War Surgery and Medicine
CHAPTER 25 — The Work of a General Hospital Laboratory
The Work of a General Hospital Laboratory
THE work which may be undertaken by the laboratory of a General Hospital can be classified as follows:
From Hospital In patients: This is similar to the work done in any public hospital in New Zealand, for all laboratory facilities must be available to the sick soldier. In addition there will be extra bacteriological and transfusion work from battle casualties and work related to the tropical or other diseases endemic and epidemic to the area. Details are given below.
From Hospital Outpatients: A base hospital often made its specialists available in outpatient clinics to the units encamped in the neighbourhood and some work from this source fell to the laboratory.
From the ‘Area’: This would include water and milk analyses from camps in the area; investigation of outbreaks of food poisoning; material from RAPs and station sick quarters; the doing of serological tests from VD treatment centres, etc.
Transfusion Work: It was found better to have the servicing of apparatus, preparation of solutions and maintenance of the blood bank under care of the laboratory; in some hospitals the Pathologist bled the donors and supervised actual transfusions.
Research Work: An enormous amount of material from the sick, from battle casualties, and from epidemics was received by laboratories: there is considerable opportunity for research which may produce valuable results—but adequate staff is essential.
Analysis of Work Done at 1 NZ General Hospital Laboratory During Thirty-one Months at Helwan
This analysis is based on the monthly reports furnished to the Deputy Director of Pathology, Middle East, and is set out in full month by month in the following table. The graph shows the fluctuation of work, relating it to the monthly admissions.page 742
Following is the total of specimens examined in thirty-one months under the various headings in the monthly reports:
|Enteric group fevers||3613|
|Pus, skin scales, etc.||814|
|Food, milk, water||355|
Consideration of the above figures shows:
That the average number of specimens examined per month fell little short of 2000. The average figure for Christchurch Hospital over a two-year period (1948–50) was approximately 3000.
The staff at 1 NZ General Hospital was 5 technicians, most of whom were partly trained; the staff at Christchurch Hospital during the above period was 17, trained or in training.
That about one-third of the work done arose from tropical diseases.
Work arising from battle casualties made only a small contribution (about 6 per cent) to the total (wound infections, part of blood counts and blood grouping).
A relatively small amount of biochemical work. Nevertheless, a wide range of chemical work was undertaken to provide all the tests normally available in a public hospital. This branch of the work is certain to show a large increase in any future war, and will require the services of a properly trained biochemist.
A high figure for tests under venereal disease: this was largely due to the laboratory undertaking serological tests for VD Treatment Centres in a large area.
Epidemic and Endemic Diseases
Enteric Fever: Cases of enteric fevers occurred occasionally, but there was one outbreak in the latter half of 1943 which involved much laboratory work—in one month 762 specimens (blood cultures, urines, and faeces) were derived from this source alone, ‘clearance’ specimens contributing largely to the total.
Dysentery: Bacillary and amoebic dysentery were endemic—peak months were November 1941, October 1942, and September 1943, when 358, 732, and 662 specimens of faeces were respectively examined. Careful search for amoebae in every case of dysentery throws much work on the laboratory staff.
Malaria: This too was endemic, but showed peak months which unfortunately almost coincided with the peak dysentery months—September 1942, 428; August 1943, 567 specimens examined.
Infective Hepatitis: Many cases were admitted during the Middle East epidemics—few were fatal. The laboratory work involved consisted of blood counts, icterus indices, and urine and faeces for bile pigments. While much of this work was not essential it was felt important to take advantage of the epidemics to make some laboratory studies. Much more might have been done with adequate staff.
Diphtheria: Occasional cases occurred throughout the period. At the end of 1942 there was both an increase in faucial diphtheria and in diphtheritic infection of wounds. At one stage the nursing staff were Schick tested and the susceptible members immunised.page 744
The Central Pathology Laboratory
The RAMC Laboratory was attached to 15 Scottish Hospital in Cairo, and was under the supervision of the DDP ME and his staff. It was used as a reference laboratory on many subjects. In particular it carried out Wassermann tests checking our positive Kahn tests, investigated anaerobic bacteria, phage-typed strains of typhoid bacilli.
The DDP ME paid regular and most helpful visits to the laboratories under his command and held an annual conference of pathologists at which current problems were discussed, recent advances in technique described, and papers on research projects presented.
Through the DDP it was arranged for the reference to any one pathologist of all the material arising from certain diseases so that sufficient material for research could be assembled.
Analysis of Post-mortem Examinations Made at 1 General Hospital, Helwan, October 1941 to March 1944
|Surgical (incl over 2000 battle casualties)||10,500 approx|
|Total (includes other than New Zealanders)||25,500|
|Post-mortems carried out—|
|On hospital deaths||90|
|‘Brought in dead’||43|
|CAUSES OF DEATH IN HOSPITAL—|
|CAUSES OF DEATH OF SOLDIERS ‘BROUGHT IN DEAD’—|
|Accident (vehicle and falls)||21|
Consideration of the volume of work done (as shown above) indicates that the technical staff necessary in a General Hospital laboratory is at least:
Technician-in-Charge: This man should be properly qualified and experienced.
Technician for general bacteriology.
Technician for faeces and urine examinations.
