Part 12

The difficulties of the problem can be realized and understood only by those who are in close association with the Services, and that the Nursing Department of the Public Health Service has been able to accomplish even a measure of success has been in a large manner due to the co-operation, counsel and advice given by the Superintendents of the established Nurse Corps of the Government.

On March 3, 1919, the Public Health Service had available 1500 beds in 23 hospitals, and practically no nurses. Chief nurses were unknown in any of the hospitals. There was no machinery for the recruiting of nurses. In regular Service hospitals, there were no quarters for nurses, and the Service is still concerned over a solution of these difficulties. At the present time, there are 1796 nurses in the hospitals operated by the Public Health Service.

As has already been said, the problem of giving the most efficient care to the disabled ex-service men in the hospitals of the Public Health Service is a little different from that of the Army, due to the fundamental differences in the organization of this corps of nurses.

The Nurse Corps of the Public Health Service is a civilian organization, pure and simple, though 99%, probably, of the nurses now serving in the Public Health Service are ex-service nurses and familiar with the problems of the care of ex-service men.

The aim of the Nursing Department of the Public Health Service is to give as efficient nursing care to the patients in these hospitals as can be given, to see that the nurses cooperate in every possible way with those responsible for the care of the patients—that is, the Medical Officers in Charge,—to recruit a sufficient number of qualified nurses to meet the needs of the Service, and to recommend the establishment of such policies in the Nursing Department as will increase the efficiency of the nursing corps. The co-operation of the Medical Officer in Charge is essential; his sympathy with and support of the Chief Nurse must be unquestioned, if the nursing service is to reach the greatest efficiency. The place of the nurse in the administrative unit of the hospital should be clearly and definitely defined, understood and observed.

One great difficulty confronting this department is the lack of nurses specially trained in the care of neuro-psychiatric and tuberculosis patients, who constitute a large proportion of our patients. To partly meet this need, a school for nurses conducted at Oteen in September 1921, was organized and, while this school was most successful, it barely touched the fringe of our necessities. The Service is considering a similar course in neuro-psychiatric nursing as soon as there is established a station where all conditions, quarters, lecturers and teaching facilities can be guaranteed to produce the desired result.

One piece of nursing work which has been far-reaching in its effects, was the establishment of a Public Health Nursing Unit in the office of the Supervisor of District #4, for the purpose of making contact with the claimant of the then Bureau of War Risk Insurance, with a view to giving the claimant, who for any reason was not hospitalized, the benefit of health supervision and health instruction. The success of the work of this unit more than justified its establishment by the U. S. Public Health Service.

The type of nurse needed for this Service is the broad-minded woman, cultured, well trained, with those qualities of mind and heart which would enable her to grasp the tremendous responsibilities in the work we are trying to do—who will be sympathetic, but firm—who will be able to emphasize the need for obedience to orders for treatment—who can be friendly, without familiarity, and loyal to the highest ideals of her profession.

The turnover is too large, by far, and is due in some measure to conditions which are unavoidable, since they are the result of the sudden expansion of the Service, the need for immediate action, and the great difficulty in securing desirable hospital stations, both from the standpoint of construction and location. These conditions are adjusting themselves gradually, and a distinct improvement in service and morale in the Nursing Department, a clearer understanding of the many problems which confront the administration and the Service in the effort to give the best medical care and treatment to disabled veterans of the World War, is evidenced; and, at the present time, the U. S. Public Health Service is able to keep the nursing force up to the necessities of the Service.

It is believed, however, that uniformity, throughout the organizations caring for these patients would go far toward establishing a more satisfactory service, and it is hoped that this meeting of all connected with and interested in the care of ex-service men will succeed in bringing about this desired result.

In the final analysis, however, it is conceded that the responsibility for the proper and successful conduct of these hospitals rests with the Medical Officers in Charge, and I can truly say in behalf of the nurses of the Public Health Service, that the nursing section will cooperate in every possible way to promote the successful organization of the hospital program, and to assure this meeting that the nurses of this Service will continue to “carry on” and to render all assistance in their power toward the accomplishment of this result.”

GEN. CUMMING: asked for discussions, stating that only two minutes would be allowed for each.

GEN. SAWYER: stated that the women were very anxious to have their suggestions.

CAPT. BLACKWOOD: stated that he wished to pay his tribute to the splendid work that has been done by the nurses. He said he had experienced hospital work when they were dependent upon the most undesirable man that could be found to take care of the sick. The man who could not do anything else was the one that took the place of the nurse. He also told his experiences in Boston when the influenza epidemic came, how in less than a month over 1300 cases were being treated by a staff of nurses scarcely larger than before, how the women worked day and night without rest and often without food, and how many of them lost their lives in the struggle.

