to the divisional clearing station. Occasionally, assault helicopters were used when the medical air evacuation platoon was overtaxed, but Dust-off was preferred because the medical aidman aboard could give emergency treatment and be- cause the patient could be regulated to the hospital best suited to his needs. In contrast to the usual practice in Vietnam of evacuating a casualty directly from the site of wounding to a hospital by air ambulance, 95 percent of the casualties in the 1st Cavalry Division (Airmobile) were first evacuated to one of the division's clearing stations, because of the size of the division’s area of operations. The remaining 5 percent, severely wounded or critically ill patients who could not have survived a stop en route, were evacuated directly to the 45th Surgical Hospital in Tay Ninh or the 2d Surgical Hospital in Lai Khe. Since there was no difference in flying time from the combat area to the helipad of the clearing station of the 15th Medical Battalion (Air- mobile) and that of the 45th Surgical Hospital at Tay Ninh, patients were evacuated to the clearing station. The two units complemented each other. Personnel at the clearing station became adept in the triage of combat casualties and in the techniques—such as administering blood and reducing shock—of stabilizing a seriously wounded patient. Sur- geons at the 45th Surgical Hospital, in turn, were freed to devote their full effort to resuscitative surgery without fear that the condition of patients awaiting surgery would deteriorate. The clearing station han- dled a surprisingly large number of casualties in a short period of time. It also weeded out the slightly wounded and the “sick, lame, and lazy” who would have become the responsibility of the 45th Surgical Hospital had they been evacuated there originally. 25th Infantry Division In contrast to the relationship between the 15th Medical Battalion (Airmobile) and the 45th Surgical Hospital, casualties from the 25th Infantry Division, which also operated in the Tay Ninh area, were DIVISION AND BRIGADE MEDICAL SUPPORT 89 evacuated directly to the 45th Surgical Hospital by Dust-off helicopters which operated from the hospital’s helipad. Use of the 25-bed facility adjacent to the 45th Surgical Hospital operated by Company D, 25th Medical Battalion, which supported the 25th Infantry Division, was limited to the care of the patient with a minor illness or a slight wound. To elaborate further on the contrast between these two methods, the 15th Medical Battalion (Airmobile) operated a clearing station and used the 45th Surgical Hospital in the classic role of a surgical hospital. Company D, 25th Medical Battalion, provided a holding area for pa- tients who could be returned to duty in a few days. Under this arrange- ment, the 45th Surgical Hospital also served as a clearing station. The same relationship existed between the remaining companies of the 25th Medical Battalion and the 12th Evacuation Hospital at Chu Lai. The three companies together operated a single 25-bed facility as a holding area. The 12th Evacuation Hospital served as a clearing station as well as an evacuation hospital. In 1968, the 25th Medical Battalion operated facilities at three loca- tions and treated 75,184 patients. Dust-off helicopters flew 8,159 mis- sions and evacuated more than 20,000 patients. In 1969, the 25th Medical Battalion treated more than 58,000 patients. That same year, Dust-off aircraft flew approximately 7,000 missions and evacuated about 14,000 patients. 326th Medical Battalion During its service in Vietnam, the 326th Medical Battalion was converted from an airborne to an airmobile unit. It lost some men and ground vehicles and acquired an air ambulance platoon which became known as “Eagle Dust-off.” This conversion paralleled the conversion of the 101st Airborne Division to the 101st Air Cavalry Division to the 101st Airborne Division (Airmobile). Even so, the battalion still did not match the table of organization for an airmobile medical battalion. Instead, it operated under a modified table of organization. To insure adequate medical support for the 101st Airborne Division (Airmobile) which operated primarily in the vicinity of Hue and Phu Bai, except for its 3d Brigade which was retained in the critical Saigon area, all elements of the 326th Medical Battalion were monitored and evaluated continually. As a result of this surveillance, changes were made from time to time to improve the unit’s performance. For example, four litter bearers, one from each medical company, were deleted in exchange for four preventive medicine specialists who were added to the staff of the division surgeon. 90 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Mobile Riverine Force The Mobile Riverine Force, created in 1967, was composed of the 2d Brigade, 9th Infantry Division, and two Navy river assault squadrons of 50 boats each. The force, designed to deny the extensive river and canal complex of the Mekong Delta to the enemy, was wholly inde- pendent of fixed support bases and operated entirely afloat. Company D, 9th Medical Battalion, supported the Mobile Riverine Force in a highly unorthodox manner. Shortly after Company D arrived at the Dong Tam base in early 1968, it established a medical facility in a con- verted armored troop carrier to provide more effective medical support for riverine operations. Later this facility, the only Army medical facility in Vietnam based in a Navy ship, was moved to a barracks ship, the U.S.S. Colleton. After the arrival of Company A, 9th Medical Battalion, at-Dong Tam in August 1968, Company D established a 37-bed facility for medical cases aboard the U.S.S. Nueces, thus freeing the unit on the Colleton for care of surgical patients. When the U.S.S. Mercer replaced the Colleton a few months later, the medical and surgical units were united aboard the Nueces. The rear section of the aid station of Company D was maintained in these ships at the base anchorage. On tactical operations, Navy armored troop carriers, preceded by minesweeping craft and escorted by armored boats, transported the soldiers along the vast network of waterways in the Delta. The units debarked upon reaching the area of operations or upon contact with the enemy. Small, specially designed craft with an aid station aboard, called aid boats, accompanied the troop boats into combat. A physician, attached to Company D during these riverine operations, went forward on an aid boat with the combat units. The aid boats functioned at night when most combat in the Delta took place. Casualties were evacuated to the ship-based rear aid station at the base anchorage by aid boats or by helicopters permanently assigned to the Mobile Riverine Force, at first by the Army and later by the Navy. The primary medical problem in riverine operations was ‘“‘immer- sion foot,” which was minimized by alternating units in combat every 2 or 3 days. While the fresh troops sustained the attack, those units relieved were allowed to “dry out” and refit. Riverine operations brought extensive modifications in the use of personnel and equipment as well as in the structure of Company D. Ground ambulances and tents were eliminated. The aid station, as noted, was split into two sections. One section remained aboard the vessel at the rear anchorage; the other accompanied the combat units. The two sections of the aid station were often separated for days. The section accompanying the combat units was split even further when DIVISION AND BRIGADE MEDICAL SUPPORT 91 two or three missions were conducted simultaneously in different areas. Since the physician attached to the company was almost always forward with the combat elements, the medical operations assistant, a Medical Service Corps officer, usually supervised the rear section at the base anchorage. This officer and the senior enlisted medical aidmen he super- vised had considerably greater responsibility for the treatment and evacuation of patients than was customary. Casualties requiring more extensive care than could be provided in the rear section were evacuated by helicopter to a hospital. Helicopters as well as shuttle craft were used to supply the aid boats from the ship-based rear section. The rear section itself was supplied from shore. 