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NAVY MEDICINE January-February 1994 Sarpoa Geaeral of the Navy NAVY MEDICINE Chief, BUMED VADM Donald F. Hagen, MC, USN Vol. 85, No. 1 January-February 1994 Dep•ty Sarpoa Geaeral Forum Dep•ty Claief, BUMED 1 Rethinking Tactical Medical Support in the Fleet Claief, Medical Corps CAPT A.M Smith, MC, USNR RADM Richard I. Ridenour, MC, USN Department Rounds 2 World War II Comfort Crew Reunites Editor Jan Kenneth Hennan LCDR J. Brado, MSC, USN 4 Reserve Dental Exercise JOTS '93 Assistaat Editor LCDR D. Wright, USNR Virginia M. Novinski Features Editorial Assistaat 7 How to Close a Naval Hospital Nancy R. Keesee J.K. Herman N.AVY MEDICINE. Vol. IS, No. I, (ISSN 019S..alll USPS 316-070) is pablilbecl bilaoalbly by the nep.n. 12 Assessment of the TQL Infrastructure in Navy Medicine meat at tile Navy, Burau at Meclic:iDc mel Surpry LT J.J. Johnson, MSC, USNR (BUMED 0911), WllhiDaton. DC 20372-5300. Second c:lau postap paid • Wllhiaaton, DC, ucl additional mailiDa oftic:a. 15 Health Psychology in the Navy: Emergence of a New Discipline POSTMAS1ER: Seadadclnuc:huaes toNary!kdi· LCDR G.M Goldberg, MSC, USN cbtec:.e Navy Public:atioasmd Forms Directorate, AT IN: Code 10363,S801 TaborAvcnuc,Pbiladelpbia,PA 19120. LCDR E. Carlson, MSC, USN POLICY: NaryM edic1 M is tbe official publicmon of LCDR B. Paige-Dobson, MSC, USN tbe Navy Medic:al Dep.tment. It is iateaded for Medic:al Oep.tmeat ~ ud c:ontaias professional iDforma· tion relative ta medic:iDe, cleatistry, IIIII the allied health 22 Chronology-World War II Navy Medicine January-February 1944 sc:ieac:es. Opiaions expressed .-e those oft he authors aad J. Mitchum do 1101 ~y represeat the official position of the Dep.r1menl of the Navy, the Burau of Medic:iDe aad Slqay,or•yad...-ataldeplrtmeatorapacy. Interview Trade -• are IISed for ideotificmon only m do 1101 represcala eador.-eal by the Oep.tmeat of the Navy 18 A Conversation With the Surgeon General or lbe a. .... of Medic:iDe llld Surpry. Allhoaah Nary J.K. Herman Mftlk-mayc :ite or extract froal direc:tives, authority for action sllould be obtaiDed froal ae c:ited refereac:e. DIS11UBUTION: Nary MaliciM is dilttibuted to Professional active duty Medic:al Oep.tmeat .,._ael via the Stm· 27 Photorefractive Surgery in the Navy dard Navy Dillribution List Tbe followiaa dillributioll is aulborized: one copy for each Medic:al, Deatal, Medic:al LCDR S. Schal/horn, MC, USN Service, IIIII Nune Corps officer; one copy for each I 0 ealiated Medic:al Department members. llequests to iD· craM or dec:raM the DUDiber ofa llotted copies should be In Memoriam forwarded to NarylthdiciM via tbe loc:al c:ommmd. 34 J.H. Bradley ... CAPT J.H. Ebersole, MC, USN (Ret.) ... LCDR N.AVY MEDICINE is published froal apprcpri•ed fimds by lllthority oft he Bureau ofMedic:iDe md Surgay N.E.G. Lopes, MSC, USN ... CAPT R.C. O'Connor, CHC, USN ... ia KCordanc:e witb Navy Public:alioas md Prilltiaa Rep· CAPT A.L. Smith, MC (Ret.) lations P·3S. Tile Secretary oftbe Navy bas cletamiDed - tbis publicmon is _, iD the ~on of busiDesa required by law of the Oepmmeat at the Navy. Notes and Announcements Faads for priatiDJ this public:atiaa bave beea approved by 21 Naval Medical Research and Development Command Highlights tile Navy Publications IIIII Priatiaa Policy Committee. Anic:lea,letten,llldadcbeuc:bqamay be forwarded to 33 Naval Health Sciences Education and Training Command Highlights the Editor, Nary AMdicilw. Dcpmmeat of the Navy, a- ofMedic:iae llld Surpry (BUMED 0911), Wah· iaatoa, DC 20372-S 120. Telcpboae(Area Code 202) 653· A Look Back 1237, 653·1297; DSN 294-1237, 294-1297. CcJatribu 37 Navy Medicine 1944 tions from the field .