War Surgery and Medicine
OTHER IMPORTANT ASPECTS
OTHER IMPORTANT ASPECTS
At first it was advised as an ideal that excision should be carried out within eight hours of wounding. It was held that if infection had spread beyond the surface of the wound excision of the infected tissue was impracticable and likely to be injurious by spreading the infection still further by breaking down any resistance already set up by the tissues. The time limit, however, was never rigidly fixed by the Army, but a twelve-hour period was deemed satisfactory by many surgeons. Later it was held that wound toilet could be carried out with benefit up to twenty-four hours, and even much later in the ordinary case.page 54
The whole question is vitiated by the use of the term ‘wound excision’, and the original idea that prompted the technique during the First World War. It was believed then that a complete excision of the wound, removing a continuous layer involving all structures, would remove all infected tissue and all organisms. This radical procedure proved impracticable and was obviously a danger to important structures, and the technique was modified to the removal of devitalised tissues, particularly of muscle. It was realised that if all infection could not be eradicated by surgery devitalised tissue which encouraged infection, especially anaerobic infection, could still be removed with benefit. This removal of devitalised tissue could be carried out at any time, and in the case of anaerobic infection its removal was the only satisfactory method of treatment.
In grossly infected wounds the main objective is generally drainage, but even in those cases any dead tissue such as sloughing fascia should be removed. It was reported at the Rome conference in 1945 that very infected wounds seen at a late stage in Yugoslav patients had been much benefited by removal of devitalised tissue, and that no harm had arisen by spread of infection.
Our outlook on the problem must therefore be revised. The time factor must now be held still to be of considerable importance, because the sooner the devitalised tissue is removed from a wound the less chance there is for infection to arise. There can, however, be no time limit for wound toilet as the removal of dead tissue from the wound is always desirable, though the extent of removal will naturally depend on the condition of the wound. In a patently septic wound little can be done except removal of muscle for anaerobic infection. In the recent wound the operative treatment is a preventive measure, so careful wound toilet is of prime importance, and on this depends the success of wound suture later. This success will to a large extent depend on the period which has elapsed between the infliction of the wound and the toilet, and also on the thoroughness of the operation.
It has been proved beyond doubt that the success of wound treatment depends essentially on the original wound toilet, and that air other measures such as the application of sulphonamides or penicillin are subsidiary.
The time factor in operation was modified by the condition of the patient and also by the nature of the injury. It was found that in patients suffering from shock resuscitation generally had to take precedence, and that time must be allowed for the treatment of shock before operation was carried out. This particularly referred to the abdominal cases. In some cases, however, shock page 55 could not be relieved except by operation. This was well marked in cases of traumatic amputation and massive muscle injury, as well as in open chest wounds and the bleeding abdomen. In these cases it was of the utmost importance to transport the patient with the minimum of delay to a Forward Operating Centre, be it MDS, FDS, or CCS, and not to waste time by stopping at staging posts on the way.
Evacuation in the Forward Areas to the Forward Operating Centre
It was well realised that time was an important factor in the evacuation of wounded men from the field of battle and that every effort had to be made to get them quickly to a Forward Operating Centre. At times great difficulties arose and long and arduous stretcher carrying had to be carried out, sometimes in hilly country, as in Greece, Crete, and parts of Italy. Whenever possible motor transport was utilised, and in the desert campaigns motor ambulances and Bren carriers were used, being driven with great courage on the battlefield; and this hastened the arrival of casualties at an operating centre. Special arrangements had to be made for the clearance of casualties through minefields.
In Italy both the jeep and the Bren carrier were used, both being fitted to carry two stretchers. The jeep proved particularly valuable under very adverse conditions, its power and four-wheel drive enabling it to go practically anywhere. Ambulance cars with four-wheel drive were much more useful than those with two-wheel drive. There were occasional delays at bridges and rivers, as at the Sangro.