4th Infantry Division The 4th Infantry Division was deployed to Vietnam in July 1966. Each brigade moved by sea with all its supporting elements. Thus, the attached medical company was able to maintain a continuous record of the health of the command. _Although one brigade of the 4th Infantry Division was initially posi- tioned in the coastal area of Phu Yen Province in III CTZ, the entire division was deployed to the Central Highlands by the end of 1966 to counter the steady buildup of North Vietnamese units in that region. During 1967, the division, and its predecessors in the Central Highlands, the 101st Airborne and the 25th Infantry Divisions, remained on the defensive. The brigades of these divisions were moved from one location to another in a series of spoiling operations as the need dictated, making it expedient at times to attach, detach, or exchange components of one division with those of another. An example of this practice was the exchange between the 3d Brigade, 4th Infantry Division, and the 3d Brigade, 25th Infantry Division. The 3d Brigade, 25th Infantry Division, was operating in the Pleiku area when the 4th Infantry Division arrived in II CTZ. Thus it was assigned to the 4th Infantry Division along with its attached medical company. The 3d Brigade, 4th Infantry Division, and its attached medical com- pany operated as a separate task force in the area of operations of the 25th Infantry Division. It was therefore inactivated and reactivated as the 3d Brigade, 25th Infantry Division. The exchange permitted direct operational control over these units. The medical companies exchanged became components of the medical battalions organic to their new divi- sions, the 4th and 25th Medical Battalions of the 4th and 25th Infantry Divisions, respectively. Army-level medical support for the 1st Brigade, 4th Infantry Divi- sion, operating in the Tuy Hoa area, was provided by the 8th Field Hospital at Nha Trang. The 18th Surgical Hospital, supplemented by 92 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM the 71st Evacuation Hospital in late 1967, serviced the main base camp at Pleiku. United States forces in the Central Highlands went on the offensive in 1968 and 1969. Predicated on the mobility of the helicopter, landing zones and fire support bases were set up temporarily and operational sweeps were conducted from these sites. Since combat units were widely dispersed, it was necessary to subdivide the medical assets supporting them to insure the best coverage. The “light” clearing station was evolved for this purpose. Under this concept, teams, each consisting of a physician and from seven to 10 medical enlisted men, deployed to the landing zones or fire support bases with the units they supported. These operations usually lasted from several days to several weeks. The forward area “light” clear- ing station worked in unison with the main components of the parent medical company at the semipermanent base camp in the rear where treatment facilities were housed in protected bunkers. The purpose of the “light” clearing station was to prepare the casualty for helicopter evacu- ation to the main section at the base camp. At this field station, casualties were quickly sorted out as to seriousness and type of wound to allow the worst cases to be evacuated first. An innovation in field medical service, the “light” clearing station allowed medical support to be provided con- currently at the base camp and in the field. As combat activities diminished in 1970, the operations of the 4th Infantry Division were curtailed. In April 1970, the 3d Brigade, 4th Infantry Division, with its attached support elements, including Company D, 4th Medical Battalion, departed Vietnam for the continental United States. The other three companies of the 4th Medical Battalion remained in Vietnam to support the division base camp at Pleiku and the combat activities of the 1st and 2d Brigades of the division in the Central Highlands. To support the mission of the 4th Infantry Division in the Cambodian incursion during May and June 1970, the 4th Medical Battalion posi- tioned a clearing station at a fire support base close to the Cambodian border. Use of the six Dust-off helicopters assigned to support the clearing station was dictated by the nature of the operation. Two maintained an orbit over the landing zone, two remained on standby at the clearing station, and two were retained on call at the base camp. The majority of casualties from the Cambodian incursion received initial medical treat- ment at the 4th Medical Battalion’s clearing station on the border. 23d (Americal) Infantry Division Task Force OrecoN, which later became the 23d (Americal) In- fantry Division, was formed in April 1967. Operating from bases at Duc DIVISION AND BRIGADE MEDICAL SUPPORT 93 Pho and Chu Lai, it moved into Quang Ngai and Quang Tin Provinces south of Da Nang along the coast. Its mission was to free Marine units operating in I CTZ South to reinforce the area southwest of Da Nang and near the Demilitarized Zone in I CTZ North where the enemy threat continued to grow in size and intensity throughout 1967. The task force was composed of the 196th Light Infantry Brigade, the 3d Brigade, 25th Infantry Division (later the 3d Brigade, 4th In- fantry Division), and the 1st Brigade, 101st Airborne Division. Formed as separate brigades, each had an attached medical company. Thus, the task force did not have a medical battalion. Medical planning and supply functions were provided by adding specialized administrative personnel to the staff of the task force surgeon, thus giving him the equivalent of a divisional medical battalion staff. Task Force OREGON having accomplished its mission, the 23d (Amer- ical) Infantry Division was formed in September 1967 for sustained com- bat operations in I CTZ. At that time, the 3d Brigade, 25th Infantry Division, and the 1st Brigade, 101st Airborne Division, were replaced by the 198th and 11th Light Infantry Brigades which had just arrived in Vietnam. These joined the 196th Light Infantry Brigade as organic com- ponents of the Americal Division. The 3d Brigade, 1st Cavalry Division (Airmobile), supported by Company A, 15th Medical Battalion (Air- mobile), and the 3d Brigade, 4th Infantry Division, supported by Com- pany D, 4th Medical Battalion, remained as attached units of the division. Initially, the 23d Medical Battalion, which was formed in December 1967 to support the Americal Division, operated with only a Headquar- ters and Company A since the other medical companies were organic to their brigades. When the Americal Division was reorganized under the ROAD (Reorganization Objective Army Divisions) concept in February 1969, three companies were added to the battalion and it was authorized a strength of 38 officers and 333 enlisted men. Medical service in the Americal Division was a mixture of the old and the new. Casualties were evacuated from the forward area mainly by helicopter, but ground ambulances were used extensively for routine re- supply, nonemergency patient evacuation, and to support MEDCAP (Medical Civic Action Program). Ground ambulances were also used extensively in the Chu Lai base area, which was more than 9 miles long, and by medical units stationed at brigade and battalion base areas along Route 1 in the Duc Pho and Chu Lai regions. Since the size of the Americal Division’s area of operations entailed fairly long air ambulance flights, medical companies were stationed at remote inland bases, such as Duc Pho. These companies retained sick and lightly wounded soldiers for early return to duty, and also provided emer- gency resuscitation of the severely wounded in preparation for the long helicopter flight to a hospital. 94 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Battalion aid stations at the firebases were near the areas of extensive combat and could provide emergency medical treatment. Inclement weather often made it impossible to evacuate patients immediately, and the battalion surgeon was on hand to care for the seriously wounded. He was also available to advise the battalion commander on medical matters and, when necessary, could use the tactical communications net to assist his aidmen in the field. Since there was no evacuation hospital in the Americal Division’s area of operations—the nearest evacuation hospitals were located at Qui Nhon, more than 125 miles from Chu Lai—patients with predictable recovery rates were retained longer than normal at the medical clearing companies. Seriously wounded or critically ill patients were evacuated to the 2d Surgical Hospital or the 1st Marine Hospital Company at Chu Lai. The companies of the 23d Medical Battalion were housed in semi- permanent installations. Throughout 1968 and 1969, patients were held for a period of 7 days at these clearing stations. At times, they were held longer, but this was the exception. Admissions to the clearing stations of the 23d Medical Battalion involving nonbattle injuries exceeded those resulting from hostile action; fever of undetermined origin was a primary cause for hospitalization. The 23d Medical Battalion was also responsible for treating sick and wounded Vietnamese civilians. During the period from 1 January to 31 December 1969, the combined companies of the battalion treated 21,891 Vietnamese patients. While much of this treatment was outpatient care for the often neglected peasant in the villages and hamlets, a large percentage of more definitive medical, surgical, and rehabilitative treat- ment was done on the wards of the 23d Medical Battalion. Company B, 23d Medical Battalion, for example, maintained a civilian war casualty ward which accommodated 30 Vietnamese patients. The ward was con- stantly full and averaged about 110 patients a month. While constantly engaged in care of the sick and injured, the 23d Medical Battalion also conducted a vigorous program to train Vietnamese health workers so they could assume greater medical responsibilities in their own villages and hamlets. Medical Support of Separate Infantry Brigades Several brigade-sized units with organic or attached medical com- panies operated in Vietnam. These included the 11th, 196th, and 198th Light Infantry Brigades that later became the 23d (Americal) Infantry Division, with their organic medical companies still intact. Others were the 3d Brigade, 82d Airborne Division, the 3d Brigade, 5th Mechanized Division, the 199th Light Infantry Brigade, the 173d Airborne Brigade, DIVISION AND BRIGADE MEDICAL SUPPORT 95 and the 11th Armored Cavalry Regiment. The medical companies of these units operated independently of any higher headquarters in contrast to their divisional counterparts which were under the command of the division’s medical battalion. The medical companies of the 199th Light Infantry Brigade and the 173d Airborne Brigade were organic to their support battalions, the 6th and 173d Support Battalions, respectively. On the other hand, the 3d Brigade, 82d Airborne Division, and the 3d Brigade, 5th Mechanized Division, belonged to the division structures even though they operated as separate brigades. Therefore, their medical companies were attached and not organic. The 37th Medical Company, which supported the 11th Armored Cavalry Regiment, differed from the others in that it was neither an element of a support battalion nor a medical battalion. It had been specifically tailored for an armored cavalry regiment. 