-e welcome IIIII will be publisbeclaa apace permits, subject to editiaJ aad possible abrid&ment. For sale by the Superiateadeat of Doc:umeals, U.S. Government Prilltiaa Office, WasbiDaton. DC 20402. COVER: V ADM Donald F. Hagen, MC, Surgeon General oft he Navy, reports on the state of the Medical Department in an interview with Navy Medicine, see page 18. Photo by HM2 Dan Kelly, NSHS, Bethesda, MD. NAVMED P·SOII Forum Rethinking Tactical Medical Support in the Fleet CAPT Arthur M. Smith, MC, USNR e Navy is beginning to explore and implement ordinarily be dangerous locations for treating and holding alternatives to a smaller carrier force. This in casualties. Hostage rescue efforts at sea have previously cludes changes in the number and types of ships in utilized specially trained medical personnel who were new battle groups. During deployments, elements of a placed aboard targeted ships via helicopter through either battle group may be split into smaller configurations of direct landings, rope drops, or other ingenious methods, ships and dispersed over larger areas to provide more for the purpose of treating casualties early, and saving extensive coverage ofa region. How will medical care be lives. Under "From the Sea," rather than splitting a task made available on many of these "dispersed ships," most force medical team among a dispersed task group, or having only modest medical facilities, neither configured attempting oftentimes dangerous ambulance mercy nor manned to manage the large numbers of casualties flights from affected ships, innovative means for bring that may suddenly arise from a single mishap at sea? ing specially trained operational medical teams to them Innovative programs are needed! On land, the British would appear imperative. Bringing help quickly to the Army Parachute Clearing Troop developed mobile surgi scene, where advanced treatment can be started immedi cal teams who backpacked all equipment needed for life ately, can actually save lives! saving interventions. These provided their major surgical Every student of naval history recognizes the dangers capability in the Falklands. The Israelis formed small, existing aboard any underway ship, in war or peacetime, highly mobile, independent resuscitation and emergency where even minor accidents can develop into major trag surgical units with their own transportation and carrying edies forsomecrewmembers. TheNavyordered a "Safety minimal equipment. They were configured for air drop or Standdown" in 1989 after 10 accidents at sea and in the air, backpack, and were used for surgical support of their within 3 weeks, killed 10 Navy personnel and injured at cross-canal attack against the Egyptians in 1973. least 71. As former CNO ADM Carlisle Trost noted atthe In 1990, during the prelude to the Gulf War, British time, "The bottom line is that safety of our personnel is a maritime forces placed a surgical support team aboard an fundamental obligation and responsibility ofleadership." ammunition ship, Fort Grange, to supply forward located These words still ring true today. Medical capabilities at emergency stabilizing surgery to injured fleet personnel. sea are an integral part of that same safety net! 0 This included a forward deployment team which carried its own gear. The team was capable of going forward aboard a damaged ship and could both resuscitate and stabilize casualties before transferring them. The team Dr. Smith is Clinical Professor of Surgery and Military Medicine could then act as escorts to undertake continuing care. atthe Uniformed Services University ofthe Health Sciences (USUHS), Our new naval strategy has a need for maintaining the Bethesda, MD, and Professor of Surgery (Urology) at the Medical sustainability of relatively isolated ships which would College of Georgia, Augusta, GA. January-February 1994 Department Rounds World War II Comfort Crew Reunites T wenty-seven former World past memories, their sacrifices, and USS Comfort (AH-6) was com War II Army and Navy crew their service to our country during missioned by the Navy on 5 May members ofh ospital ship USS World War II," saidLCDRJimBrado, 1944. She replaced the original hos Comfort (AH-6), including doctors, MSC, the hospital ship's assistant pital ship USS Comfort(AH-3)which nurses, medics, machinist mates, officer-in-charge and public affairs distinguished herself in World War I. boatswain's mates, electricians, and officer. "We want them to know Comfort's World War II mission firemen recently gathered on board they're not forgotten." began after she set sail for the South the current USNS Comfort (T-AH Since USNS Comfort(T-AH20) is Pacific to care for Allied sailors and 20), lay berthed in Baltimore, MD, the third ship to bear the name, this soldiers wounded during the island for a first-ever reunion on board their reunion had special meaning for many hopping campaign against the forces namesake ship. former crewmem bers who remember of the Japanese empire. (The hospital "This was a great opportunity for serving their country on the World ship was operated by aNa vy crew but former crewmembers to reflect on War II namesake. Army medical personnel staffed the Army/Navy crew members of the World War II hospi tal ship USS Com fort (AH-6) gather on the deck of the Navy's current USNS Comfort (T- AH 20). 