War Surgery and Medicine
THE WORKING OF A FORWARD SURGICAL UNIT SITED AT AN MDS OR CCS
THE WORKING OF A FORWARD SURGICAL UNIT SITED AT AN MDS OR CCS
The Pre-operative Ward
Trestles for a total of thirty stretchers were required for a CCS in the pre-operation ward, with overflow capacity of about the same number for exceptional rushes. The original number was practically always sufficient if two tables were working continuously and if cases were kept on the move and shifted to the wards, either when operation was not deemed advisable or to await operation after all resuscitatory and other preliminary treatment had been carried out. One special ward handy to the theatre was selected, where cases awaiting operation could be housed, the names remaining on the pre-operation list and the cases sent for from the theatre as required.
It was here that the major cases were sorted and thoroughly examined, under conditions of adequate lighting and facilities for the dressing of wounds and thorough cleansing of the patients. Wounds were inspected, and those details necessary for the guidance of the operating surgeon were noted. If no surgery was to be performed, an adequate description of the wounds was given for the information of subsequent units. Abdomens and chests were examined carefully, and head and spinal wounds investigated.page 72
Transfusion and X-ray
A transfusion team was absolutely essential for resuscitatory measures and for advice concerning the suitability of the patient for operation. An X-ray plant, when available, was set up, usually in, or alongside, the pre-operation tent or hut, so as to be readily available for investigating the doubtful cases. The types normally requiring X-rays were:
Abdominal injuries, especially those of a doubtful nature.
Head and spinal cases.
Injuries in relation to joints, especially the knee joint.
Doubtful fracture cases.
Some difference of opinion arose during the war as to the value of X-ray examination, but experienced surgeons found it invaluable in doubtful cases, especially in injuries about the diaphragm and loin. Many abdominal operations were saved because of the information obtained.
Orderlies: These were trained in the careful handling, in the removal of clothing from, and the washing of the wounded. They became adept in the rapid and gentle handling of serious cases and in the application of splints and the preparation of cases for operation.
Lists of Cases for Operation: This was kept in order of urgency. It needed constant readjustment as more serious cases were admitted or as cases recovered, following transfusion, sufficiently to withstand operation.
Resuscitatory Measures: These have already been discussed elsewhere, but consisted essentially in rest, moderate warmth, warm drinks, and the essential measure of blood and plasma tranfusion.
Types of Cases for Early Operation: The priority of operation did not remain stable during the war. At first the order of priority was:
Large flesh wounds.
The abdominals did badly in the early campaigns owing to the mobile warfare and the difficulty of getting them back to the relatively immobile CCS. This led to the employment of the MDS as an operating centre for these cases, and it was proved that cases could be saved in this way, but early evacuation proved disastrous.
At first head cases were dealt with early, but then they were sent back to the base unit in Cairo as non-priority cases.page 73
The sucking chest was always a first priority case, whether it was dealt with by pad and strapping or by operation. Large flesh wounds were at first dealt with after the abdomens, and were often sent back to the CCS while the abdomens were dealt with at the MDS. Then it was realised that severe muscle wounds, and especially the traumatic amputation cases, steadily deteriorated and could not be resuscitated, in spite of transfusion, till operative removal of the traumatised tissue had been undertaken. These cases then became first priority. The abdominal cases, on the other hand, were found to do better if a longer period was given for them to recover from their original shock, and a short period of rest quite apart from the transfusion was of great benefit to them. It was also realised that the abdominal cases did not die of infection but of shock, and that most of the mortality occurred in the first twenty-four to forty-eight hours.
There was a difference of opinion as regards the amount of bleeding in these cases, and many held the view that as a rule little bleeding took place. However, our experience was definite that in about half the cases there was a considerable quantity of blood in the peritoneal cavity, and that in a few cases bleeding from mesenteric vessels was severe. However, the majority of the abdomens could be left several hours to recover before operation, provided a close watch was kept and no suspicion of continued bleeding was present. The change of priority made it desirable for the abdominals to be dealt with at the CCS level, and the serious tissue wounds and the traumatic amputations took their place at the MDS level.
All wounds except small perforating wounds unassociated with any swelling, or small spattered wounds, needed surgical treatment for the removal of the traumatised tissue. The wounds of the different areas and structures are dealt with under other articles.
Technique in the Operating Theatre
This was generally of the simplest kind. The patient was lifted on his stretcher on to the operation table or on to trestles and the operation performed without shifting him from the stretcher. Generally another table or trestle was used for preliminary treatment before operation, or more commonly for the preparation of another patient who could be got ready for the surgeon pending completion of operation at the first table.