37th Medical Company At the beginning of 1969, the function of the 37th Medical Company was to support the 11th Armored Cavalry Regiment operating in the Blackhorse area. Since all combat casualties from January through April 1969 were treated at the 7th Surgical Hospital, which was adjacent to the 37th Medical Company’s clearing station, the company limited its activities to routine sick call and vigorous support of MEDCAP. In May 1969, the 7th Surgical Hospital was inactivated. The 37th Medical Company inherited its superior facilities and reorganized its treatment capability considerably. The emergency room and ward were expanded, the dental clinic was enlarged, and an X-ray unit was installed. At the same time, a section was deployed to Quan Loi to support com- bat operations in the forward area. When the 37th Medical Company was assigned the task of support- ing the 3d Brigade, 1st Cavalry Division (Airmobile), which was also operating in the Blackhorse area, in May 1969, a mutual support pro- gram was established with Company C, 15th Medical Battalion (Air- mobile), 1st Cavalry Division (Airmobile), with which the 37th Medical Company shared its facilities. During the summer months, the 37th Medical Company received an average of 2.7 casualties a day, who were evacuated to the rear clearing station by a medical evacuation helicopter from the 15th Medical Battalion (Airmobile). The superior facilites at this rear station, especially the X-ray unit that had been installed, per- mitted many less serious battle injuries to be treated entirely at the clear- ing station level. When the 199th Light Infantry Brigade replaced the 1st Cavalry Division (Airmobile), the 37th Medical Company, in co-opera- tion with Company C, 7th Support Battalion, 199th Light Infantry Brigade, continued to provide routine sick call and casualty support in 96 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM the area. Early in December 1969, the main body of the 37th Medical Company was deployed in Quan Loi to support the elements of the 11th Armored Cavalry Regiment. A small element was based at Bien Hoa to take advantage of access to the supply depot at Long Binh. Task Force Shoemaker Task Force SHOEMAKER, which participated in the Cambodian incursion, was composed of the 1st Brigade, 1st Cavalry Division (Air- mobile) ; the 11th Armored Cavalry Regiment plus the 1st Squadron, 9th Cavalry Regiment; the 2d Battalion, 47th Mechanized Infantry Regiment; the 2d Battalion, 34th Armored Regiment; the 5th Battalion, 12th Infantry Regiment; and the 5th Battalion, 60th Infantry Regiment. The medical support of this operation illustrated the flexibility of the medical service in offensive sweeps by brigade-type units. The task force received its medical support from elements of the 15th Medical Battalion (Airmobile) and the 37th Medical Company at the base camp at Quan Loi, near the center of the intended zone of opera- tions. In addition two clearing stations in protected bunkers existed at this site. A forward command post of the 15th Medical Battalion (Air- mobile) was added to Company C, 15th Medical Battalion, and the 37th Medical Company, the units operating the two clearing stations. A special emergency medical team composed of a physician, two clinical technicians, three aidmen, and a radio operator was formed out of the Headquarters and Company A, 15th Medical Battalion (Air- mobile). Available for duty anywhere in the task force’s area of opera- tions, it established a forward emergency treatment station at Katum where an aid station existed. Flown in with its equipment by helicopter, the team was functioning within an hour. A medical helicopter remained on station with the team. In anticipation of many casualties, the bulk of the whole blood supply in Vietnam was moved forward for use by the 37th Medical Company and Company C, 15th Medical Battalion (Airmobile). The estimate of 500 to 800 casualties within the first 3 days of the operation failed to materialize, and the usable portion of the whole blood supply was re- turned to the 9th Medical Laboratory for redistribution. The Air Ambulance Platoon, 15th Medical Battalion (Airmobile), moved up to Quan Loi for the operation. The platoon leader and his operations assistant were joined by the battalion commander, S-3, and an assistant of the 15th Medical Battalion (Airmobile) to co-ordinate the use of medical assets. Two helicopters were assigned to the 37th Medical Company in direct support of the 11th Armored Cavalry Regiment while three others operated out of Quan Loi with Company C, 15th Medical Battalion (Airmobile). Other medical evacuation helicopters were sta- DIVISION AND BRIGADE MEDICAL SUPPORT 97 tioned at landing zones and fire support bases. A Dust-off helicopter re- mained on standby at Quan Loi to evacuate casualties from the clearing station to a hospital. After 4 days, the task force was dissolved and the 1st Cavalry Division (Airmobile) took over the operational control of all the former com- ponents of the task force. Operations shifted eastward inside of Cam- bodia north of Bu Dop. A second emergency medical team from Head- quarters and Company A, 15th Medical Battalion (Airmobile), was emplaced at Bu Dop. To summarize the operation, the 15th Medical Battalion (Airmobile) moved a “jump” command post forward to Quan Loi, which consisted of the battalion commander, S—3, an assistant, and the air ambulance platoon leader and his operations officer. Two emergency medical teams were established, one at Katum and one at Bu Dop. Each team treated about 30 emergency cases. The air ambulances of the 15th Medical Bat- talion (Airmobile) were positioned at a variety of places within the area of operations to insure adequate evacuation capability. The 45th Medical Company (Air Ambulance) provided one helicopter on standby at Quan Loi for the backhaul missions in addition to a liaison officer in the forward area with the medical battalion. This arrangement proved to be one of the key factors in providing the best possible medical care to the combat troops involved in the Cambodian operation, Trial Reorganization By mid-summer of 1967, it was apparent that the impact of the heli- copter on the doctrine and organization of field medical service was not transitory. The almost exclusive reliance upon the helicopter ambulance had virtually eliminated the battalion aid station, and often the division clearing station, from the chain of evacuation when a surgical, evacua- tion, or field hospital was within the same flying time or distance. Many medical officers with combat experience in Vietnam agreed that the reliance upon the helicopter was not a condition that was limited to the peculiarities of the Vietnam conflict. Enough experience in a variety of operations over the previous 2 years had been accumulated to support the belief that the time had come to conduct the appropriate tests so that modifications could be instituted. A hundred physicians were interviewed in the field, often under combat conditions, as to their recom- mendations. Their reports were analyzed along with the critiques that had been solicited over the previous 2 years. It was apparent that realignment of personnel and organization was needed to allow for a more efficient application of medical assets. The consensus was that there were too many physicians in the division and brigade medical organization to make full use of their talents. Plans for 479-653 O - 73 - 8 98 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM a new alignment were developed and tested by the 1st Infantry Division from October 1967 into March of the following year. It was estimated, on the basis of the test, that the number of physicians in the division could be reduced from 34 to approximately 12 without impairing the quality of medical care available to the troops. During the test period, the brigade surgeon, artillery battalion surgeon, and engineer battalion surgeon positions were eliminated. The artillery and engineer battalions retained their medical sections as did the aviation battalion and cavalry squadron. The medical battalion was moved from the support command to division control and the infantry