Patients AWOL for a period of 7 days may be readmitted to hospital
but only to the hospital from which they are absent. After 7 days,
absence, they are dropped from the rolls of the hospital, and
further hospitalization can be authorized only by the Director.
4. Under (c) Patients discharged for Disciplinary Reasons, there are
three limitations
1. No patient who is mentally irresponsible shall be discharged for
disciplinary reasons.
2. No patient shall be discharged for disciplinary reasons, if his
physical condition is such as to endanger his life by reason of
such discharge.
3. No patient shall be discharged for disciplinary reasons, except
on the recommendations of a Board of Officers approved by the
Medical Officer in Charge of the institution.
Provision is made for minor punishments.
The Board of Officers above referred to is to be composed of two medical
officers on the staff of the hospital and a representative of the U. S.
Veterans’ Bureau appointed by the District Manager. When it is
impracticable for the District Manager to appoint a representative he
will request the Medical Officer in Charge of the hospital to appoint a
member of his staff to represent the Veterans’ Bureau.
Patients discharged for the first time for disciplinary reasons receive
transportation home. They are not readmitted to hospital except by the
authority of the Director.
On the second or subsequent discharge for disciplinary reasons or for
being AWOL, the board may recommend a forfeiture of compensation up to a
maximum of 75% each month for a period of three months time.
Patients discharged under any of the above classes who are, following
their first discharge, readmitted to hospital and after this 2nd
admission are discharged for completion of treatment revert to their
former status with a clean record.
5. Under (d) patients disciplined by forfeiture of compensation without
discharge. Provision is made whereby patients who have committed an
offense when it is not deemed necessary or advisable to recommend their
discharge because of the nature and gravity of the offense, or because
of the patient’s physical condition, forfeiture of their compensation up
to a maximum of 75% each month for three months may be made effective.
Provision is made for the proper recording of all patients discharged in
all districts, for the making of all forfeitures effective and here
after all admission cards will bear a notation indicating whether or not
the patient has been previously discharged under this order Section II
of General Order 27–A is as follows:
Patients discharged for disciplinary reasons will not be readmitted to
the hospital from which discharged. So far, of the patients discharged
for disciplinary reasons, 71 have been readmitted to hospitals.
The principal complaint received from patients discharged has been that
they knew nothing of General Order #27.”
ADMIRAL STITT: stated that it had been the rule to have all the papers read
before opening the discussions.
SURGEON P. S. RAWLS, U. S. P. H. S. (R): read the next paper, “Relation of
District Managers to Hospitals”, as follows:
“The District Manager and his District Medical Officer need no
introduction to you. You are all familiar with their responsibilities.
They are the representatives of the Veterans’ Bureau with whom you come
in contact most frequently.
The office of District Manager was created by the Director, Colonel
Forbes, when he assumed direct control of District organizations. The
District Manager is charged with the responsibility for all phases of
the work of the Veterans’ Bureau in his district. The Director also
appointed a District Medical Officer who, through the District Manager,
is responsible for all phases of medical work of the District—the
examination, treatment, hospitalization, dispensary, convalescent and
follow-up care—in fact the entire physical rehabilitation of patients of
the Veterans’ Bureau. And only recently the additional responsibility of
the determination and rating of disability has been added.
The medical organization of the District Office has been developed
primarily for the purpose of establishing claimants of the Veterans’
Bureau as patients entitled to treatment, and the furnishing of proper
treatment, under regulations, orders and instructions issued by the
Central Office. The District Manager and his District Medical Officer
are charged execution of these instructions. They are charged with
hospitalization of patients in your hospitals and during such
hospitalization, they must look to you to assume the burden of
responsibility. In order to prevent misunderstanding and to define the
relation of the Veterans’ Bureau and its District Manager to the Service
hospitals and their Commanding Officers, Field Order #23 was issued
which states in Paragraph #2 and #3 as follows:
You will note that one of the duties of the District Manager is to keep
you informed of the general aims and policies of the Bureau. This means
contact—close personal contact, if possible, with the Commanding
Officers of the hospital, working together, keeping informed—the
District Manager with the work and problems of the Commanding Officers
informed of instructions through the official channels of the Service to
which he belongs.
When the District Manager hospitalizes patients in your hospital, he
must, necessarily, have certain reports, as he is still responsible to
the Director for these patients. The reports of physical examination, on
the proper Bureau forms are obviously essential. Important, too, is the
prompt and accurate report of admission to and discharge from hospital
of patients of this Bureau. Mention has been made of the multiplicity of
reports asked for and the Bureau and its District Offices are making
definite effort to relieve you of this burden. With the extensive
decentralization of the work of the Bureau to the District Offices and
the closer cooperation of those offices with your hospitals the request
for reports made upon you in the past will be reduced. I feel confident
that this result is already evident if comparison is made with
conditions of a year ago. During the recent conference in Washington of
District Managers, District Medical Officers and Vocational Officers,
the question of reduction of reports and forms was urged resulting in a
careful revision and some elimination which should indirectly affect
you.