It was usual for the surgeon to don a mackintosh overall, a cap, and a face mask—the mask being considered the most important part of the technique. Plain soap and water was used for skin cleansing, and shaving was freely utilised, both as a preparation for adhesive strapping extension and for cleanliness. Iodine was the usual antiseptic skin application.page 74
Gloves were worn by some surgeons as a routine, sometimes being changed for every operation, and sometimes the gloved hand was cleansed between operations. Other surgeons used gloves only in septic cases. For abdominal operations the full surgical technique, with donning of sterile gowns and gloves, was carried out.
As regards guards, the custom varied. Some surgeons used the ordinary sterile linen guards sparingly. Others used mackintosh and rubber guards, boiled or otherwise sterilised between operations. The washing of guards and gowns was, of course, a difficult procedure in forward units, and at times the supply of water rendered washing impossible.
Note Recording at Operation
At the conclusion of the operation the surgeon himself immediately filled in the details in the operation book and also on the Field Medical Card AF 3118, and, if he so desired, also filled in a follow-up card by means of which he could ascertain the later progress of the case at the Base. Clear directions had to be given so that nothing was overlooked later during evacuation. If any dangerous complication might arise, such as bleeding, warning had to be given. The time of wounding and of the operation had to be noted.
Morphia, ATS, and sulphonamide and penicillin dosage were also noted. Specialist cases to be referred to special centres were clearly marked with special tabs. Dangerously and seriously ill cases were marked DI or SI. Illegible and incomplete notes were liable to add serious risks to the patient's life or satisfactory progress. A sketch of the wound and fracture, if any, was made with indelible pencil on the plaster splint, and other details were also added. This recording was rightly considered of the greatest importance, and the essential details were printed in bold letters, as was the name of the surgeon.
Resuscitation in the Forward Areas
Rest was a prime necessity, as was also the maximum comfort that could be given. Warmth was only desirable in as far as it gave comfort. Any excessive heating had been proved deleterious, especially before full replacement of blood volume had been carried out.
The restitution of blood volume by blood, plasma, and serum was the most important factor in resuscitation. Blood had been proved to be essential when blood loss had been severe and the haemoglobin content had been markedly lowered. Plasma and page 75 serum were of value as supplements to blood and in cases not associated with actual blood loss, but with loss of serum, as in burns and blast. Fluids by the mouth, especially warm fluids, were of great value in all except abdominal cases. The gentlest method of handling in transportation had to be utilised.
Continuing shock from active bleeding, and absorption from mangled tissues and infected, especially anaerobic, tissues had to be noted, and time had not to be lost in resuscitation when operation alone could relieve the condition. Post-operative resuscitation was often neglected and was often as important as treatment before operation. Plasma or serum could be given in the RAP and ADS with great benefit in serious cases, and the continuance of this transfusion in the ambulance during transportation to the operating centre proved of very great value.
The general comfort of the patient was very important, and the provision of hospital beds instead of stretchers made considerable difference to the comfort of patients in front-line units. It was impossible to nurse chests and abdomens well on a stretcher.
Fluid was of first importance, as the wounded were always dehydrated, and copious fluid, if possible by mouth, saved much more elaborate medication. The warmth of drinks was also of value in itself. Chest cases were sat up as soon as possible.
Skin attention was necessary, especially in spinal cases and for those in plasters or splints. Plaster splints had to be constantly watched to prevent constriction of the limb and pressure sores. Gangrene easily ensued, and ischaemic paralysis developed, if tight plasters were not cut up and adjusted.
The ring of Thomas splints had to be watched to see that undue pressure was not being exerted on the crutch or on the tuber ischii. The external aspect of the ring of the splint had frequently to be padded to make it fit the limb more accurately. Pressure on the back of the heel and cutting-in of strapping just above the ankle were common troubles.
Fractured jaw cases and severe facial and neck injuries demanded constant attention.
Heads: Head cases, so frequently semi-delirious, took up much of the time of the harassed sister in the ward. Immediate postoperative treatment generaly consisted of sedatives, such as paraldehyde.
Chests: If respiratory distress was marked, early tapping of the haemothorax or haemo-pneumo-thorax was indicated. At first air replacement was used during the first twenty-four hours as a page 76 preventative of fresh bleeding, but this was later given up as unnecessary and undesirable. Later, early tapping became a routine in all cases whether distressed or not, and this was repeated frequently till the chest became clear.
Abdomens: These were at first nursed in the Fowler's position, but towards the latter part of the war this was given up and the cases nursed flat. This gave more comfort and also fewer chest complications. Gastric suction and intravenous fluid remained the routine throughout the war, but fluid by the mouth was introduced, first of all simple fluids, and then definite nourishment was given in the majority of the cases, even when the gastric suction was still being utilised.