Between the RAP and the ADS motor ambulances were generally used, and from the ADS to the MDS and back to the CCS motor ambulance convoys were always available. In the desert the rough and uneven surface made evacuation by ambulance a trying ordeal for the patient, especially if the journey was a long one, and this also applied in Italy where the roads in the forward areas were sometimes very rough, especially in the winter.
Classification of Cases for Forivard Surgery
This consisted first of the sorting out of cases into those (i) definitely requiring surgery or resuscitation, (ii) possibly requiring surgery and further investigation, (iii) not requiring surgery.
This was best carried out at the ADS so as to obviate any further disturbance of the wounded man till he was admitted to the Field Ambulance or the CCS where the operative procedures were to be carried out. The casualty should not have to pass through any intermediate medical unit. The position was aptly page 56 illustrated by a Norwegian surgeon in Italy who said that in New Zealand a patient being sent by ambulance from the country to hospital would not stop at every doctor's surgery on the way.
The second sorting was done according to the priority of operation in those cases requiring surgical treatment. This was carried out at the operating centre to which the casualty was first admitted, which was in our force generally the MDS of a Field Ambulance.
At the beginning of the war the operative priorities were:
Serious wounds and traumatic amputations.
This degree of urgency in the performance of operative treatment decided to a great extent where the operation should be carried out. The lack of mobility of the CCS in the desert campaigns rendered it necessary to deal with the first three priorities at the MDS. The priorities were recorded on the Field Medical Card, generally by writing the essential diagnosis in large letters and by underlining.
Special centres were later established by the RAMC, and arrangements were made to classify the cases in the forward areas and arrange evacuation to the special centres as soon as possible. The special centres formed were Head, Facio-maxillary, Ophthalmic, Orthopaedic, and Chest. Special coloured stickers were produced to designate each of these, and these were affixed to the envelope of the Field Medical Card.
Operation at MDS or CCS?
The distribution of the surgical work between the MDS and the CCS was always a difficult problem, and one on which there was at times considerable difference of opinion. As has been stated, at the beginning in 2 NZ Division the greater part of the work was carried out in the MDS. This established a precedent in the NZMC, and for the whole period of the war it was the custom to carry out a part, and often the greater part, of the major forward surgery in the MDS. There was a differentiation between the work of the MDS and the CCS according to the terrain and the type of warfare. At times the MDS did the major part of the work; at other times the work was concentrated in the CCS, and again there was often a very satisfactory division of the work between the two units. The priorities of the different page 57 types of casualties with regard to operation altered during the war, and this led to an adjustment of the work of the units, Initially the abdominals were first priority, but later, at Cassino. this was changed and severe limb wounds and traumatic amputations became first priority, and abdominals were placed lower in the list and considered more suitable for operative treatment at the CCS. In Italy, except at the Sangro, less surgery of a major type was carried out at the MDS. The Field Dressing Station as instituted in the British Army to take the place of the MDS was never utilised by 2 NZEF, our well-equipped and buttressed MDSs and our mobile CCS supplying all our needs.
The RAMC did not utilise the MDS to the same extent, and the consultant surgeons to the British Army generally did not approve of the MDSs functioning in this manner.
Although a great deal depended on the local and military position, and also on the quality of the staff available, points in favour of operation at the MDS were:
The cases could be operated on earlier and after less exhausting travel.
The earlier operation led to less infection and also the saving of some lives among the seriously shocked casualties.
With FSUs available and also FTUs, the conditions could at times be made very suitable. Beds were available both in the FSU and the light section of the CCS.
As the great aim in forward surgery is to operate and excise the wound before infection has become ingrained, it would seem that operation at the MDS would save much sepsis and some lives.
The points against operation at the MDS and in favour of the CCS level were:
If no undue delay occurred at the dressing posts it was possible in ordinary circumstances to evacuate the casualties speedily to the CCS to ensure timely excision of the wounds there.
The patients were removed from the danger and noise of the battle area and the staff had more rest.