He stated that one of the most important questions confronting us today is the question of pay of the nurses, that they had not been recognized in the way that they should be, that stenographers whose work is not as valuable receive from $100 to $150 a month and nurses from $60 to $100, and that effort should be made to pay them more in proportion to their qualifications. He stated that the charwomen received more than the nurses.

He stated further that the ratio of nurses to the number of patient which had been stated as 1–10 was too much to expect in hospitals such as his, where only about 15% of the patients were bed patients.

COL. EASTMAN: stated that this should be one nurse to every ten bed patients.

SURGEON STITES[STITT?]: said he did not believe any Commanding Officer could run a successful hospital without the cooperation of the Chief Nurse. He spoke also on the statement previously made “Kindness without familiarity”, stating that if too friendly some patients think others get more attention because of familiarity with the doctor, nurse or attendant.

SURGEON HEDDING: gave the situation at Ft. Bayard, ten miles from anywhere, with 1100 patients and 86 nurses taking care of them. He stated that the Public Health Service had authorized the keeping of 50 riding horses. He said that the nurses were happy, that the men were happy, and that many nurses were asking to come to Ft. Bayard.

GEN. CUMMING: asked Captain Wieber to talk.

CAPT. WIEBER: stated that he was from Ft. Lyon, Colorado, 7 miles from the nearest city, an establishment with 400 patients at the present time and nurse corps of 21. He said that the nurses were happy and content with the work given them. He also wished to give his tribute to the field and other nurses in the service. He stated he had had the same experience as Dr. Blackwood in the early nursing service, and that some of the men who took care of the sick were half idiots. He said he fully realized now the value of female nurses, and believed he could not get along without them.

GEN. CUMMING: “That next subject is a very important one—‘Diet’—to be presented by Miss Clara M. Richardson, Asst. Supt. of Dietitians, U. S. P. H. S.”

MISS CLARA RICHARDSON: read the following paper—“Diet”.

“The subject “Diet” is a rather broad term and would suggest a variety of different phases, all of which might be equally interesting. Let us consider the subject however in its relation to the ex-service man and the care given him in hospitals established for his benefit.

Among these patients we find the necessity for a wide variety of diet, ranging from the more common types as liquid, soft and light to the more complicated pathogenic diets. In what are termed the General Hospitals are found patients suffering from many ailments such as nephritis, diabetes, colitis and many gastric disturbances. In some Public Health Service Hospitals, as many as four hundred special diets are served daily. In planning and equipping new buildings provision should be made for such a volume of work. It is impossible to satisfactorily serve many special diets from a general kitchen without proper facilities. Careful planning is not only necessary in the kitchen, but also in the serving and dining rooms. The patient on regular diet who may, perhaps, be eating corned beef and boiled potatoes is not likely to see his neighbor eating broiled steak and mashed potatoes, without making some comment. If this is not handled carefully, serious trouble may result. Where there are a number of small dining rooms it will be found wiser to use some of them for special diets.

In one hospital the large mess hall was divided into sections. There happened to be a number of doors, over each of which were placed signs reading—Diabetic Diet, Nephritic Diet, etc. This arrangement worked very satisfactorily, the patients filing in in an orderly manner wherever their particular diet was indicated. This is a matter which is entirely dependent on the construction of the hospital however.

Of course, care must always be taken that patients on regular diet who want a few extras do not slip into a special diet dining room. In a hospital too large for the dietitian to easily recognize her patients, this may be regulated by a pass of some description. Often times the Officer of the Day in making his inspection of meals may discover one of these visitors.

Not only must we consider the patient who comes to the dining room, the bed-ridden patient is perhaps worthy of even greater consideration. His appetite must be coaxed, his tray must be attractive, and above all, his food must be hot or cold, as the case requires. The satisfactory conveyance of food from kitchen to patient is a problem in all hospitals. Many institutions are so arranged that it is necessary to serve a few trays in almost every corner of the building. In such cases, it is well nigh impossible to attain the desired results. The ideal arrangement is one whereby the sick patients are focussed at a point near a kitchen. If Medical Officers would arrange this, other conditions permitting, they would find that many of the difficulties of food service would be eliminated.

A very successful development of this method in a hospital of a thousand bed capacity was recently brought to my attention. There were probably about two hundred patients on special diet, all served from a central diet kitchen. Trays were all set up under the direct supervision of the dietitian—a card bearing the patient’s name was placed in one corner, and the tray was immediately taken from the kitchen directly to the patient. As a result, patients from other parts of the hospital made every effort to be put on wards thus served.