battalion medical platoons were placed under its direct command. Thus the medical battalion commander controlled all medical resources. As a result of the test, all the brigade, artillery, and engineer surgeon positions were eliminated from the division medical organization. One- half of the wheeled ambulances and their crews were eliminated from the medical battalion while the medical platoons of the infantry battalions were reassigned to it. Operational control of the entire division medical service was delegated to the division surgeon. Exact utilization of medical officers varied with each division and brigade, but by the end of 1970, all were operating under the general concept that physicians should not be assigned to combat and combat support units. CHAPTER VII Aviation Medicine Approximately two-thirds of the Army aviation resources supporting operations in Vietnam were assigned to the units of the Ist Aviation Brigade. The remaining aircraft and men were assigned to those units organic to the divisions; relatively few were assigned to artillery, engineer, aircraft maintenance, signal, or other support units. Although the strength of the 1st Aviation Brigade was not much greater than 25,000 men, its approximately 50 flight surgeons provided primary medical care on an area basis to more than 35,000 troops. In some areas, the dispensaries of the Ist Aviation Brigade were the only source of outpatient care. The medical units of the brigade established liaison and close working rela- tionships with their nearest supporting hospitals, referring patients for consultations, inpatient care, and specialized treatment. The flight surgeon is a physician who has received formal training in the specialized field of aviation medicine. His mission includes the pre- vention and treatment of disease, injury, and mental or emotional de- terioration among aviation flight, ground crew, and maintenance personnel. He monitors the programs of flyers and is expected to par- ticipate in frequent flights. He is confronted by the problems of traumatic injury; of acute and chronic disease, ranging from the common upper respiratory infections to the most uncommon of tropical diseases; of psychiatric disorders, which run the gamut from occupational fatigue through the minor disorders of personality to overt psychoses; and of personal hygiene and environmental sanitation, including dietetics, venereal disease, insect control, and a multitude of bizarre and homely worrisome matters. The flight surgeon treats physical and mental condi- tions that might endanger pilots or passengers. Whether in the examina- tion room or upon the flight line, he must be able readily to detect incipient major and minor disorders of personality in men who, in their zeal to fly, frequently try to conceal the disorders. He administers and prescribes medications and treatment, and he reviews and studies the case history and the progress of the patient. He also acts as consultant in his specialty to other medical services and provides aeromedical staff advice. In addition, the flight surgeon serves as medical member of air- craft crash investigation teams and, when possible, contributes to aero- medical research and development. 100 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM The number of flight surgeons authorized in Vietnam reached a maximum of 86 in August 1968; by November, 98 were actually assigned there. This maximum contrasted with shortages during such periods as August 1967, when these assignments fell to 40 percent below the au- thorized strength. The flight surgeon, assigned to a unit of an aviation brigade, was supported by a medical detachment team which provided dispensary service. These teams were assigned generally on a basis of one detachment per two aviation companies. The unit flight dispensary was usually located next to the airfield, often in a unit billeting area, and the flight surgeon and his staff usually lived with the troops that they served. This arrange- ment, allowing for optimum rapport and medical services, was especially advantageous when the airfields were under attack, and it proved vital during the 1968 Tet Offensive, when many airfields were isolated. Flyer Fatigue The aeromedical problems that faced Army aviation units in Vietnam provided a challenge to their supporting flight surgeons. No problem, however, was more common yet more elusive than that of flyer fatigue. It became more pronounced after 1965 when the buildup of U.S. forces gained momentum and remained a significant limiting factor in the con- duct of airmobile operations. By the end of 1966, aviators were flying 100 to 150 hours or more per month, and the need to know how much an aviator could fly before he was so fatigued that he was no longer effective or safe was evident. Army aviators were assailed by a multitude of stresses, each to some extent capable of endangering their missions. The stress from hostile fire was aggravated by such factors as heat, dehydration, noise, vibration, blowing dust, hazardous weather, exhaust from engines and weapons, and labyrinthine stimulation. Additional stress was caused by psychic elements, such as fear, insufficient sleep, family separation, and frustra- tion. These stresses, acting on the aviator day after day, combined with the physical exertion of long hours of piloting an aircraft, caused fatigue. The ever-increasing requirements during the years 1967-68 for avia- tion support caused the accrual of extremely high aviator flying times in all units. Night operations, with their extra demand upon the critical judgment of the aviator, increased. The shortage of crews often forced an individual to undertake both day and night missions without adequate rest. In response to expressed concern of the unit commanders and of avia- tion safety officers, flight surgeons at all levels of aeromedical support studied every aspect of the fatigue problem. Because fatigue was the result of many variables, it defied easy definition and precise measurement. AVIATION MEDICINE 101 Emphasis, therefore, was placed on prevention—eliminating or reducing those factors in the aviator’s environment that caused stress. General Neel, Surgeon, USARV, noted in the Command Health Report for August 1968 that approximately 70 percent of aircraft acci- dents were found to be the result of pilot error and that pilot fatigue had been implicated as a contributing factor in a large proportion of acci- dents. He indicated that the only way to cope with pilot fatigue was pre- vention by reducing the aviator’s flying hours. His recommendation was “that immediate action be taken to provide additional aviators to USARV insuring at least 100 percent authorized aviator strength to reduce the degree to which pilot fatigue is contributing to the loss of lives and expen- sive aircraft.” This was never done. The unit flight surgeon’s close scrutiny of charts that showed each pilot’s flying hours for the previous 30 days, followed by close co-opera- tion among the unit commander, platoon leaders, operations officer, noncommissioned officers, and flight surgeon, proved an invaluable system for collecting data on which the flight surgeon based his final recommendation to the commander. By the end of 1968, this system was utilized by most of the aviation units. Some flight surgeons, notably Captain Philip Snodgrass, MC, of the 269th Aviation Battalion at Cu Chi, believed that the relationship of days flown to days off and, particularly, the provision of a scheduled “on-off” work cycle were more important than the total number of hours flown. Captain Snodgrass’s staff study of a “goal-directed” flying- hour schedule indicated that a series of 5 or 6 days flown, followed by a scheduled day free from flying and from other duties, resulted in a unit that evidenced less fatigue and could fly even greater numbers of hours. This idea was adopted by many units and proved workable and effective. Fatigue in the enlisted crew members was a less obvious, though very real, threat. These individuals, who accompanied the aircraft on all its missions, returned to their base camps only to work many additional hours in providing required maintenance and preparing for the following day’s missions. With the added requirement of aiding in perimeter defense and in the multitudinous other details of combat aviation, they performed under great stress. Efforts by the unit flight surgeons in their behalf centered upon improving their living conditions, eliminating some extra duties, and increasing their numbers. By 1970, fatigue as an entity was still no better defined nor more capable of measurement than before. Moreover, the attempt at limit- ing aviator flying hours by regulation had been proved ineffective in the combat environment, and the requirement for continued study of the problem was evidently needed. 