The conditions at the CCS were normally superior so that operation could be carried out more satisfactorily, and more relieving staff was available.
The facilities for, and standards of, nursing were definitely superior. Nursing sisters were available and their presence alone made a vast difference.page 58
The patients could generally be held as long as necessary. This was of great importance to many cases, especially abdomens. If the CCS had to move up it could do so in sections.
Sterilising was better. X-ray was available.
It was the opinion of every unbiased surgeon of experience that the CCS was normally the best place to carry out the major forward surgery. In such circumstances as the Mareth battle, however, when 2 NZ Division was out of contact with the CCS and casualties could not be evacuated readily, then the surgery rightly was carried out in the MDS, the cases being held there and evacuated later. At other times the work was split up between the two units, partly according to priority and partly according to the severity of the necessary operative procedures. Finally, during the Po battles the forward surgery was performed by the MDS, by the CCS, and also by the base hospitals, a condition of affairs rendered possible by excellent arrangements for evacuation. With air evacuation some of the work could be left to the base hospital, where no further shifting of the patient was required.
From the experience gained during the war it can be concluded that the decision as to the units in which forward surgery of different types should be performed must be made according to the circumstances at the time. The advice of the consultant surgeon of the area would be invaluable in this regard.
Staffing was, of course, the most important aspect of the forward surgical problem.
The Field Surgeon
The ideal forward surgeon was a young man in his early thirties who had had a sound training in surgery under capable seniors in a first-grade hospital. He had to be physically very fit and able to undergo severe strain and work long hours. (Forward surgeons often needed spelling at the Base after a period of six to twelve months in the forward area.) He had to be temperamentally stable and optimistic. He had to have initiative and the ability to improvise. He gained experience and training invaluable for the future. A sense of true values was obtained with judgment, decision, and courage, and a knowledge of serious illness, shock, and sepsis which was of great value in later life. Many men of this type were always available in the profession, and New Zealand had many of them.
Surgeons in the Field Ambulance
Arrangements were made to have at least one medical officer in each ambulance capable of performing major surgery. When the MDS of the Field Ambulance was utilised to carry out the page 59 major part of the work, the light section of the CCS (with its excellent equipment and experienced surgeon) was attached to it, and, at times, also another field surgical team sent forward from a base hospital. With one or two teams made up from the Field Ambulance staff to do the less serious cases, a considerable amount of work could be accomplished.
Surgeons in ihe CCS
Young surgeons were selected for the CCS, at least two being normally available, so that the CCS itself could provide two surgical teams. In times of activity, however, extra surgical personnel were essential, and FSUs, often British, were attached.
The pre-operative resuscitation was generally carried out by an attached FTU, and the selection of cases for operation was done by co-operation between the FTU and the surgeons concerned. Post-operative care as required was also given by the FTU. The Field Transfusion Officers in the Middle East were carefully selected young medical officers, trained by Lieutenant-Colonel Buttle at the Base Transfusion Unit attached to 15 Scottish Hospital in Cairo. They were a new development of the war and gave the greatest service, displaying initiative, energy, and judgment of a high degree. One unit was normally attached to each active forward surgical unit. In our own New Zealand force the officers were first chosen from pathologists and bacteriologists, and these proved eminently suitable. It would have been profitable to have increased the number of transfusion units and especially transfusion officers. An active CCS could have usefully employed two transfusion officers.
The anaesthetists attached to the FSUs were called upon to assume heavy responsibilities as so many of the wounded were suffering from profound shock. In the British units specialist or graded specialist anaesthetists were utilised, and these proved of great value. In 2 NZEF we were deficient in specialists and none were available for this purpose, though some training was given to young officers undertaking this work. The value of a highly experienced anaesthetist was seen by us when we had attached to our CCS Major Cope, a British specialist of high standing. He proved invaluable not only as an anaesthetist, but in consultation on post-operative complications and in the training of our own officers.page 60
The orderlies had to be carefully chosen as they had, in the Field Ambulances, to do all the work in the operating theatre and also to nurse the patients, as no nursing sisters were available. Even in the CCS they carried out very responsible work.