The preparation of satisfactory menus and procuring of the requisite foods for special diet cases of course necessitates buying certain fruits and vegetables out of season. It also increases the number of chops, steaks, etc. used. It must be expected that the ration expenditure of a general hospital where such cases are cared for will be proportionately higher than where few special diets are served, as for instance in a neuro psychiatric hospital. It must also be expected that the ration of a hospital caring for tubercular patients will be higher in accordance with the increased amount of eggs and milk consumed. It is usually necessary to make special effort to tempt the appetite of this type of patient—he often is not hungry and is apt to waste his food. The market conditions in different localities will also be found to have a very direct bearing on the cost of the ration. The central northwestern states provide the best and cheapest market in the country. A menu which might cost 54¢ in this section would perhaps run 20¢ higher in some other locality.

In the preparation of menus, too much stress cannot be laid on the value of fresh fruits and fresh vegetables. Of course, it is necessary to use dried and canned goods to a certain extent, but care should be taken that the fresh articles are not entirely eliminated. The patient will probably say that he does not like salads. They are good for him, however, and after a little persuasion he will learn to like them, and will often ask for them. The personality of the dietitian counts for much. If she will go among the patients, talk with them in the dining room and let them know that she is really interested in them, they on their part, are ready to cooperate. Such cooperation is absolutely necessary, for upon the attitude of the patient depends the atmosphere of order and quiet in the dining room. An undercurrent of dissatisfaction is sure to result disastrously.

Another important factor in the success of the dining room service is the appearance of the room itself. I once saw a group of patients moved from a big barn of a mess hall, which was too large for the number accommodated and which could not be made attractive, to a smaller dining room, new and freshly painted, with curtains at the windows, and flowers on the tables. Those boys who had been noisy and boisterous in the first room, were as quiet and orderly as one could wish in the second.

We find in these hospitals every kind of patient from the boy who on account of religion does not eat certain foods, to the boy who eats anything he can procure, regardless of whether he is on a diet or not. Dietetic treatment in the latter case is practically impossible, while the former is usually very reasonable and gives little trouble.

Again we find the patient who is earnestly trying to improve his condition. If his ailment requires careful feeding, he may come to the dietitian to talk over with her the question of his diet. Here is an opportunity for the trained dietitian to give helpful instruction concerning the dietetic value of different kinds of food as they pertain to his particular case.

The ward surgeons may in may cases render valuable assistance to the dietitian in her problems, by instilling in the patient a confidence in her judgment. Of course, the doctor must himself feel sure that his confidence is not misplaced. There should be the closest cooperation between the ward surgeon and the dietitian. She should confer with him as to special diets, and thru him should ascertain the progress of the patients on those diets.

There should also be a complete understanding of just what is meant by liquid, soft and light diets. Experience has taught us that doctors, nurses and dietitians from different localities do not always give the same interpretation to these terms. It will save much confusion for all concerned if some standard is agreed upon.

The question of diet in these hospitals therefore resolves itself into three problems—first, an effort to secure the foods necessary for a wide variety of diet; second, an effort to serve these foods in a wholesome, appetizing manner amid attractive surroundings; and third, an effort to instill in the ex-service man a feeling of contentment and satisfaction which will go far as an aid to dietetic treatment.”

MR. J. D. SULLIVAN, of St. Elizabeths Hospital, gave the following discussion “Diet and the Service of Foods, at St. Elizabeths Hospital”.

“In preparing menus and estimating the amounts of foods needed for the population of St. Elizabeths Hospital, we base our calculations on the standard dietary tables, as published by the office of Home Economics, and the experimental stations of the department of Agriculture.

From extensive investigations carried on by the experts on dietetics, it has been found that the average man using much muscular energy in work or play, will require food sufficient to supply 4000 calories of energy daily; the average woman using much muscular energy, will require 2700 calories; the average man doing little or no work 2700 calories; the average woman or girl doing little or no work, will require 2100 calories.

Many of our patients are engaged daily at some work, and they lead a fairly active life; their food requirements, together with the employees of the hospital, can safely be calculated from the standard dietary tables.

Those amongst the hospital patients whose mental and physical condition is such that they require special attention and care, the food for them is prepared and served under the direct supervision of Dietitians specially trained for this work, and the amounts and kinds of food used is in accordance with each patient’s individual needs as ascertained by observation from day to day.

