Evolution of the System
The development of the medical laboratory system in Vietnam derived from knowledge and experience from the Far East Medical Research Unit attached to the 406th Medical General Laboratory in Japan, the U.S. Army Medical Research Unit (Malaya), the U.S. Component of the SEATO Medical Laboratory in Bangkok, and the Field Medical Laboratory Project, USARMDC. The system was based on a concept of the laboratory as a component of medical service, with a specific function of generating medical technical information for the purpose of patient care, disease prevention, advice to the, command, and forensic activity.
The first medical laboratory unit in Vietnam, a mobile detachment of the 406th Medical General Laboratory, began operations as laboratory augmentation of the 8th Field Hospital in Nha Trang in 1962.
In late 1965, the 528th and 946th Mobile Laboratories of the 9th Medical Laboratory arrived in Vietnam and were placed under operational control of the 406th Mobile Laboratory. These units were to support the 85th and 93d Evacuation Hospitals. Within 6 months, the headquarters and base section of the 9th Medical Laboratory arrived and assumed control over these units. In August 1967, the 406th Mobile Laboratory was placed under operational control of the 9th Medical Laboratory.
In January 1968, the 74th Medical Laboratory was activated and organized to replace the 406th Medical Laboratory (Mobile) and was placed under operational control of the 9th Medical Laboratory. By September 1968, the 946th and 528th Medical Laboratories (Mobile) were, inactivated and their personnel assigned to the 9th Medical Laboratory. These two mobile laboratories, or mobile sections of the 9th Medical Laboratory, continued operations in Long Binh and Qui Nhon.
The 9th Medical Laboratory
From May to December 1966, the 9th Medical Laboratory was assigned to the 44th Medical Brigade under the 1st Logistical Command. The equipment was antique, and efforts to obtain new equipment and supplies were unrewarding. Building facilities, located 15 feet from a dirt
highway, were inappropriate and inadequate. As a result, little productive work was accomplished considering the high potential of the personnel. In December 1966, the laboratory moved from the small dusty store to a newer building, a Vietnamese constructed barracks. Although the building was larger, the site was less favorable.
In June 1967, authorities decided to construct new facilities for the central laboratories at Long Binh for the purpose of establishing more appropriate buildings, bringing the 9th Medical Laboratory and the 20th Preventive Medicine Unit together for more coordinated function, bringing the 9th Medical Laboratory in close support of major hospitals at Long Binh to free a mobile laboratory for service elsewhere, and bringing the 9th Medical Laboratory in close range of its supply and personnel support units. It was not until December 1968, however, that, the laboratory moved into its new fixed facilities, but not before it had been exposed to hostile fire and isolated twice earlier that year.
The 44th Medical Brigade was transferred from 1st Logistical Command to the Surgeon, USARV, in 1967. After this transfer, a set of equipment and supplies, developed by a USAMRDC contract, was ordered from manufacturers in sufficient quantities to provide for all medical laboratory services within the 44th Medical Brigade.
In his role as USARV pathology consultant, Colonel. Baker recommended assignments of all medical laboratory personnel within the 44th Medical Brigade, after their initial 2-week period of special training in the base laboratory in Saigon. (Chart 14)
An innovation in staffing that produced outstanding results in 1968 was the assignment of an internist to the laboratory staff to head an infectious diseases department. In the 6-month period after the internist arrived, the output of diagnostic information in febrile cases more than doubled. In 1968, 29,160 diagnostic serology procedures were performed.
Veterinary laboratory officers played an important role in Vietnam. They tested ice for chlorination potability and developed serologic methods for diagnosis of melioidosis, leptospirosis, scrub typhus, and murine typhus.
The thrust of medical zoology in the laboratory system, was for quality control, mainly in laboratory diagnosis of malaria and amebiasis. The malaria smears reviewed by the laboratory increased each year, from 1965 to 1969, as follows: 1965, 300; 1966, 1,199; 1967, 3,312; and 1968, 8,176. This review for quality of smear, staining, and identification of parasites was returned to each unit submitting smears, so that any deficient technique could be recognized. Where needed, special visits by central laboratory personnel were made. Similarly, materials
CHART 14- A FIELD MEDICAL LABORATORY SYSTEM IN VIETNAM
were provided to hospital laboratories to make trichrome stains of all stool specimens considered positive for amebic dysentery. Some specimens were submitted for review and diagnosis confirmed. The procedure for confirmation was cause for greater care, on the part of technicians in field units.
Under supervision of the base laboratory, advanced laboratory procedures were established for hospitals, carrying major Surgical loads where advanced intensive postoperative care was practiced. Because hospital facilities were widely scattered, with restricted land communication between them and a base laboratory and with a strictly limited number of laboratory personnel available, it was imperative that the chemistry procedures provided be essential for clinical decisions and be performed competently in forward areas.
By late 1967, surgeons recognized that advanced laboratory methodology provided information on the condition of their patients which challenged their knowledge and prior experience. Similarly, the opportunity for Army physicians to establish definitive etiological diagnoses on
eight febrile diseases, being encountered for the first time in their careers, was not only a benefit to the patients but also a positive factor in professional morale.
The base laboratory maintained a courier system for specimens and reports between dispensaries, some clearing, companies, all hospitals, and the 9th Medical Laboratory. Despite its imperfections, the courier system operated by virtue of the determination of the couriers. After 1968, couriers were helped in part by access to the Otter aircraft assigned to the 44th Medical Brigade.
An automatic data processing system was established to retrieve disease information by place and time. By late 1968, weekly summaries of etiological diagnostic findings in febrile disease were prepared by computer and distributed to all hospitals, preventive medicine units, and division surgeons. The summaries gave the patient's name, identification number, and unit information which was necessary since patients often remained only a short time in facilities where the working diagnosis and treatment were initiated. Routine laboratory reports were often returned to the hospital after discharge of patients and went into their records without notice of the attending physician. The weekly summary was an attention-catching mechanism that allowed the physicians to review cases with specific findings for educational benefits on diseases occurring in Vietnam. This information served also for the purposes of disease prevention and advice for continuing military operations.
By 1968, the medical laboratory system had largely matured, It provided advanced technology where it was needed with a limited number of skilled persons strategically placed. Many persons with special skills were regularly called upon to assist in solving unusual problems. Each area pathologist was either assigned to, or closely associated with, the 9th Medical Laboratory.
The greatest need for pathologists was in supervising clinical pathology, in managing the flow of work within the laboratory, and at times even in maintaining advanced equipment. However, the most important role of the pathologist was in his relation with clinicians in understanding the nature of illness and trauma and in assuring that the most appropriate specimens reached the laboratories. A pathologist in the base laboratory was assigned the task of supervising clinical pathology throughout the 44th Medical Brigade laboratories to assure standardization of methodology.
Anatomic pathology required fewer pathologists. The greatest and most essential workload in anatomic pathology was the forensic cases. A large workload of interest to the pathologists was the surgical pathology on biopsies submitted by volunteer surgical teams working, with the indigenous population, Since provision was made for frozen sections in
the larger military hospitals, the processing of paraffin sections and their reading was centralized in Saigon.
The medical laboratory service in Vietnam finally reached a high level of quality service after several years. By 1970, as a result of coordination between the medical laboratory system and preventive medicine, a level of effectiveness comparable to that in World War II had been achieved. The primary failure had been an inordinate delay in bringing about a close coordination between the medical laboratory system and the preventive medicine units. Since both activities were an integral part of the laboratory system, this had not been a problem in World War II.