At the CCS a senior surgeon was especially valuable in deciding on the necessity and urgency of operation and resuscitation. In our CCS during the war the COs were all senior men with surgical experience, well capable of fulfilling this function. Our consulting surgeon who was attached to the CCS during a major part of its rush periods always worked in the pre-operative ward helping in the diagnosis and the decision as to operation, and being available for advice and help to the FTU and the surgeons. It was felt that units which did not have a senior surgeon available for this work were severely handicapped, and an unfair burden was placed on a transfusion officer when he was called upon to do the work himself. A senior surgeon—in our relatively small force the consulting surgeon was the obvious choice—should be utilised in the CCS not only in the pre-operative ward, but as adviser in the theatre and in the wards. There was no work more important in the whole of war surgery measured in the opportunity of saving life and disability.
General Control of Surgical Staffing in 2 NZEF
The reinforcement of the surgical potential of the Field Ambulances and the CCS depended largely on the field surgical units and teams which were attached when the forward units were active. Unequipped surgical teams from the base hospitals were occasionally used.
There was a definite lack of fluidity in the utilisation of surgical personnel during the war, due to many reasons. The main reason was the rigidity of the unit establishments, which caused many difficulties. This prevented the recognition of any specialist, officer or man, not included in the list. It tended to fix the staffs of the medical units according to the establishment and not according to the work to be performed. It at first led to the waste of skilled medical officers' time in the performance of routine military duties. The officer commanding a medical unit tended to demand his full establishment, even if at the time this was not essential. He also held on to personnel lest, when the unit became busy, he should find himself shorthanded. He also naturally did not like to have page 61 the best of his staff transferred to other units when he was doubtful of their return. The forward areas were often a long way from the Base. The OC was responsible for the efficiency of his unit and especially for the quality of the medical work done in his unit, so he could not but be anxious to have a full and well-qualified staff.
British FSUs and FTUs were commonly utilised by our forward units. It would have been possible for surgical teams to have been shifted from our base hospitals to the forward surgical centres for short spells during periods of high activity, and then shifted back again to the base hospitals when the acute phase was over. This would have enabled our men to get valuable training in forward surgery and also would have given relief to the overworked forward surgeons. The war was fought in short spells, and a concentration of all available surgical talent should have been brought about first at the front and later at the Base. This would have saved medical personnel and given everybody fuller employment. The medical personnel should never again be kept in watertight compartments. They should be used as fluid reserves to shift as the senior officers consider advisable.
Role of a Consultant
The responsibility for surgery should be given to the consultant surgeon as it was in other forces. Even in our small force this was the best arrangement. The consultant himself should be in the thick of the surgical fray, where his services would be of most value and where he could observe every activity and all surgical staff. He must be ever active and know his staff intimately and be ever ready to give counsel and advice and practical help. There was a tendency to retain him at the Base for administrative matters such as boarding and approving of medical boards. At times there was a feeling of jealousy by senior officers at the Base when the consulting surgeon attached himself to the forward units during periods of activity. This could only have arisen through ignorance of the true function of a consultant and the necessity to have him in the position where he could be of the maximum use to the wounded men. He should have been expected to be in the forward operating units as his first duty and expected to take his part in the work of the unit in whatever position he thought best. This would undoubtedly be in the pre-operation ward assisting in the diagnosis and sorting of cases, and at times assisting in the theatre or spelling the surgeons. The RAMC appointed consultant surgeons to the forward areas as well as to the Base, and they proved invaluable. They were a great help to all forward surgeons, including our own. For our small New page 62 Zealand force naturally one surgical consultant was sufficient, and he was able to alternate between the forward areas and the Base acting as a useful liaison officer.