Conference of Officers in Charge of Government Hospitals Serving Veterans of the World War

by Unknown

“Mr. Spangler has given us a very complete description of the general method of procurement, storage and issue of supplies required in the management of hospitals. It may be permissible, however, to elaborate a few of the details and to call attention to certain common errors on the part of hospital personnel using these supplies.

It is a well established principle for the efficient distribution of supplies that the final “break-up” be made as near the ultimate destination of the supplies as is practicable. This requires, of course, a sufficient number of supply depots located in suitable sections of the country from which the individual hospitals can secure their supplies with the least practicable delay. The question of size and location as well as rental cost of warehouses is ofttimes the determining factor in the number of depots from which supplies are to be distributed. From the standpoint of economy in operation, fewer depots of larger size are the more desirable; from the standpoint of prompt distribution, the larger number, more widely distributed are the more desirable. It requires a great deal of study of transportation lines and traffic conditions to decide upon the happy mean between these two.

The average person who uses hospital supplies has very little conception of the great amount of storage space which is necessary in order to carry at all times in the warehouses a six months’ stock to the end that requisitions may be filled immediately upon receipt. As an illustration, the Medical Department of the Army had in operation within the territorial limits of the United States on November 1, 1918, ten large distributing depots, with an aggregate floor space of more than 2,000,000 square feet. This area expressed in square feet is so staggering as to convey a very inadequate conception of its size. To those of you who are familiar with the methods of describing land in the central and western states, it may be made intelligible by saying that the area exceeds that of a forty acre tract. In fact, it is approximately 45 acres. If you can conceive of such a tract piled ten feet high with supplies, allowing, of course, for roadways and aisles you will get some conception of the mass of material which had been accumulated for the Army at that date. Then bear in mind that there were thirty-three camps, each with its large general hospital, having three warehouses, approximately 25 × 125 feet more or less completely filled with supplies and you can get an idea of the quantity of supplies required for current use in those hospitals and for dispensary service of the camp. As a further illustration of the quantities of supplies necessary it may be permissible to state that the quantity of gauze of various meshes, from that required in bandages down to the coarsest grade used in surgical dressings, not forgetting, of course, the muslin, that was procured by use between April 6, 1917 and March, 1918, was sufficient to have provided a strip a yard wide around the earth at the equator and a bow knot consisting of several hundred miles in addition. If the yarn which was required in weaving this mass of material had been all made into one single thread, one end of it might have been hooked on the limb of some giant tree on earth with the other end dropped into one of the spots on the sun and still had a few thousand miles to spare. The number of beds actually available for use in the hospitals in the United States on January 1, 1919, if placed end to end would have stretched over a distance in excess of 90 miles. If the mattresses had been placed side by side and end to end to form a square, they would have covered sixteen acres.

Proper warehousing is a very necessary part of the supply service. For efficient warehousing as well as for prompt and satisfactory distribution of supplies, a standard list of articles to be used is necessary. These articles should be grouped in the warehouse in conformity with the class to which they belong,—textiles in one place; drugs, medicines and reagents in another; hospital furniture in another, and so on through the entire list of supplies.

Warehouses should be located on railroad spurs so that supplies may be delivered directly from cars into the warehouse and from the warehouse directly into the cars. Concentration of storage space is desirable on account of the shorter distance to move supplies when unloading and loading. To this end a depot consisting of several stories, one above another, affords the minimum trackage necessary in handling supplies and it is desirable that such a building be selected when practicable.