General Cases: Further resuscitation with blood or serum was commonly required, and was given more frequently in the latter part of the war.
Essentials of Treatment of Special Types of Cases
Ordinary Limb Wounds: Adequate exposure of the wounded surface, especially in the depth of the wound. Removal of all devitalised tissue which does not necessitate damage to vital tissues. Preservation of bone fragments. Removal especially of damaged and avascular muscle. Relief of tension and provision of drainage. Application of bacteriostatics and antibiotics, such as sulphanila-mide and penicillin, to the wound. Dressing to ensure the wound being left open. Provision of rest by splintage, generally plaster, more elaborate if a fracture be present. The plaster splints padded, and split before evacuation.
Head Cases: Referred to forward neurosurgical centre for operation. Details given under head surgery.
Chest Cases: Wounds, except simple penetrating or perforating wounds, excised with removal of rib fragments. Sucking wounds closed by pad stitched in place, after the muscular layer had been sutured to close the chest. Early tapping of the chest carried out with introduction of intra-pleural penicillin. Details given under chest surgery.
Abdomens: Careful resuscitation before operation with urgent operation only in those cases not responding and deemed to have continued bleeding. Routine catheterisation before operation. Suture of small intestine and stomach wounds. Exteri-orisation of large intestine except healthy wounds of the right colon. Drainage for bile and rectal injuries, and when in doubt and always in retro-peritoneal areas. Infrequent operation in liver and kidney injuries. Routine post-operative gastric suction and page 77 intravenous salines and glucose, with fluids by the mouth. Nursing flat on back for first forty-eight hours.
Spines: Suprapubic drainage for paraplegic cases.
Burns: No operative measures. Treatment of shock by plasma and simple dressings. Parenteral penicillin.
Traumatic Amputations and Gross Muscle Injuries: Early and radical operation with free excision of damaged muscle and other tissue, not waiting for full resuscitation.
Amputations: Should preserve as much limb as possible, except that in the lower limb the amputation should be at least three inches above the ankle to prevent a possible unnecessary re-amputation later. The same applies in lesser degree to thigh and arm amputations. Flaps should be fashioned if at all possible so as to enable delayed primary suture to be done four days later.
Factors Governing Time of Evacuation
Patients from the forward areas were normally evacuated at the earliest possible moment. As soon as a patient had recovered from his anaesthetic he could be transferred by ambulance. There were certain types of cases that had to be retained. There were never enough of these cases to embarrass the forward operation centre. There were:
Cases Unfit to Travel, whatever the lesion. Resuscitation by blood and fluids could, within a relatively short time, render most cases fit to travel. Naturally the distance, and the type of transport, influenced the decision as to fitness.
Abdominals: Were held at the site of operation for from ten to fourteen days. Experience conclusively proved the life-saving value of this procedure. No abdominal case was evacuated till it was definitely stabilised and free from either wound or peritoneal infection.
Chests: Severe chest cases associated with dyspnoea and cyanosis were often quite unfit for travel, and often had to be held for several days. Aspiration, blood transfusions, and rest enabled them to travel later.
Burns: Severe burns cases were often too shocked or too toxaemic to travel, and had to be held for some days.
Anaerobic Infection: Gas gangrene and severe anaerobic infection of wounds necessitated holding till the condition stabilised, so as to avoid change of surgeon and ensure careful watching.
Haemorrhage: Serious danger of haemorrhage necessitated retaining the patient for observation.page 78
Gangrene: Impending gangrene, following vascular injury, required the retention of the patient till the position was clarified. ‘Half alive on the field is better than dead at the Base’ (Donald).
On the other hand:
Head Cases travelled very well, the only bar being extreme restlessness, making handling during transit impossible.
Chest Cases, if they had no distress in breathing, travelled comfortably.
Spine Cases travelled satisfactorily.
All Fractures travelled well if splinting was well done.
Evacuation of Cases from the Forward Operating Centres
In the earlier campaigns in the Middle East, with the rapid movement, the evacuation of casualties was very difficult and entailed often long and rough desert and road transportation. The lack of mobility of the CCS also threw the forward operating work on to the Field Ambulances, and this necessitated rapid evacuation so as not to hamstring the field medical units, which perforce had to keep up with the Army. This early and prolonged evacuation of the serious cases had serious effects as regards the survival of abdominal and other casualties.
In Greece train evacuation to Athens was available in the early stages, but during the retreat long ambulance carry was necessary; fortunately the casualties were light. In Crete sea evacuation was available, but only in the early stages of the campaign.