102 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Care of the Flyer Program Flight Physicals The problem of performing periodic physical examinations on flying personnel began with the first Army aviation unit in Vietnam. Equip- ment and facilities were not available for an adequate examination. This handicap was partially overcome by Department of the Army waiver of the requirement for routine periodic examinations for rated aviators in Vietnam; however, despite the waiver, many still requested them. Periodic examinations for crew chiefs, flight surgeons, and aerial ob- servers were also waived; required initial examinations were performed as well as available equipment allowed. Modifications of organization and the addition of equipment helped eliminate these difficulties. Aerial door gunners were not given a complete examination. After reviewing their medical records, the flight surgeon gave them a general examina- tion which included visual tests and their “Adaptability Rating for Mili- tary Aeronautics.” A statement of medical qualification was then issued by the flight surgeon. Waiver authority was retained by USARV headquarters for medical standards for pilots, crew chiefs, flight surgeons, and aerial observers. Headquarters policy on standards for pilots was strict. Policy on stand- ards for others who were expected to participate in aerial flights was considerably more lenient; conditions were waived if they were not dangerous to the individual’s health and would not interfere with mission completion. Significant Medical Conditions The incidence of infectious disease among aviation personnel in Vietnam generally paralleled that of other troops in the area. Many diseases, however, were more serious for flying personnel because of possible time lost from primary duties. Basic preventive medicine, there- fore, was of prime importance to the unit flight surgeon. Diarrhea and upper respiratory infections were particularly costly in terms of aviator availability. Aviation companies normally operated a single mess and, on some occasions, were rendered ineffective for short periods because of epidemic gastroenteritis. Food and ice procured from local handlers were frequent sources of these outbreaks despite constant screening and surveillance by the flight surgeon. Venereal diseases, nota- bly gonorrhea, were of particularly high incidence. Breakdowns in basic field medicine practices and water supply con- trol occurred. Individual soldiers were occasionally charged with the treatment of water without adequate knowledge of the techniques in- volved. Failure to maintain adequate chlorine residual and even the AVIATION MEDICINE 103 accidental use of nonpotable supplies presented problems. In April 1968, in the 1st Cavalry Division (Airmobile), thousands of cases of gastro- enteritis severe enough to cause loss from duty occurred almost simul- taneously, and many more men were symptomatic without loss of duty. Investigation implicated contaminated water. The 164th Aviation Group, located in the Delta region with headquarters at Can Tho, had out- breaks of hepatitis during the summers of 1967, 1968, and 1969. Mass immunization with gamma globulin was required to abort these episodes, some of which apparently originated from using nonpotable ice and frequenting Vietnamese food establishments. Aircrews frequently encountered skin disorders, often miliarial or fungal in etiology. The long hours of flying while dressed in protective equipment and the intense dust clouds raised by helicopter operations contributed to the adverse dermatological environment. External otitis sometimes caused restriction of flying duties. Malaria was significant only sporadically. Basic mosquito control measures were effective in secure base areas, and it was there that air- crews usually spent their evenings. The continuous presence of the avia- tion unit flight surgeon with constant emphasis on preventive medicine techniques and health education for the aviator undoubtedly contributed to the low incidence. Medication and Therapy Traditional aeromedical philosophy on the use of drugs by flying personnel is conservative. AR 40-501 and AR 40-8 specifically limit their use. The flight surgeon’s duty was to promote a state of individual fitness that allowed the flyer to meet the myriad stresses of combat flying. Ideally, the use of systemic therapeutic agents should have been pro- hibited in Vietnam, as they are elsewhere, but realistically, the unit com- mander needed the maximum number of personnel to carry out his mission. It was the duty of the flight surgeons to evaluate the risk of using therapeutic and prophylactic agents against the impact of losing personnel to flying duties while undergoing treatment. On this basis, the flight surgeon frequently administered certain drugs without re- stricting the aviator from flying, and other drugs after careful eval- uation of the pilot’s condition and his particular response to the drug. When the acute medical condition of an aircrewman did not prohibit flying status, he was often allowed to fly after a period of drug use to determine his susceptibility to side effects. Antibiotics and decongestants were used but antihistaminics, sedatives, and tranquilizers were prohibited. Aviation personnel had to take the weekly malaria chemoprophylactic tablet; those who exhibited significant side effects were evaluated by the 104 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM unit flight surgeon and placed on chloroquine tablets if the reaction was due to the primaquine component. Many aviation units required their men to take the chloroquine-primaquine tablet on Monday night rather than on Monday morning because of the diarrhea that sometimes OC- curred shortly after ingestion. The incidence of glucose-6-phosphate de- hydrogenase deficiency was low. Dapsone, when introduced in Vietnam, was used only where rec- ommended by the appropriate medical authority; a very low incidence of methemoglobinemia was evaluated in the 7/17th Air Cavalry Squad- ron by the unit flight surgeon and the WRAIR team in Saigon. The incidence of fungus infections prompted therapy with griseofulvin in selected aviators, who continued to fly during long-term treatment. Throughout the years of Army aviation operations in Vietnam, the practical approach to the question of therapeutic agents turned out to be effective. Safety Accidental injury was a source of significant personnel loss. Aircraft accidents, until the spring of 1968, caused more aircrew injury and death than did enemy action. Less spectacular but also significant were those casualties caused by weapons accidents, vehicle mishaps, and sports. Relatively simple injuries removed the patients from flying duties for the duration of treatment. All flight surgeons participated in the flight safety program at all levels of command. In addition to their constant fatigue monitoring and their vigilant protection of the mental, emotional, and physical health of all aircrews, they served as advisers in evaluating and proposing protective armor for both aircraft and aircrew. Aircrew Wound Experience The vulnerability of the helicopter when used as a tactical aircraft is extremely serious. The ways in which the vulnerability of the crew may be reduced is a significant matter. During 1965 and 1966, studies were made on the effectiveness of armor for both men and equipment. Al- though helicopter crashes frequently were caused by enemy fire, evidence existed that few were the result of injury to the pilot. By the end of 1965, crashes had caused 101 fatal and 79 nonfatal injuries, and “missiles and shells” had caused 43 fatal and 673 nonfatal wounds. Effectiveness of seat armor was implicit in the notation “most fatalities due to wounds of head, throat, and upper torso.” Medical input requested by the 1966 Army Materiel Command study group for a study in Vietnam was provided by representatives of AVIATION MEDICINE 105 USAMRDC (U.S. Army Medical Research and Development Command). In April 1966, Captain James W. Ralph, MC, produced a staff study on aviation casualty reporting for the Army Concept Team in Vietnam in an attempt to determine whether or not the data being compiled was being analyzed and could be applied to studies of protective equipment. With the collaboration of Major (later Colonel) James E. Hertzog, MC, Surgeon, Ist Aviation Brigade, and Aviation Medicine Consultant, USARYV, a form was developed for reporting wounds. In June 1966, USARV Regulation 40-42, “Wound Evaluation and Analysis,” was published, requiring that specific data be reported on all crewmembers wounded in Vietnam, and placing the responsibility for implementation upon the unit flight surgeon. By early 1967, only a small percent of wound incidence had been reported because of communica- tion and transportation difficulties. The number and locations of the medical facilities hindered the flight surgeons’ interviewing and record- ing the pertinent data on every wounded aircrewman. Late in the year, the regulation was amended to provide for reporting by the commander of the medical facility receiving an injured aircrewman; the amendment resulted only in total failure of the reporting system. Although the amount of wound data reported by flight surgeons in 1966 was meager, the available information showed that both personnel armor and aircraft armor were of great protective value. Life Support Equipment At the onset of Army aviation operations in Vietnam, crewmembers flew their support missions in H-21 aircraft, dressed in fatigues or U.S. Air Force issue coveralls, leather gloves, and 1959 model APH-5 flight helmets. With the exception of occasional flak jackets of Korean War vintage, any additional protection was