New Zealand Medical Services in Middle East and Italy
Much more work was undertaken at the MDS than at the Cassino period. This was partly due to the late setting up of our CCS and partly to some temporary difficulty in evacuation. The New Zealand surgical team, which had its designation changed to 1 NZ FSU, at this period was attached to the active MDS, as was the NZ FTU. This weakened the surgical staff of the CCS, especially as Major A. W. Douglas was the most experienced New Zealand abdominal surgeon available at that time. There had been a change of commanding officers in all three field ambulances and their approach to the problem possibly was different from that of their predecessors.page 593
An opinion written at the time by the CO of 4 Field Ambulance is of interest:
It would appear desirable to utilise the ambulances' surgical amenities to the full, for the additional experience is of great value to both the surgeons and orderlies. It is only during actual battle conditions that the surgical departments of Field Ambulances have the opportunity of surgical work, and it is felt that the fullest opportunities should be given to the three Field Ambulance Surgical Teams before bringing surgical assistance from the CCS. Normally at the CCS the surgeons and orderlies have long and constant surgical opportunities, which naturally are denied to the ambulance teams.
Following the now accepted principle of excision and dressing of all wounds at the earliest possible opportunity, during this period as open MDS the greater proportion of cases have been dealt with surgically at the MDS. Over two thirds of all the battle casualties received complete surgical treatment and were fit to be sent on direct to a NZ Gen. Hosp.
As facilities for nursing are better at a CCS all non-urgent abdomens and chests were sent to a CCS for surgery.
This opinion, clearly enunciated, shows the ideas of the zealous young field ambulance officer. A more balanced outlook is shown by an older officer, a surgeon of a field ambulance surgical team, who gave an account of the work at the MDS as follows:
Type of surgery attempted during recent offensive of the Division:
1. Severe Cases:
Badly mutilated limbs requiring amputation.
Blown off limbs.
Severed main arteries.
Collapsed cases of compound femurs and compound leg fractures.
2. Light Cases: As many of these as possible were done but with only two surgical teams operating it was impossible to do them all. Everyone is agreed that the sooner after wounding a light case receives operative attention the better the wound will heal and the sooner will he be fit for duty again. With the very excellent surgical set-up that is now available with the Field Ambulances I would recommend that the aim should be to operate on all light cases at the MDS and to then evacuate them direct to the forward NZ Gen. Hosp. Many of the lighter cases could then be passed on to Base where the next surgery could be done. This would help to relieve pressure on both the CCS and the forward hospital, as well as being an advantage to the patient.
At Tavarnelle we were unable to do all the light cases. There we had three surgeons but only two surgical teams so that it was impossible to keep two theatres going for the whole period of 24 hours. Therefore many light cases had to be passed on to the CCS. Also for part of the time resuscitation had to be done by the MDS. More recently when the 5 Fd. Amb. provided the open MDS, although there were three surgical teams available there were only two surgeons for the greater part of the time, so that it was impossible to maintain two theatres in operation simultaneously over a period of more than 4 hours during the 24 hour day. To achieve the ideal of operating upon all light cases at the MDS during any future similar Divisional offensive operations we would recommend the following set-up:page 594
1. Three MOs for Reception. In the absence of the FTU one to supervise the resuscitation and pre-operation Tarpaulin.
2. Three surgical teams, each complete with surgeon, anaesthetist, NCO, orderlies and own operating equipment. Organised on a 12-hourly basis there would be always two teams working simultaneously throughout the 24 hour period. When the pressure is on, all three teams could work simultaneously over a short period of 4–6 hours. Such a set-up would I am sure be able to deal with even more light cases than the total passed through the MDS at Tavarnelle.
The 1st NZ FSU was attached to the MDS during the greater part of this period and performed 90 operations during July and 30 during August. The large majority of the cases were of severe limb wounds. There were sixteen deaths.
It was noted by the FSU at the time that:
Abdomens: Generally operations on these are not done unless the condition is too serious to allow of transfer to the CCS, or if the CCS is sited too far away to be reached in a short time.
Adequate nursing facilities now obtainable with the addition of a nursing section have been proved to be of great value.
Chests: Are usually not done if the pleura is penetrated. Use of intercostal nerve block has been of definite value for relief of pain prior to transport back to the CCS for operation.
Penicillin has been used locally as a powder in wounds until supply ran out a few days ago. Sodium penicillin is being used for the same purpose at present. The crystals are coarser and owing to greater solubility, probably are absorbed more quickly. Recently penicillin Na has been used with much greater frequency parenterally in large wounds. If possible cases are held until they have received dosage for at least 24 hours.
Undoubtedly, the FSU and ambulance surgeons had displayed the judgment to be expected of experienced surgeons in the selection of cases to be dealt with at the MDS level. More surgery was probably carried out at the MDS as the CCS was understaffed, being short of three medical officers while at Siena.
Evacuation to the CCS except for a short period before one-way traffic was instituted was very satisfactory. Major Douglas drew attention to the frequent moves of the field ambulance units. Between 19 and 27 July his 1 NZ FSU set up its theatre in six different locations. With moves as frequent as these it was obvious that abdominal cases could not be adequately nursed, and the same applied in lesser degree to all serious cases not fit for immediate evacuation. All such cases undoubtedly should have been dealt with in a more static unit in this campaign, which meant that the CCS and the staffing should have been adjusted accordingly.
Blood reactions were more common at this period, and reactions were also noted following intravenous glucose injections. A quantity of blood had to be discarded, and also infected bottles of plasma and glucose saline. It was noted at the CCS that the supply of blood was very scanty, and because of the hot weather and the long distance page 595 it had to be transported was often stale, and undesirable reactions were too numerous. The position was somewhat eased when two refrigerators were installed at the CCS.