The decision in the early part of the year 1917 to restrict the number of articles, particularly surgical instruments, which would be manufactured for the use of the hospital services of the Government and for civilian use made it possible to provide the essentials for hospital services with the limited manufacturing facilities which were then available. Such a list had been in use in the Medical Department of the Army for many years and doubtless similar lists obtained in the hospital services of other departments of the Government. This standard list presupposes specifications for the articles enumerated therein; specifications again presuppose personnel qualified to determine what those specifications should be. To write concise and adequate specifications requires familiarity on the part of the personnel writing them with the articles described therein and not only with the articles themselves, but with the process of their manufacture. The prime essential of the efficient supply service therefore is not limited to the funds provided by Congress but embraces as of equal importance a personnel trained in the actual purchase, inspection, storage and issue of the supplies, secured at the cost of the appropriations which have generally been so liberally made by Congress. The actual buying of an article and the placing of the contract therefore, is a comparatively simple matter, but the question of determining whether the articles purchased will satisfactorily accomplish the object for which they were procured is an acquirement which comes only with years of observation and experience, and then in those persons whose inclinations the more readily adapt them to the routine necessary to acquire this experience. Whatever may be the standard of any article which may be selected, the assurance that the article delivered conforms to the article specified rests solely upon the qualifications of the person designated to inspect and accept it.

From years of experience in presenting the needs of the hospital service of the Army to Congress, I am convinced of the urgent necessity for economy along all lines of expenditure and activities. Economy does not necessarily mean the elimination of activities nor the discontinuance of the use of various articles in order to bring the gross expenditure within the sums appropriated. It does mean, however, that no greater quantity of any article, however insignificant, which may be issued to the user, shall be used for that purpose than is actually necessary to accomplish the results desired. It means that the services of employees shall be fully and efficiently used. It means that the articles which are not consumable in character shall be handled with such care and regard to their future usefulness as will continue them in efficient service for the greatest length of time. As an illustration, it is common practice among many physicians when writing prescriptions for various ailments to prescribe a four ounce mixture and to dismiss the patient. The same practice has obtained very largely in the hospital services of the Government. If, instead of issuing the usual four ounce mixture a two ounce, or a one ounce mixture had been prescribed, equally good results would have been obtained, since the patient in many instances actually takes only a quarter, a third or a half of the four ounce mixture, recovers from the ailment for which it was prescribed and throws the medicine away. This is particularly true in military practice. If the lesser quantity be prescribed and further medication be found necessary, the patient for whom it is prescribed will return to the doctor, giving him an opportunity for another and more complete physical examination and consideration of the remedy, of the result obtained and of any other more suitable, or have the prescription refilled if it be necessary. A dozen tablets should be dispensed in place of customary two or three dozen. In other words, in the hospitals and dispensary services of the Government the medicines issued should be in quantities not to exceed the retirements of three days. This will result not only in the saving of drugs themselves, as well as of bandages and surgical dressings issued, but will result in material saving in the cost of the containers in which they are issued. We too infrequently consider the sum which the aggregate saving of the few cents here and the few cents there will reach at the end of a year in the larger hospital services. With supplies abundant and seemingly easy to secure everyone who uses them is prone to become prodigal in their use and I cannot emphasize too strongly the need for economy along these lines. The application of the old saying, “take care of the pennies and the dollars will take care of themselves” to the every day use of supplies in hospitals would result in enormous savings at the end of the year.

I was very much impressed with the remarks of Dr. Lavinder on specialization of medical practice and the tendency in governmental institutions to carry it to extremes. This is no where more pronounced than in the demand for hospital supplies. What our patients need is plenty of attention and simplicity in equipment and treatment. Efficiency, yes, but simplicity especially. How often it happens that a medical officer at a governmental institution becomes imbued with the idea that he requires certain special apparatus which must be obtained at considerable cost to the procuring agents to carry out his theories of treatment. In a few months, or a couple of years at the longest, he is relieved from those duties, at that hospital and goes elsewhere. The officer who follows him conceives that an entirely different set of instruments and equipment is necessary for the treatment of the same class of patients than those used by the former medical officer. The instruments and equipment of the former officer are returned to the store rooms where they take up valuable space and new equipment is secured by the incoming officer to take their place.

The elimination of these personal peculiarities and requirements will do much to reduce the enormous expenditure which is everywhere being made for hospital supplies and equipment.

In closing, permit me again to stress the need for economy in the use of all supplies required by governmental hospitals, for an earnest effort to use the equipment provided to its utmost efficiency and an honest effort to get the most out of all the expendable supplies used in the treatment of the patients committed to our care. If we are honest in these efforts we will have no difficulty in convincing both Houses of Congress of the justness of our requests for funds to carry out the purpose committed to us.”