Technician for biochemistry—a properly trained biochemist.
Technician for media making and section cutting.
Technician for haematology.
‘Trainee’ or general duties man for washing up, sterilising, etc.
Spare Technician: At base hospitals each man was entitled to 1½ days off duty per week and to two annual leave periods of 14 days; as a technician cannot be replaced by a general duties man a ‘spare’ is an essential.
Transfusion Orderly, if blood transfusion work and intravenous solution preparation is undertaken by the laboratory.
This suggested staff of 8 (plus transfusion orderly = 9) for dealing with approximately 2000 specimens per month may be contrasted with the Christchurch Hospital staff of 17 (plus 3 transfusion staff=20) for dealing with approximately 3000 specimens per month.
In 1940 the first General Hospitals went to the Middle East with each a Pathologist and each one partly trained technician (private). It was soon found that the RAMC War Establishment provided for 600 and 900-bed hospitals laboratory assistants as follows:
and this establishment appears to have been that of 2 NZEF in 1942, as under the capitation agreement with the British Government the 2 NZEF WE was tied to the British. The difficulty of staff shortage in laboratories was overcome by ‘attaching’ nursing orderlies (privates) ‘for training’. Thus in August 1943, 1 NZ General Hospital (average daily bed state over 800) had three ‘attached for training’ and a ‘transfusion orderly’. Even this staff necessitated much ‘overtime’ and night work in the many busy periods.
This ‘attachment for training’ was later prohibited, resulting in a report to DMS by the Pathologist 1 NZ General Hospital (October 1943) indicating the work undertaken and staff required much as above, and suggesting an establishment of:
|600 Beds||900 Beds||1200 Beds|
(exclusive of orderlies for transfusion work and for ‘area work’ if undertaken).
In November 1943 the War Establishment was amended to:
|600 Beds||900 Beds|
which was a step in the right direction.page 746
Rank of Laboratory Technicians
|General Hospital (600 beds):|
The 2 NZEF WE compared very unfavourably with this, and it seemed that the technicians who had served long and worked hard in the Middle East had been treated unjustly in contrast. Accordingly it was suggested that after:
3 months a trainee should become Lance-Corporal
9 months a trainee should become Corporal
18 months a trainee should become Sergeant
if there was a vacancy for a sergeant on the establishment.
In reply it was suggested from the office of the DGMS that qualified technicians on enlistment should become sergeants at once and that trainees ‘after 6 months efficient service’ should become sergeants. The first of these proposals was fair: the second over generous.
However, it was recognised as a bad principle that the different divisions of the New Zealand Army should have different ranks for personnel doing the same work—and letters to this effect reached the Minister of Defence and appeared in the daily papers. One difficulty lay in the question of similar rank for radiographers, dispensers, etc.
Finally, after considerable correspondence in July 1944, the WE for 2 NZEF was amended to:
|600 beds||900 beds|
For the future it might be suggested that the Senior Technician-in-charge should be a qualified and experienced ‘Hospital Bacteriologist’ and should be given commissioned rank. There should also be in every General Hospital laboratory a technician with considerable experience in biochemistry.
A General Hospital laboratory should always have a Pathologist (Medical Officer) in charge.
Training of Technicians
The first two General Hospitals reached the Middle East with each a single technician—partly trained in one case and slightly trained in the other—a fantastically inadequate provision, when it is known how much work fell on the hospital laboratories.
Not until 1943 was any attempt made to provide trained technicians from New Zealand (and then these were sent with rank already above those who had trained and worked long in the Middle East).page 747
Training of technicians was therefore carried out in all the General Hospital laboratories and proved very satisfactory. It must, however, be emphasized that a trainee is for a considerable time of no use—in fact, an encumbrance—in a laboratory, and that a nucleus of several trained (qualified) technicians is essential for the provision of a first-class laboratory service.
General Hospital Laboratory Equipment.
The laboratories of the General Hospitals in 2 NZEF were in the main furnished with standard RAMC equipment. This was well thought out and of good quality. It was designed to operate anywhere, and as kerosene was the fuel for incubators, sterilisers, etc., it was independent of electric light and gas, though when available these were, of course, used for heating and lighting. With the standard equipment, and using its boxes as benches and cupboards, it was possible to operate an efficient laboratory in a hospital tent, as, for example, 1 NZ General Hospital laboratory at Farsala in Greece. Criticism may be made of the rather cumbrous design of some of the larger laboratory pieces—e.g., the incubators, which could be better designed for transport. Other suggestions for improvement are:-
Provision of at least four microscopes for a hospital of 600 beds.
Provision of some sort of microscope lamp (? high-pressure mantle type, kerosene burning) for use when electricity is not available.
Provision of a better centrifuge (electric or hand).
Provision of better haematological apparatus-Haemoglobinometer, better quality counting chambers and pipettes.
Provision of a colorimeter (the MRC Grey Wedge Photometer could well be used) for biochemistry—this would enable the more usual standard biochemical methods to be used.
On a future occasion it might well be ascertained in advance what sort of laboratory equipment a General Hospital might expect at its destination overseas.
* Battle casualties included: Chest wounds, 6; abdominal wounds, 2; brain and cord wounds, 4; septic wounds, 5; haemorrhage, 2.