2 NAVY MEDICINE What a modern hospital ship's operating room looks like. medical treatment facility aboard.) eight other people were injured. Ac During that campaign, the vessel had cording to one crewmember, the en six cruises and won two battle stars. emy plane penetrated the ship, finally She was decommissioned on 19 April stopping in an operating room, where 1946 and transferred to the Army on doctors were performing surgery. the same day. That is where most of the deaths oc Sea stories and war memories curred. Anothercre\\memberbrought abounded throughout the reunion, re the actual kamikaze's gunsight with kindling old friendships and enter him to the reunion. taining the present Comfort crew, as The heavily damaged ship was still the veteran Navy crewmembers and able to proceed to Guam where it Army medics from the 205th Hospi received a dispatch from ADM tal Complementtoured the mammoth Chester Nimitz, then Commander-in ship. Manyofthem were amazed that Chief, Pacific Fleet, highly commend the modern day vessel has 12 operat ing both the Army and Navy crew for ing rooms, 50 combat casualty re their cool and efficient response to ceiving emergency rooms, 100 inten the attack. Kamikaze gunsight: Bill Fadden shows off sive care unit (ICU) beds, and was The present day Comfort has a sis a souvenir from that day nearly 49 years the first ship to have a CAT scanner ter ship, the USNS Mercy(T-AH 19) ago when a suicide plane dove into his hospital ship. afloat. homeported in Oakland, CA. Both Twelve reunion shipmates recalled ships are part of the Military Sealift in great detail the fateful day, 28 April Command and are currently in Re or disaster relief mission. When the 1945 when a kamikaze crashed duced Operating Status (ROD); the ship is activated, the medical staff is through their ship's superstructure. ship, its medical equipment, and sup composed of Navy personnel who With approximately 500 patients on plies are maintained by small crews come from over 10 Navy medical board from the Okinawa campaign, of approximately 44 Navy personnel facilities, but primarily from the Na she was steaming 50 miles from the and 20 civilian merchant mariners. tional Naval Medical Center, coast and traveling fully lit in accor Comfort's crew keeps the ship and Bethesda, MD. D dance with the Geneva Convention her medical treatment facility ready when the kamikaze hit the starboard to achieve fu II operating status (FOS) - StorybyLCDRJimBrado, MSC, USNS side oft he deck amidships killing 28 within 5 days of activation for war Comfort. Photos by Tom Walsh, MSCLANT, persons, including 6 nurses. Forty- time contingency, or a humanitarian Bayonne, NJ. 3 January-February 1994 Reserve Dental Exercise JOTS '93 M embers of the 4th Dental Mobile Construction Battalion No. 5 lights, the room proved large enough Battalion, part of the 4th which was also working on the is for three dental chair work areas. Marine Division, spent land. Another operatory was placed in the 17 days on active duty in May 1993 Carriacou, a picturesque Caribbean local medical clinic across the street treating the inhabitants of the island island of roughly 13 square miles, is from the school. of Carriacou located just 20 miles inhabited by 6,000 citizens of the north of Grenada in the Caribbean. south Caribbean nation. The word Ingenuity and an Extension The exercise provided a rewarding "Carriacou" is a derivative of a Carib Cord or Two treatment environment unlike any Indian name meaning "island ofm any Before the Grenadines were an in thing in a typical Navy dental clinic. reefs." Scores of reefs surrounding dependent country, the island chain the island make the typically blue had been protectorate of the United Tasking Caribbean waters vary in shade from Kingdom. On Carriacou, electricity Members