In selecting foods for St. Elizabeths Hospital we aim to have meats, milk, eggs, cheese, sufficient to furnish 20% of the energy needed. Cereal foods 〃 30% 〃 Vegetables and fruits 〃 20% 〃 Fats 〃 20% 〃 Sugars, sirups 〃 10% 〃

A diet made up of foods in this proportion will be sufficiently bulky, and will furnish the right proportion of protein, fats, carbohydrates, mineral matter, and vitamines.

As the report of the daily average per capita consumption of foods used will show we use slightly more than the amounts considered sufficient according to the standard dietary tables, because of the mental condition of many of our patients there is apt to be a considerable amount of food unavoidably wasted; also approximately three-fourths of the population are male adults, and for this reason they require more food than would be needed for an evenly mixed population.

From the investigations carried on in the office of experimental stations, the conclusion has been drawn that the total amount of protein needed every day is estimated to be 100 grams; one-half or 50 grams is taken in the form of animal foods, the remainder is taken from the cereals and vegetable foods.

It is well to encourage the use of cereal foods, especially where economy is to be considered, and they should be used as freely as can be without making the diet one-sided.

The use of cereals and vegetables increase the wholesomeness of the diet, by providing the minerals, and the bulk necessary for the normal digestion of the more concentrated food materials, and makes the diet more varied and attractive.

In the use of the cereal foods, bread should have the first consideration; the best bread that can be obtained should be provided; bread that is well flavored, light, of good texture, and well baked.

It is also well to remember that large quantities of cereal foods may not seem attractive if served alone; they may be made very appetizing if combined with small amounts of the more highly flavored or seasoned foods. A well seasoned soup may lead to the eating of a large quantity of bread. A little savory meat or fish, or a small quantity of cheese, may be used to flavor a fairly large dish of rice or macaroni.”

MISS FLORENCE D. HANKS of the U.S. Naval Hospital at Annapolis: She stated that cooperation is the big thing, that without it the dietitian is helpless. She said she has received the most hearty cooperation from the Chief Nurse and Commanding Officer, and stated further that in different hospitals liquid, soft and regular diets are different, and that it must be immediately understood just what the doctors mean.

MISS GENEVIEVE FIELD, Head Dietitian of the Walter Reed General Hospital:

At Walter Reed there are all kinds of patients to deal with. They have at least one dietitian present at every meal, and the patients feel free to bring comment or criticism to them at any time. In the wards the nurse is directly responsible for the service of food. If any food is not just as it should be the nurse is expected to telephone to the kitchen and report it, and it is immediately corrected. The nurse also knows just what is appetizing to certain patients and may request certain foods for them. One big problem is the patient who has been in the hospital for a long time and needs special attention, and it is these patients that the dietitians try the hardest to please. The menus are sent daily to the ward, and the nurse makes out her diet request list. She stated also that for the regular diets 1 pt. of milk and 1 egg are allowed per day; for light diets 1 qt. of milk and 1 egg; for soft diets 1½-qt. milk and 2 eggs; and for liquid diets 1½ qt. milk and 4–6 eggs.

CAPT. EARL P. GREEN, Mess Officer at Walter Reed: Stated he had been three years at the Walter Reed and that during that time many problems have come up. He stated that food and service are the two principle things about feeding people, but the greatest difficulty is service. It is very important to get the people serving the food confident that it is all right. He said a nurse could take the best food to a patient and if she thought it was not good the patient would not eat it. Good food can be bought with money, but service cannot. He said he used to get his complaints from the Post and Star, but this has been eliminated by requiring the nurse to report anything which she thinks is wrong in the diet, and that no complaint is too small to investigate. He believed the mess department could hide nothing, but should be fair and above board.

GEN. SAWYER: “Recently the White House and my office have been bombarded with what seems to us to be a propaganda against the reduction of the ration cost in one of the hospitals of the Public Health Service. This brings to my mind two thoughts: first, in the matter of administration of the affairs of your hospital be sure that you do not take too many people into your confidence in considering any changes you have in mind to make. The fewer people that do the talking and the more that do the acting the better you are off. Also, I would like to express the feelings of Mrs. Harding, who has given a great deal of attention to the matter of the world war veteran and the matter of his feeding. This is what we would like these veterans to have—a generous diet of wholesome food, well-prepared and neatly served.”

MR. L. C. SPANGLER, Associate Medical Purveyor of the public Health Service presented the subject “Hospital Supplies”, reading as follows:

“The term Hospital Supplies may be construed in its broadest sense to mean everything used in a hospital. A fully equipped modern hospital in its various departments will use approximately 5000 different articles.