During the second Libyan campaign the difficulties were extreme and the New Zealand casualties were captured during the critical stage. Even when relieved the convoys had to traverse long distances of rough desert before reaching the railhead behind the frontier, where adequate resuscitation was first available. The condition of many of the casualties when they reached 2 NZ General Hospital at Gerawla was that of extreme exhaustion, and often dehydration following the long period of marked restriction of water supply. Few abdominal cases were seen at the Base—a silent commentary on events.
From the railhead area some cases were evacuated by air, and some also by the coastal road with staging posts set up on the way to the Delta. The difficulties of looking after casualties with the many changes of medical units on the long route of evacuation were realised. It was appreciated that constant changing of dressings was undesirable, as was the constant shifting of seriously wounded men.page 79
During the pre-Alamein and Alamein periods the evacuation route was short, and means of transport by road, rail, and air were all available. Air transport was very gradually introduced in the desert. At first use was made of the return journey of supply planes, and ihese were used in the second Libyan campaign. These planes were subject to enemy attack, and several were shot down. Strong efforts were made to obtain ambulance planes, but aircraft-were in short supply and could not be spared for this purpose. The South Africans and the Australians supplied the first ambulance planes in the desert, and these were available at the Alamein period, but the ordinary supply planes still carried the majority of the patients. Air transport was utilised both to take head cases to base hospitals for their primary surgical treatment, and also to evacuate serious cases, including abdominals, shortly after operation. This proved quite unsuitable for the abdominal cases, and many of these patients died shortly after arrival at Cairo. Major-General Monro, Consultant Surgeon MEF, drew attention to this, and a conference held in our divisional area recommended that in future all abdominals should be held in the forward areas for ten days before evacuation to the Base, and that other seriously ill cases, such as chests, should also be held till deemed fit to travel. The recommendation was immediatefy adopted and beds were supplied for abdominal and other serious cases to the forward units, both the Field Ambulances and also later the FSUs. Head cases were not affected adversely by air transport.
During the advance from Alamein to Tunis at first road and rail transport was utilised, but later, as the distances increased, air was used increasingly, transport planes being employed on their return trip to the advanced bases, such as Tobruk, to which the railhead had been extended. Medical units were commonly sited near the airfields. Fortunately casualties were light, so that the majority of the serious cases were able to be carried quickly back by air.
Air transport was particularly useful during the left hook at Mareth when our own ambulance personnel constructed a landing ground alongside our Field Ambulance centre, thus enabling the evacuation of serious cases when the road access was in the hands of the enemy. Sea transport was utilised from Tobruk, Tripoli, and Sfax.
In Italy motor ambulances were largely used, rail services being seriously dislocated by the German demolitions. The railways were rapidly repaired, however, and gradually came into use, and they carried out the greater part of the long evacuations. Air also came more into the picture, and, with complete dominance in the air, safety was ensured; as the length of evacuation steadily page 80 increased, more and more casualties were evacuated by air. Finally, hospital ships were utilised both from Anzio, and later from Ancona on the Adriatic coast.
In general, for short distances ambulance transport remained the routine method. For intermediate distances the ambulance train was used, whilst for long distances air transport was supreme. The hospital ship was again the most useful method of transporting large numbers over long distances, such as from the Middle East to New Zealand. It was also useful for intermediate distances in the Mediterranean, but was at times subjected to danger from bombing and mines, even though the Geneva Convention was adhered to by the enemy.
DIAGRAM OF CHAIN AND METHODS OF EVACUATION, ITALY, 1944
Analysis of Methods of Transportation
The Effect of Transportation by Road: This was never comfortable, and on rough roads could be very uncomfortable and distressing. The movement had a deleterious effect on all wounds, and it was for this reason that wounds could not be sutured in the forward areas, and why splinting was so necessary even when there was no fracture.
Air: The only difficulties with air transport were: (a) the road to the aerodrome was often very rough; (b) some uncertainty as to the exact time of the evacuation; (c) in some planes ordinary stretchers could not be used, and the patients had to be shifted on page 81 to the stretchers and back again at the end of the flight; (d) if the plane had to fly high, some extra distress was caused to chest cases.
Apart from these relatively minor difficulties, air transport, especially for long distances, was ideal, and was responsible for great improvement in the comfort of patients, and also must have contributed to a decrease in mortality amongst the very severely wounded cases.
Train: Patients could be transported long distances by train very comfortably, and this was the best practical method for large numbers.
Ship: Travel by sea had the advantage that operative measures could be carried out during transit.