of the American diplo green to aqua. Not as developed for is supplied at 220 volts as it is in matic community in Grenada re tourists as Grenada, boat building and England. The dental equipmenttrans quested dental support through the raising farm animals are the main ported to the island from the United State Department and the occupations of the residents. States operates on 110 volts and would USCINCLANT command. USCINC During a site visit several months have been ruined had any of it been LANT directed the Marine Corps before the exercise, CDR Bob Carney plugged into the nearest outlet. Reserve to provide a field dental fa had met with several of the commu LCDR John Berg, DT2 Grant cility to treat residents of Carriacou nity leaders on Carriacou. It was de Abbott, and DT2 Bart Sudderth spent and nearby smaller islands. Called cided thatthe best place for the dental several hours working with employ JOTS '93 for Joint Overseas Training clinic would be in one of the class ees of the Carriacou electrical com Service, the operation included three rooms at the Hillsborough Middle pany running extra power lines to the Naval Reserve dentists and seven den School. schoolroom and setting up transform tal technicians. In addition to the field dental equip ers to convert the 220 voltage to 110. The 4th Medical Logistics Com ment, there was a dental chair and In the end, the Canadian equipment pany in Newport News, VA, shipped compressed air unit at the school left and one of the U.S. dental compres field dental equipment to Grenada by members of a Canadian dental sors were hooked up to operate the via U.S. Air Force transport. Once in group that had spent time on the is three dental operatories in the school Grenada, a Grenadian coast guard land in the late 1980's. room. cutter transported the equipment to A 20 by 15 feet classroom was After each day's work, the dental Carriacou. There dental technicians designated as the dental treatment gear was disinfected, and the school and dental officers loaded it onto area. Clean with cement floors, shut room was converted into a berthing waiting trucks provided by Naval ters for ventilation, and fluorescent area using cots and sleeping bags. 4 NAVY MEDICINE A collision during a cricket match re sulted in this frac tured maxilla and avulsed tooth. "Open Wide" patients were citizens of the Grena to work together. At approximately Soon the participants in JOTS '93 dine Islands. Of these, roughly one 1530 on a Wednesday afternoon a 14- settled into a daily routine. There were third of our patients were children. year-old schoolgirl collided with a always long lines of people waiting to Water for most oft he island's resi classmate during a game of cricket. see the American dentists. At 0700 dents comes from rain and is stored in The collision resulted in a compound DT2 Abbott and DT 1 Valerie Powell cisterns next to the house. With no fracture of the anterior maxilla and handed out cards to people who wished fluoride available to the residents of the avulsion of a front tooth. The girl to be treated. Although 15 cards for the island, dental decay proved to be was immediately brought to the den each dentists were distributed, they a real problem. Additionally, many tal clinic at the Middle School. After ended up seeing between 18 and 25 mothers did not understand the link the bleeding was controlled and the patients daily. Because so many between sugary liquids and nursing fracture reduced, Dr. Berg performed people wanted dental care those who bottle caries. Because of these fac root canal therapy on the avulsed tooth were not fortunate enough to receive tors, our group treated large numbers to prepare itforreimplantation. While a card were advised to see if the doc of carious primary teeth and saw the girl received care, Carriacou' s tors could work them in to the office scores ofc hildren with end-stage ram physician arranged for her transfer to by day's end. Usually there was a line pant decay. the government hospital on Grenada. waiting for appointment cards by In an attempt to explain the link Injust90 minutes from thetimeofthe 0515! between dental health and diet, DTCS injury, the student had been treated We were all touched by children Jill Fernandez, an instructor in the and