The most direct method of improving this condition will be placing a
representative of the District Manager in your hospital. He will be able
to act with the authority of the District Manager on many matters now
causing difficulty and delay.
I should like to take this opportunity to call your attention to certain
phases of treatment which the Veterans’ Bureau and the District Manager
expect you to give to patients, namely, to disease or disability
developing for which the patient was not admitted to hospital and to
conditions which are not apparently of service origin. In this
connection, I would remind you that the Director is charged with
providing treatment to beneficiaries taking Vocational Training for
disease or disability not due to misconduct, although not related to any
service disability. This is embodied in Regulation #12 recently issued
and from which I quote:—
The relation between the District Manager and the Commanding Officer of
Service hospitals should be one of mutual cooperation. The success of
the hospitalization program of the Bureau depends on this. The
intelligent and sympathetic support of every Commanding Officer is
essential and the Central Office firmly believes that every District
Manager will give you his unqualified support in your work in
hospitalization of patients of the Veterans’ Bureau. The one thing that
I would impress on you above all others and which will do more than all
the instructions that could be issued, is get together with the District
Manager.”
COLONEL H. M. EVANS, of the U.S. Veterans’ Bureau: discussed the subject
“Physiotherapy and Occupational Therapy in Hospitals” as follows:
Mr. Chairman, Ladies, and Gentlemen:
The subjects of Occupational Therapy and Physiotherapy constitute what
has been designated as the Section of Physical Reconstruction in
hospitals. Early after the United States entered the War the Surgeon
General of the Army realized that it was necessary to utilize all the
agencies that would aid in the recovery of men disabled in the War. He,
therefore, established a Section in the Hospital Division of Physical
Reconstruction, to include Occupational Therapy, curative work-shop
instruction, and Physiotherapy which includes Electrotherapy,
Hydrotherapy, Mechanotherapy, Thermotherapy, massage, and directed
exercise. Col. Frank Billings, of Chicago, was made Chief of the
Section, and the Work was developed until there were 48 hospitals with
more or less perfect equipment in Physiotherapy and Occupational
Therapy, 2000 Occupational Aides and curative work-shop instructors, and
1200 Physiotherapy Aides and Medical Officers. There were as many as
34,000 men engaged in some form of Occupational Therapy in one month,
and 20,000 different men treated by Physiotherapy.
Upon the retirement of Col. Billings I was made Chief of the Section,
and the work continued to develop until 69 per cent. of all hospital
patients were doing some form of work in Occupational Therapy or
Prevocational Training. There were many hospitals that maintained an
average of 5000 Physiotherapy treatments a week for a number of months.
As the men were discharged from Army Hospitals the burden of the Public
Health Hospitals became greater, and many of the individuals who had
been active in the Army work became associated with the Public Health
and established as a part of their hospital program the Section of
Physical Reconstruction, to include Occupational Therapy and
Physiotherapy. This work has developed throughout the past year and a
half. It was not thought within the province of the Public Health to
develop Prevocational Training.
The speaker, having resigned from the Army, accepted a commission in the
Public Health Service and was detailed to the Federal Board for
Vocational Education as Medical Officer in Vocational Training. For a
year and a half in this capacity he assisted in developing 181 centers,
most of which were in connection with hospitals, in which the
Prevocational Training was the major part of the work. Under this
management there were about 800 teachers employed, and about 14,00 men
engaged in some form of work. Unfortunately, the necessity of calling
this Prevocational Training, in order to have it come under the Federal
Board law, gave a wrong impression of the work as done in hospitals.
When the Veterans’ Bureau came into existence, it took over the
activities of the Federal Board and the Bureau of War Risk Insurance and
correlated these with the Public Health Service, the Veterans’ Bureau
having, under the law, power to do anything that was necessary in the
rehabilitation of the ex-service men.
The Centers that had been operated under the Federal Board were divided,
and all those attached to hospitals were put under the Medical Division
and the work was considered as Occupational or Prevocational; all
Centers that were for Section 2 trainees were designated as Vocational
Schools, and on November 17, 1921 a program for Physical Reconstruction
in Veterans’ Bureau Hospitals was approved by the Director, as outlined
in _Exhibit A_.
In accordance with this approved plan, which had previously been
approved by the Federal Board of Hospitalization, it became necessary to
have a procedure; as all other personnel in hospitals were responsible
to the Commanding Officer and controlled from the headquarters in
Washington, it was deemed advisable and consistent to have all Veterans’
Bureau personnel that were detailed to a hospital placed on Central
Office Payroll and directed by Central Office. In accordance with this,
on January 18, 1922, a procedure was approved, to be issued as a General
Order, as shown in _Exhibit B_.
This makes it very plain as to the attitude of the Federal Board of
Hospitalization and the attitude of the Director of the Veterans’ Bureau
toward Physical Reconstruction.
