War Surgery and Medicine
DEVELOPMENT OF THE FIELD SURGICAL UNIT
DEVELOPMENT OF THE FIELD SURGICAL UNIT
It has already been stated that during the First World War surgical teams, consisting of a surgeon, an anaesthetist, an-orderly, and sometimes a sister, were constantly used at the CCS to page 46 supplement the surgical staff of those units. There was no regular army establishment for these teams, so that at the beginning of the Second World War they were not provided. Early in the desert campaigns, however, the need for such reinforcement was realised. A surgical team was sent up from the Base to 4 NZ Field Ambulance in September 1940.
The Consultant Surgeon Middle East Force, Major-General Monro, RAMC, quickly realised the importance of surgical reinforcement in the forward areas, especially under desert warfare conditions. During the first Libyan campaign in 1940 great difficulties arose owing to the rapidity of movement and the impossibility of moving the CCS, itself devoid of transport. Surgical teams similar to those employed in the First World War were sent from the base hospitals, but lack of transport and equipment limited their usefulness. The Field Ambulances to which they were at first attached had no surplus of transport, and certainly no surplus of surgical equipment as they were not normally equipped to perform major surgery, which was the function of the CCS. It was found necessary for the teams to take their own minimal surgical equipment, such as surgical instruments and appliances and theatre requisites, and sufficient transport for their own conveyance. Each team collected what it could and what it thought necessary from its own base hospital, and gradually satisfactory equipment of all kinds was provided. The Field Ambulances did not have any spare tentage available, either for operating theatres or personnel, so that had to be obtained in various ways by the teams. Healthy rivalry and initiative were shown by the different teams in getting their supplies, and this demonstrated to the authorities what was essential and minimal in the equipment of these teams.
On 28 February 1941 a conference with New Zealand representation was held at General Headquarters, Cairo, to discuss the problem of forward surgery, and it was agreed that a mobile surgical service was necessary in the desert, and that a series of surgical teams should be established, based on a CCS. They should be available to move forward to suitable locations, but should be independent of Field Ambulances so as to prevent these becoming immobilised.
Following this conference arrangements were made to set up equipped surgical teams, and two were attached to Field Ambulances in Greece, one of them being a New Zealand team. During the second Libyan campaign a team was attached to a South African Field Ambulance near Maddalena, and our Mobile Surgical Unit acted as part of the New Zealand Division's medical services.page 47
After the campaign the teams were further developed and increased in number, and their equipment added to. The teams then became stabilised as Field Surgical Units, with an official establishment of personnel, transport, tentage, and equipment, but no rigid uniformity was insisted on. For instance, there was considerable diversity in the operating theatres of the different units. Some operated in special theatres built on lorries, some in tarpaulin shelters, the majority in EPIP tents. All units accumulated equipment in excess of the minimal establishment to suit the individual surgeon. Beds were later provided for all units to enable abdominal and chest cases to be more satisfactorily nursed, and also to be held in the units for a period, generally of ten days. The staff consisted of one surgeon, one anaesthetist, two ORAs (Operating Room Assistants), one clerk, and two drivers (ASC).
The equipment included operating-room furniture and equipment, including surgical instruments, theatre linen and dressings, and emergency lighting. Tentage for personnel was also carried, and sufficient transport for the equipment and personnel was provided. There was no provision for cooking, and none for the housing and nursing of patients, and lighting was generally provided by the mother unit.
The unit was essentially set up to provide extra operating facilities for the host unit, be that a Field Ambulance or a CCS. This constituted a distinct weakness in comparison with the Mobile Surgical Unit as set up in 2 NZEF. The units were formed essentially to deal with the more serious types of casualties such as the abdomens, and skilled surgeons were provided, but after operation there was no skilled nursing available. This was of particular importance when the FSUs were attached to a MDS of a Field Ambulance, where no nursing sisters were available. The nursing orderlies of our Field Ambulances did become very proficient and were given preliminary training in the base hospitals, but they could not be expected to give the same service as a trained nurse. The CCS with its staff of six sisters had naturally great advantages in this respect. The increasing emphasis placed on post-operative nursing and the longer retention of patients at the Forward Operating Centre made the question of nursing of much more importance.
As reinforcements of operating potential, however, the units were eminently successful, and the staffs were very carefully, selected. The posts were looked upon as prizes of great honour by the staffs of the base hospitals.