was on a commercial flight to waiting with their mothers for hours pediatric dentistry department at the Grenada for definitive care. on end through the heat oft he day in New York University CollegeofDen Lisa Hamlet, a Jamaican-trained the hope of getting dental treatment. tistry, gave instructional lectures to dental Nurse, volunteered time and Most 2-week exercises involve children and schoolteachers on talent during the JOTS '93 exercise. treating dental patients who are on Carriacou and on the island of Petit In addition to treating pediatric pa active duty or are attached to the Re Martinque. tients under supervision of the Navy serve forces. JOTS '93 was unique for During our stay on the island, one dental officers, she provided valuable the types of patients seen and the incident in particular proved how well insight into the lives of the residents procedures performed. Almost all members of the exercise had learned of Carriacou. Her ability to calm January-February 1994 5 LCDR John Berg takes an X-ray as part of root canal therapy. Below: The author with one of his pa tients. scared children and encourage appre hensive patients greatly improved the practice environment. JOTS '93 proved to be an outstand ing training exercise for all involved. A four-chairdental facilitywas estab lished in an austere third world envi ronment with limited support. Re serve dental officers and dental technicians on Carriacou provided surgical and pediatric services in ad dition to fillings and cleanings for island residents. Root canal therapy, denture repair, instructions for home fluoride use and even house calls to shut-in patients were also provided by the naval dental clinic personnel. In addition to excellent training opportunities, the residents of Carriacou experienced the benefit of state-of-the-art dental care. The good will created by such an exercise im proves the United States' reputation in the area served and throughout the world. 0 -Story by LCDR Douglas Wright, USNR. 6 NAVY MEDICINE Features How to Close a Naval Hospital ' E s no privilege to make the BRAC Subic was not obligated to leave some in place. However, TQL changed its (Base Realignment and Closure) form of medical care system behind. focus from normal operation of the ist. Ask any employee of a mili For all practical purposes, the United hospital to a closure mode. tary base or hospital slated for closing States presence in the Philippines During brainstorming sessions, the or realignment. The potential loss of had ended. Because the Long Beach executive steering committee came careers and livelihoods, the possible Naval Shipyard will continue to oper up with several hundred items ofc on uprooting off amilies, and the vacuum ate, a nearby medical clinic at the cern. After grouping them under sepa created by termination of military Naval Station in Terminal Island rate headings, it formed six teams. medical care in a major metropolitan would have to be upgraded to carry These teams would deal with issues region can be catastrophic. Naval the increased load. Add the problems involving facilities, military person Hospital Long Beach, CA, is no ex of critical care for active duty, and nel, civilian personnel, patient care, ception. Built in 1967 as a 350-bed dependent and retired care for those equipment, and administration and "midsized" facility, it will close its beneficiaries who would remain in operational issues. doors forever on 31 March 1994. the Greater Los Angeles area. And Once these categories were estab Although rumors had been circu thus, Long Beach became a pioneer. lished, the next chore was manning lating for some time that Long Beach the teams. It was evident that no one was a target for closure, rumors be Closure Plan person could address all facilities is came reality in October 1991 when Once the dust had settled, Long sues, nor could one individual have Congress and President Bush ap Beach got right to work. CAPT Fred all the answers for personnel matters. proved DOD's recommendations and Jackson, MC, then commanding of The executive steering committee the closure process began. The BRAC ficer, charged his staff with both selected team members who had a process normally allows a base 5 years crafting and executing a closure plan. working