In addition to the agencies described, which are usually a part of
Physical Reconstruction, there have been placed for administrative
purposes the Follow-Up Nurses of the Veterans’ Bureau, which includes
265 graduate nurses, distributed throughout the various districts, and
acting in the capacity of Follow-Up Nurses under the direction of the
Medical Officers, performing duties in accordance with regulations as
outlined in Field Order #18, _Exhibit C_.
During the past month the Follow-up Nurses performed the duties as shown
in _Exhibit D_.
Upon the division of the so-called Training Centers, as outlined, the
number of teachers and the number of trainees which were strictly in
hospitals were reduced, so that the Report for December, 1921, shows a
summary, as given in _Exhibit E_.
The greatest difficulties in the way of proper establishment of physical
reconstruction have been, First, Adequate space for hospitals. Up to the
present time this has been considered an extraneous service and it has
only been possible to secure suitable quarters in a relatively small
number of hospitals; but upon the approval of the Federal Board of
Hospitalization and the Director of the Veterans’ Bureau, it now becomes
an integral part of the hospital program, and little difficulty should
be experienced in the future. Second, It has also been difficult to
secure proper personnel, particularly for Occupational Therapy for
mental cases, and in order to have this work efficiently done it is my
opinion that school of training should be established at St. Elizabeth’s
Hospital, whereby a sufficient number of Occupational Aides, who have
had experience with other types of patients, may have the opportunity to
receive special training in handling mental cases. When you remember
that in the Army there were only 48 special officers in Physiotherapy
and that we now have 100 hospitals, and most of these would need a
special officer for this work and are contemplating establishing a
number of clinics in each district, it is absolutely necessary to make
some provision for training medical officers in Physiotherapy.
We have had authority for some months to employ 100 Physiotherapy Aides
and have utilized every aide that has been made available by Civil
service, and have but 7. If we are to meet the requirements in
Physiotherapy it will be necessary to establish a training center for
Physiotherapy Aides, and it is suggested that the facilities for this
work at Walter Reed Hospital and the various Bureau Clinics, and the
Hydrotherapy department at St. Elizabeth’s be utilized for the training,
and that a regular program be utilized and course of study provided to
meet the requirements of this service.
Another one of the difficulties that is not only applicable to
hospitals, but to all centers of Vocational Training, is the method of
disposing of fabricated articles. The amount of paper work necessary
incident to this and the fact that the money does not revert to the
service but to the general treasury makes it a very unsatisfactory and
cumbersome procedure, and some legislative should be asked for to enable
the Veterans’ Bureau to proceed as the Indian Service proceeds in
disposing of fabricated articles, or articles that are the result of the
work of the trainees. Under the new procedure all personnel of the
veterans’ Bureau detailed to a hospital are directly under the Medical
Officer in Charge. The special work is directed by the Educational
Director, who should be considered as one of the staff of the hospital.
The greatest criticism that has been partially sustained in regard to
Occupational Therapy has been that men who are physically able to do
more purposeful things have been kept making trivial things, First,
because it was relatively easy to amuse them, Second, Because of some of
the articles the patient has derived considerable revenue from the sale
thereof. The whole scheme should have in mind, First, The Therapeutic
value of the activity, Second, The Prevocational Training of the
activity, with the hope that you could shorten the time of
hospitalisation and also shorten the time of Vocational Training by the
amount of Prevocational work done in a hospital.
Prior to the work in Army Hospitals much individual work had been in
Physiotherapy and Occupational Therapy, but this was not correlated. One
man emphasized the static machine, another man built up his institution
upon the basis of Hydrotherapy, another upon the physical exercise, but
it remains for the work in the Army Hospitals to coordinate these
agencies and present a solid front for Physiotherapy. One of the things
that remains yet to be accomplished is a proper coordination between
Physiotherapy and Occupational Therapy. It is waste of energy and money
to have a Physiotherapy Aide spending hours of time in massaging a
stiffened joint when, if her work could be supplemented by properly
directed physical exercise in a shop or upon the farm, the same member
could be so used as to assist in restoration quite as readily as from
massage. It is expressly understood that all the work in Occupational
Therapy should be upon prescription of the Medical Officer in Charge of
the Hospital or his designated agent, and a proper cooperation between
the Medical staff and the staff of the Reconstruction Section will
insure most satisfactory results, and that this cooperation of the work
will be very necessary in order to secure proper efficiency.
In the General Order referred to the ratio of teachers to patients per
teacher must be considered as a general guide only, as it is quite well
known that in mental hospitals the number of men that can be cared for
by a single aide or teacher will be less than in other hospitals, and it
must also be understood that the character of treatment in Physiotherapy
will also modify the number of treatments that may be given by each
individual.
I am particularly grateful for this opportunity to present the matter of
Physical Reconstruction to the men who are caring for the disabled
veterans, and who can do so much to make this phase of the hospital
program a success.