provided by makeshift means. The aircraft were not armored and were relatively vulnerable to enemy fire. In general, survival kits were also makeshift. The need for measures to increase the survivability of aircrewmembers was evident. In 1962, the Army Materiel Command initiated a long-term research and development project to reduce the vulnerability of Army aircraft and aircrew. The results of this project and the related efforts of other com- mands, such as USAMRDC, provided much of the equipment lacking in those early years. Flight surgeons in the field provided impetus to this development effort. While crash-injury fatalities in aircraft hit by ground fire were three times those caused by bullet wounds, the need for protection from small arms fire was recognized through work done by the U.S. Army Ballistic Research Laboratories. By 1965, the H-21 helicopters had been phased 106 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM out of Vietnam, and all UH-1 aircraft were equipped with armored seats for the pilot and copilot. Unfortunately, the great need for an armored seat for the gunner and crew chief on UH-1 aircraft was never met in the field, although development was undertaken. Body armor of bullet-protective plates in a canvas carrier was intro- duced in 1965 for protection of the torso. It was widely accepted by air- crews. The pilot and copilot of the aircraft utilized the chest protection only, since they were otherwise protected by the armored seat. Body armor containing both front and back protective plates was worn by other crewmen of the aircraft. There are many documented cases of individuals sustaining direct hits on these protective plates without in- jury other than bruises. In January 1966, the Department of the Army approved a project for the development of flight clothing which would provide fire protec- tion, be compatible with cockpit design, and resemble the uniform worn by the foot soldier. Deliveries to Vietnam of a two-piece Nomex uniform began early in 1968, and by year’s end adequate quantities were on hand to meet all requirements. In 1969, the fire-resistant flight uniform, having been well received by aircrews, was made Standard A for the Army. Individually carried survival kits were considered necessary by most flight surgeons and aircrewmen in Vietnam early in the war. A variety of survival kits were developed and made available in quantity. How- ever, as experience accumulated in Vietnam, it was noted that survival kits were seldom utilized by the survivors of downed aircraft. Few persons were rescued if downed in hostile territory more than a few hours. The consensus of flight surgeons and other aeromedical personnel was that items of signal equipment were most valuable. The survival radio, if working, appeared to be the most important item in the location and rescue of downed aircrewmen. Recognition of this fact led to emphasis upon the continuing development of more reliable survival radio sets. Before 1961, flight surgeons had cited the need for better head pro- tection, including fragmentation protection. Early in 1967, after more than 6 years of development, the AFH-1 helmet, which met specifica- tions, was delivered to aviation units but proved to be too small for many of the aircrewmen. Major (later Lieutenant Colonel) Anthony A. Bezreh, MC, who, as aviation medicine consultant and 1st Aviation Brigade surgeon, had provided primary impetus to the improvement of items of safety equipment, reported the results of a survey done on this helmet. Later attempts at modifying it were largely unsuccessful, and until 1969, aircrews were wearing a mixture of APH-5 and AFH-1 helmets. AVIATION MEDICINE 107 In 1969, a new flight helmet, the SPH-4, incorporating markedly improved retention and noise attenuation qualities, was procured for use in Vietnam and received immediate acceptance in the field. It proved effective in the prevention of injuries and became Standard A early in 1970. CHAPTER VIII Preventive Medicine The Preventive Medicine Division, Office of the Surgeon, USARYV, was organized late in 1965 to advise the command on the incidence, prevalence, and epidemiological aspects of diseases which were likely to occur among U.S. Army combat soldiers and, therefore, to be hazardous to military operations in Vietnam. The 20th Preventive Medicine Unit (Field), formerly the 20th Preventive Medicine Laboratory, was the first preventive medicine unit deployed to Vietnam. Originally this unit and later four preventive medi- cine detachments functioned independently, but late in 1967, higher echelon technical support was required and the four detachments were assigned to the 20th Preventive Medicine Unit which then assumed re- sponsibility for the countrywide U.S. Army preventive medicine pro- gram. When the 172d Preventive Medicine Unit (Field) became operational on 29 July 1968, the responsibility for preventive medicine support in Vietnam was divided between the two units. Both units were assigned to the 44th Medical Brigade, and each was augmented by two detachments, one control team and one survey team. Thus, countrywide deployment followed, from Quang Tri in the north to Can Tho in the south. Communicable Diseases Malaria Steady progress in the reduction of malaria in Vietnam had been possible through vigorous command emphasis, improved preventive regimens, and increased control measures. A major change in the chloro- quine-primaquine chemoprophylaxis program was instituted with Change 1 to USARV Regulation 40-4. This change stipulated that units in high-risk areas were to take daily dapsone tablets in addition to weekly chloroquine-primaquine tablets as chemoprophylaxis against Plasmodium falciparum, the malarial parasite responsible for nearly 98 percent of infections occurring among troops. The command surgeon notified field commanders to enforce this change when manpower losses due to infec- tions with P. falciparum were greater than 20 cases per 1,000 per annum per major unit. The Wilson-Edeson test, adopted by the 172d Preventive Medicine Unit, to measure the amount of chloroquine in urine, was rapid and PREVENTIVE MEDICINE 109 convenient for field use. This test helped field commanders evaluate ob- jectively each unit’s malaria chemoprophylaxis program and resulted in a dramatic drop in the malaria rate in the units tested. Since slightly more than 80 percent of all cases of malaria occurred in combat units, it was the responsibility of field commanders to provide consistent and con- tinuous command emphasis on preventive measures. In addition to chloroquine-primaquine and dapsone chemoprophylaxis, personal pro- tective measures to control malaria were stressed. Skin repellents, aerosol insecticide dispensers, bednets, and headnets were in general use by field units. Combat units in remote forward areas received repellents and aerosol dispensers routinely. For personnel departing Vietnam, commanders were urged to insure that the malaria chemoprophylaxis records of all returnees were re- viewed as soon as possible after arrival at their new duty station to make certain that each returnee had signed a “malaria debriefing” statement. This procedure was recommended to prevent manpower loss and to limit the spread of malaria from infected soldiers to susceptible persons in the United States and other areas. Those individuals who had not completed the 8-week chloroquine-primaquine course and the 28-day dapsone course were to be given sufficient tablets to complete the malaria chemo- prophylaxis course they were on in Vietnam. Infectious Hepatitis Beginning in 1966, all troops in Vietnam were inoculated with gamma globulin during their first and fifth months of assignment to control infectious hepatitis. Later, as the troop strength increased, a system of selective priorities was set up for the use of this serum, based upon the premise of the greatest need. Most cases of infectious hepatitis were caused by eating or drinking contaminated food or water. The disease was of special concern when those infected were cooks or food handlers. Continuous efforts were made to inform all troops of the dangers inherent in consuming food purchased on the economy, where contact with the virus was unavoidable. Diarrheal Diseases The most common disease among U.S. soldiers in Vietnam was diarrhea. The rate for this disease showed seasonal variations with peaks each year during May and June, but the greater number of cases were sporadic and were usually caused by a breakdown in unit mess sanitation or by eating locally procured vegetables contaminated with Shigella and Salmonella. No specific etiological agent was identified for most of the diarrheal cases admitted for treatment. Shigellosis accounted for most cases for which an agent could be identified. 