knowledge ofs pecific areas. to close, but Long Beach's planners What issues had to be addressed at the Although the team members were soon learned that since their budget outset? When you close a Navy hos mostly in-house people, some outsid had been cut significantly, operations pital, what happens to staff, patients, ers were tapped. Because the dis would cease in 1994, 2 years earlier the physical plant, and equipment? posal of equipment was a major con than expected. The hospital established a Base Clo cern, an employee from DRMO There were few models for Long sure Division as part of its Health (Defense Reutil ization Marketing Of Beach to follow. In the Philippines, Care Operations Department which fice) became a member of that team. the United States and the host govern would coordinate all closure activi Also, when the civilian team was ment had agreed to close the Sl.lbic ties. It also restructured its executive formed, both the union and EEO were Bay Naval Base with an even shorter steering committee under TQL (total included. To keep them manageable, timetable. But unlike Long Beach, quality leadership), a process already the executive steering committee lim- January-February 1994 7 ited team size to I 0 or fewer people. The teams came to be known as qual ity management boards (QMBs). In keeping with the broad outlines ofTQL,CAPT Jacksongavethenewly appointed executive steering commit • tee broad latitude. He also empow ered the QMB leaders and members. They would not have to report to him or to the executive steering commit tee for approval of every detail of their plan. He merely wanted good communication to prevail and to be kept informed of progress. The only decisions he reserved for himself and the executive steering committee were those regarding policy where higher authority approval was required. Although the Long Beach situa tion was not totally analogous to Subic, Long Beach benefitted from the Subic experience. L TEd Salenga, a mem berofthatclosure team, transferred to Long Beach and shared lessons learned, particularly in the areas of equipment and facilities. Once the word ofLong Beach's closure spread, the staff was bombarded with phone calls from all over the world request ing items, such as a new CAT scanner can take an action item, put it up on Equipment?"' In this way, miscom and recently modernized X-rayequip the wall, and see how that will impact munication is minimized and the pro ment. LT Salenga, citing his own what one oft he other QMBs is doing. cess proceeds. experience, suggested that the San If we see a potential conflict, we get Because there will be a continuing Diego HSO (Healthcare Support Of those two teams together." Navy presence in Long Beach after fice), an organization with a global As the major player in the closure the hospital closes, an outpatient clinic perspective, become the "middle plan, the executive steering commit at the Naval Station will continue to man" and coordinate the time-con tee meets for 2 hours every other operate but wi II not provide such spe suming equipment disposal activity week. QMBs may present problems cialties as orthopedics, urology, and for major medical equipment items. and solutions and then, if required, ENT. However, family practice, in the executive steering committee de ternal medicine, optometry, social Executing the Plan cides a proper course ofa ction. Health work, occupational health services, As head of Health Care Opera Care Operations then assembles the military sick call, and limited labora tions, CDR James Banks, NC, keeps QMB leaders, bringing them up to tory and radiology will be offered. tabs on the total picture. His biggest date on executive steering committee Memoranda of understanding have role is to monitor what teams are decisions. "Then we go around the been established with local medical doing and ensure that one isn't ob room," explains CDR Banks, "and facilities, provider groups, and diag structing another. He points to the say, 'Team leader from Facilities. nostic services to provide specialty master chart on the wall of his office What are you working on? What do care not available at the Naval Medi which provides an instant update. "We you need from Civilian Personnel or cal Clinic. 8 NAVY MEDICINE