Their simplicity with the minimal equipment not only made their formation easy, but allowed their rapid transfer from one page 48 host unit to another, as circumstances demanded. This applied particularly when a unit was attached to a Field Ambulance, which did not as a rule act for long as a forward surgical unit, the MDSs of our three ambulances generally taking it in turns to deal with the major casualties. With regard to the CCS, however, a unit remaining active for a considerable period and generally throughout a campaign, an FSU was often attached for a long time, so that it became a smooth-working part of the machine.
The New Zealand Field Ambulances had surgical teams attached during the pre-Alamein period, first British teams and then teams from our CCS and our own Base Hospital at Helwan. From then to the end of the war our own FSU was regularly attached, generally to the Field Ambulance, and sometimes to the CCS. We also had RAMC FSUs, often with FTUs as well, attached to us for considerable periods, both with the Field Ambulances and the CCS. The CCS in particular was seldom without an attached British FSU of excellent quality. The personnel of these units worked in the utmost harmony with us, and brought with them a freshness and breadth of outlook in itself of great value to our own units. Our New Zealand force during the period of the war in the Middle East and in Italy relied a great deal on the RAMC for FSUs and FTUs in our forward units. This was partly due to the prominent position given to our units, which were servicing other than our own troops. It was also due to shortage of young surgeons in the NZMC suited to the work, as well as to the somewhat rigid retention of personnel in our base units. There was no reason why each of our three base hospitals should not have formed a surgical team and sent it forward to help in the rush periods, withdrawing it to the base unit as soon as the rush was over. We were very well served by the attached British units and could hardly have done without them, but we should have been able to pull our weight better, especially as we contributed practically nothing to the common pool of administrative medical personnel.
Reserve Unequipped Surgical Teams
These were utilised occasionally to supplement the equipped teams, the FSUs. In times of stress these teams were able to spell the overworked surgeons. With no equipment they could be rapidly transported, often by air, and could walk straight into a working operating theatre. Our CCS was thus reinforced during the battle of Mareth by teams supplied by 3 NZ General Hospital, then located at Tripoli. The benefit was considerable both to the page 49 CCS and the personnel from the hospital. Unfortunately, with the dwindling staffs of the hospitals this was not repeated, but 2 NZ General Hospital sent up a medical detachment from Caserta to the forward areas during the final Po battles.
Method of Employment of Surgical Teams and FSUs
The employment of FSUs was the logical method of supplying extra and well-trained surgeons for forward surgery, but the method of their employment was at times open to criticism. The fluid battle conditions in the early desert campaigns led to the surgical teams being attached to the Field Ambulances. It was normal at first for only one team to be attached to a Field Ambulance, and there were not many teams available. As casualties often occurred in one particular area it thus led to a concentration of work on one team. This team worked till it was exhausted as there was no possible relief, and serious cases naturally banked up awaiting operation. The surgeon could not give of his best, and treatment for the control of bleeding and the prevention of infection was delayed. The lone team could only handle efficiently relatively few casualties, and could be fully justified only in positions separated a considerable distance from the main battle area. The desire of senior combatant officers of brigades to have a competent surgeon available for their men irrespective of the likely number of casualties, though displaying a keen appreciation of medical needs, proved often an embarrassment to the medical administration. It was found necessary to concentrate the medical units responsible for forward surgery in one centre, so as to have available for the care of the wounded the maximum number of surgeons, thus enabling distribution of work and spelling of personnel. The operating theatre assistants needed rest just as much as, and even more than, the surgeons. There were many methods of arranging the reliefs of surgical teams, but it was recognised that no surgeon should operate normally for more than sixteen hours in any twenty-four, and that no more than 12–16 operations of magnitude per team in any day was desirable. There were other duties of importance besides operating, and the surgeon had to keep a watch on the post-operative treatment of his patients, while a pre-operative knowledge of them was also helpful.
The realisation of the evils of the deficiencies of the lone team led to the attachment of two or more teams to the active MDS and, with an FTU also added as a normal part of the operating centre, large numbers of casualties could be adequately dealt with by operation. The evils of the lone operator were seen more in page 50 the RAMC Field Ambulances than in our own. Provision had been made in our units for surgical work, both by the provision of extra equipment and, especially, by the appointment of at least one medical officer in each ambulance capable of performing major surgery. This ensured one surgical team from the Field Ambulance's own staff, so that any attached team was not working on its own. In addition, the surgeons of the inactive Field Ambulances were frequently utilised in the active MDS to form extra surgical teams. The surgical work was apportioned so that the surgeons of the attached FSU, or at times of the Light Section of the CCS, dealt with the major cases such as the abdomens, whilst the Field Ambulance teams operated on the less serious cases.