110 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM Measures were continued to improve mess and water sanitation and waste disposal practices, and to educate the soldiers in basic field and food sanitation. The use of disposable paper plates and plastic eating utensils eradicated a potential source of diarrheal disease—inadequately cleaned mess gear. Skin Disease Skin disease caused by prolonged exposure to wetness followed by secondary invasion of the injured tissue by fungal or bacterial agents was a problem among U.S. Army ground troops fighting in inundated areas during the monsoon season. The Office of the Surgeon, USARYV, recommended that all combat units be provided with zipper boots, inserts, and nylon socks. The most useful preventive measures were limit- ing participation in combat operations in wet areas to 48 hours, intensive foot care during the “drying out” period which followed, frequent changes of boots and socks, and prophylactic use of griseofulvin. Fever of Undetermined Origin Fever of undetermined origin was a major cause of morbidity in Vietnam. Elaborate studies were initiated before 1966 in an attempt to identify the etiological agent or agents involved. By 1968, through laboratory efforts, 40 percent of the admissions were identified as caused by arboviruses or other arthropodborne agents. The preventive measures used were insect sprays and bednets. Rabies As the U.S. Army troop buildup in Vietnam increased, there was a concomitant rise in the number of animal bite cases treated in USARV medical facilities. The major difficulties were the sheer number of pets acquired by Americans, the large number of small units and detach- ments scattered among the Vietnamese communities, and the lack of a meaningful civilian rabies control program. There were no cases of rabies among USARV personnel during 1965-70, although several thousand soldiers received the antirabies vaccine prophylaxis when the biting animal was not apprehended. To control rabies in pets, the preventive medicine rabies control program required that each unit commander determine the number of animals to be allowed in his area, that all animals be registered, and that each animal be vaccinated against rabies and restrained within the unit area. Little restraint of pets was ever noted in Vietnam. PREVENTIVE MEDICINE 111 Other Communicable Diseases Other communicable diseases of special concern occurred in Vietnam and could have become a threat with the increase of troop strength and acceleration of combat operations without an effective preventive medi- cine program. The admission rates for common respiratory disease and influenza remained relatively moderate from 1965 to 1970. Although an out- break of influenza in Hong Kong in July 1968 was caused by a strain of influenza virus sufficiently different to warrant concern over a prob- able pandemic, only a few cases appeared in military units in Vietnam. The monovalent vaccine became available in limited amounts in January and February 1969. Melioidosis, a glanders-like disease observed in rodents and occa- sionally in man, was rarely encountered by the Army before deploy- ment of troops to Vietnam. Pseudomonas pseudomallei, the causative agent of melioidosis, was cultured from samples of oil, market fruits and vegetables, well water, and surface water. These may have been the source of infection since man-to-man transmission was not observed. Recognition and early treatment were the prime factors in reducing the melioidosis mortality rate in 1968. Dengue fever was reported in small numbers during 1966, and scrub typhus cases in even fewer numbers. Immunization against typhus, rou- tine since late 1962, was temporarily discontinued on 25 February 1969, because available vaccines were not potent enough to protect individuals against louseborne typhus fever. Although both cholera and plague were prevalent during 1966 among the civil population of Vietnam, no cases of cholera occurred among U.S. troops from 1965 to 1970. As of 19 April 1968, five confirmed cases of plague and one unconfirmed case had occurred among U.S. Army personnel. Environmental Sanitation Field Sanitation Training Instructors in preventive medicine units and detachments continu- ously stressed basic hygiene and sanitation, malaria chemoprophylaxis, insect and pest control, waste disposal, and unit and individual protective measures against arthropodborne and waterborne diseases as well as other health hazards that caused discomfort to troops or damage to materiel. Water Supply Surveillance Major emphasis was placed on medical surveillance of field water points and cantonment water supply systems. Preventive medicine units provided first-echelon surveillance of water supplies for organizations 112 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM without assigned medical personnel, and second-echelon surveillance of water sup- plies for all others. The USARYV require- ment for free available chlorine in water was strictly enforced: 5.0 parts per mil- lion after 30 minutes contact at field water points and 2.0 parts per million at field consumption points. Preventive medicine units also pro- vided medical surveillance of iceplants, including residual chlorine and bacterio- logical testing of the quality of water. Ice consumed or used for chilling foods and TREVEN TIVE Men ICINE beverages was supplied by iceplants op- TD Ewe i Foobota vot erated by the Army or by Army-approved ~~ g,.cpack Spraver-Dus- local civilian firms. TER Waste Disposal Practice Monitoring waste disposal practices was another important preven- tive medicine activity; no major breakdowns in the waste disposal sys- tems were related to disease outbreaks. In general, field units used urine soakage pits, with or without “urineoils,” and “burn-out” latrines for the disposal of human excreta. For liquid wastes, oxidation ponds and sewage lagoons were used as well as septic tanks with soil absorption beds. Refuse—garbage, trash, kitchen wastes—was disposed of in sanitary fills. Infectious wastes from hospitals and other medical facilities were dis- posed of in high-temperature incinerators or by special packaging and burial. Food Service Sanitation Messkit sanitation procedures were almost totally unnecessary in Vietnam. Troops provided with rations used plastic trays, paper-plates, or, in rare cases, chinaware. The individual combat meal (C-ration) was usually eaten with the utensils provided with the ration. The use of food service disinfectants, an item of special interest for USARV annual gen- eral inspections, was emphasized. Pest Control Measures Pest control in USARV was an integrated program involving the co-ordinated efforts of unit field sanitation teams, contract engineer entomology services, and preventive medicine units and detachments. Unit self-help sparked by trained field sanitation teams was the backbone of the program. In addition to pest control, preventive medicine person- PREVENTIVE MEDICINE 113 nel provided first- and second-echelon support to unit programs and insured that field sanitation teams were trained. Contract engineer ento- mology services were provided at major installations and base camps throughout Vietnam by Pacific Architects and Engineers and by the Philco Ford Company. Preventive medicine units conducted ground fogging and mist operations in remote areas where contract entomology services were lacking. Close liaison and co-operation were encouraged by medical entomologists with engineer entomologists to insure rapid ex- change of information. The engineer program was unique in that it was the first time in recent history that the mission of pest control had been given on a broad scale to a civilian contractor in a combat zone. Quarantine and Inspection Procedures Early in the 1960’s, the Armed Forces Pest Control Board was desig- nated the co-ordinating agency for development of appropriate insect and rodent control programs for the Armed Forces. The Armed Forces had become increasingly aware of the real threat of accidental importa- tion into the United States from Vietnam of pests and diseases of agri- cultural and medical concern, The inherent problems of inspecting vast quantities of cargo at U.S. ports of entry demanded the establishment of a preshipment quarantine inspection program for military cargo. Quaran- tine inspection of vessels, aircraft, and retrograde cargo in Vietnam was part of a co-operative preventive medicine program between the Depart- ment of Defense, the USPHS (U.S. Public Health Service), and the USDA (U.S. Department of Agriculture), during 1969. More than 350 medical personnel of the Army, Navy, and Air Force were trained and certified as USPHS and USDA quarantine inspectors. A 24-hour daily inspection service was maintained at major maritime and aerial ports operated by the Armed Forces for incoming and outgoing cargo. In addi- tion, by special arrangement, cargo shipments were inspected and certi- fied at auxiliary ports located throughout Vietnam. Professional Conferences Three USARV preventive medicine conferences were held during a 12-month period in 1968 and 1969. These 1-day conferences were con- ducted as working seminars and included formal presentations and informal study groups. About 75 individuals attended each conference. Besides participants from all USARV commands, there were preventive medicine representatives of the Surgeon, USMACV; AID; and ARVN. The seminars and panel discussions covered all phases of preventive medi- cine and provided the means for exchange of information and the opportunity to profit from the experience of personnel in different areas of Vietnam. 479-653 O - 73 - 9 CHAPTER IX The Military Blood Program Time is crucial in the collection, delivery, and distribution of whole blood for large numbers of traumatic casualties. From 1965 forward, the stimulus behind the plans for a whole blood distribution program to support U.S. forces in the war in Vietnam was the need for speed. Blood is perishable, and its useful life is short. From donor to patient, liquified whole blood has a life expectancy of 21 days. Still, the most desirable blood for transfusion is the freshest blood available of the group and type specific for the recipient, completely and accurately processed and cross matched—a combination of perfections difficult to achieve in war. Evolution of the System The dominant conviction of the early blood program planners in USARPAC and USARV was that whole blood requires professional surveillance in handling from the moment it is drawn from the donor until the moment it is administered to the patient. Contaminated blood can be lethal. By 1965 and the buildup of forces in Vietnam, the time had come to move with haste. Fortunately for the planners, requirements for whole blood increased slowly in 1965 and not with the same explosive force experienced at the beginning of the Korean War. Another asset was the substantial number of directives and guides already written and the existence of the Military Blood Program Agency. Colonel Neel, Surgeon, USMACV, Major (later Colonel) Frank W. Kiel, MC, Commanding Officer, 406th Mobile Medical Laboratory, Vietnam, and Colonel Joseph F. Metzger, MC, Commanding Officer, 406th Medical Laboratory, Japan, in late 1965, were guided by three major principles based on experience gained thus far in the collection, processing, handling, and distribution of blood for troops in Vietnam. These medical officers, however, could not envision that requirements for whole blood would climb slowly but steadily from less than 100 units per month in 1965 to 8,000 units by February 1966, skyrocket to more than 30,000 units per month by 1968, peak at 38,000 units in February 1969; and fall rapidly to less than 15,000 units by mid-1970. (Chart 12) THE MILITARY BLOOD PROGRAM 115 CHART 12—UNi1rs oF BLoop AVAILABLE IN SouTH VIETNAM, BY MONTH, January 1965-DeceEmBER 1970? 40,000 30,000 AN A Ww UW, 20,000 “\_ poll] 10,000 = 1965 1966 1967 1968 1969 1970 !Includes shipments from the continental United States, the Pacific Command, and blood collected in South Vietnam. Source: Report, U.S. Military Whole Blood Program in Support of Combat Operations, South Vietnam, 1965-1970, prepared for the Deputy Surgeon General, February 1971. The first guiding principle was that a source of whole blood outside Vietnam and the Pacific Command was essential. Donor resources in the Pacific could not meet the demands for whole blood during the buildup. Second was the establishment of a central depot in Saigon where all whole blood shipped from Japan could be received, transshipped, and distributed for use in the field. Third was the need for a system of forward mobile blood storage subdepots operated by the Army and colocated with hospitals and medical units in the Army, Navy, and Air Force along the South Vietnam coast. A single American hospital in Vietnam, the 8th Field Hospital, ad- ministered all whole blood transfusions until the spring of 1965. Every 10 days, 10 units of universal donor low titer group O blood were shipped to the hospital from Japan to meet the small demand for transfusions. Seldom did the demand for blood exceed the supply, and even during the surprise attacks by the Vietcong at Qui Nhon and Pleiku, in Feb- ruary 1965, the 406th Mobile Medical Laboratory bled local donors to supply the needed 123 units of whole blood. After the 3d Field Hospital arrived in Saigon in May 1965, it became the central blood depot in Vietnam, and the 406th Mobile Medical Laboratory, a satellite of the 406th Medical Laboratory in Japan, was charged with distributing whole blood to all U.S. forces in Vietnam. 479-653 O - 73 - 10 116 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM In the meantime, with the expanding need for blood, reorganization of the whole blood program for PACOM (Pacific Command) was underway. Colonel Metzger was also designated Blood Program Officer, PACOM, with direct responsibility to CINCUSARPAC (Commander in Chief, U.S. Army, Pacific) for the co-ordination and integration of plans, policies, and procedures to insure blood for all areas in USARPAC, including USARYV. The embryonic whole blood distribution system in Vietnam con- tinued to expand and by 1967 was serving all Free World forces in Vietnam, excluding the RVN Army which met its own blood needs. The responsibility for supervising and operating the central blood bank in Vietnam came under the technical direction of Colonel Hinton J. Baker, MC, Commanding Officer, 9th Medical Laboratory, 3d Field Hospital, Saigon. The USARV Central Blood Bank operated under the parent laboratory’s 9th Medical Laboratory Detachment and was supported by personnel from the 3d and 51st Field Hospitals, and five subdepots in the blood distribution system: the 406th, 528th, and 946th Mobile Medical Laboratories at Nha Trang, Qui Nhon, and Long Binh, respec- tively; the Naval Support Activity Hospital, Da Nang; and the 96th Evacuation Hospital, Vung Tau. As troop strength grew and combat casualties increased, the task of distributing whole blood, plasma, and related products in South Vietnam developed into the largest blood distribution system ever undertaken by a single organization. Colonel James E. McCarty, MC, became Blood Program Officer, PACOM, in June 1968 and commander of the 406th in Japan at the same time. He and his predecessor, Colonel Metzger, visited South Viet- nam regularly, conferred with the surgeon, and inspected blood facilities throughout the country. Initial Sources of Whole Blood The primary source for whole blood used in South Vietnam until July 1966 was the 406th Medical Laboratory in Japan. Mobile bleeding teams were dispatched from the laboratory to donor resources in Japan, Korea, Okinawa, and Taiwan. A very valuable donor resource was found in the Yokosuka Naval Base when the Pacific fleet came in, and reserve donor resources also existed in Hawaii, Guam, and the Philip- pines. With vigorous command support and the dedicated work of blood- drawing teams, supply kept pace with demand until June 1966. Blood collections in PACOM rose from 201 units in January 1965 to 7,426 in January 1966 and 12,984 in June 1966. Blood collected in PACOM was processed and shipped from the 406th in Japan to large troop concentrations along the coast of South THE MILITARY BLOOD PROGRAM 117 Vietnam at Saigon, Nha Trang, Qui Nhon, and Da Nang. By 1965, it was apparent that this plan would not work because aircraft could not be scheduled economically from Japan to each of the four areas regularly enough to keep ‘the supply levels of blood at the proper level. Communica- tions between Japan and the coastal cities were poor, and shipments of blood often arrived in Vietnam without the knowledge of those persons handling it. Planners had also become sharply aware that blood could not be handled as a routine supply item even in a dedicated medical supply system. In short, by 1965 it was clear in PACOM that the whole blood distribution system should consist of a central depot in Saigon with several small mobile subdepots located in areas of high troop intensity. Agencies for Expansion of Blood Supply The Military Blood Program Agency In June 1966, the need for whole blood in Vietnam became urgent. Blood donor resources in PACOM had been exceeded, and the blood program officer estimated that 1,000 units of low titer group O blood per week would be needed. CINCUSARPAC sent a request to the MBPA (Military Blood Program Agency) to ship the needed blood to the 406th. Four years earlier, in May 1962, responsibility for implementing and co-ordinating the whole blood program in CONUS was delegated to the Secretary of the Army by the Secretary of Defense. Hence, The Surgeon General of the Army established the MBPA on 17 July 1962 to support emergency requirements for whole blood in war. The agency, staffed by medical officers of the three services, maintained close working rela- tionships with the U.S. Public Health Service, the Office of Emergency Planning, Executive Office of the President, and the American Red Cross. Armed Services Whole Blood Processing Laboratory The MBPA incorporated the donor collection and processing capabili- ties of the three military departments. Blood was collected by 42 donor centers designated by The Surgeons General of the Army, Navy, and Air Force and shipped by air to the triservice ASWBPL (Armed Services Whole Blood Processing Laboratory), McGuire Air Force Base. (Chart 13) All group O blood was titered, and after a thorough inspection and verification of groups, Rh types, and other essentials, blood was flown via Elmendorf Air Force Base, Alaska, to Yokota Air Force Base in Japan. At each point, shipments were re-iced, if necessary, and flown to the 406th Medical Laboratory in Japan. From Japan, whole blood was 118 MEDICAL SUPPORT OF THE U.S. ARMY IN VIETNAM CHART 13—MiLiTARY BLOOD PROGRAM AGENCY OPERATIONAL SCHEME FOR TriservicE COLLECTING-PROCESSING oF WHOLE BLoop To SHIP THROUGH THE ARMED SERVICES PROCESSING LABORATORY, MCGUIRE AIR FORCE Baskg, N.J., 1966-70 Unified and Specified Command : I Y ¥ Military Blood Program