War Surgery and Medicine
FORWARD SURGERY: CLINICAL FEATURES — Treatment of Wounded in the Field
FORWARD SURGERY: CLINICAL FEATURES
Treatment of Wounded in the Field
The Unit Stretcher-bearers
These were normally the first to contact the wounded man in the field. Although not members of the Medical Corps, they were trained by the RMO to render first aid before carrying the casualty to the RAP. They applied field shell dressings and attended to bleeding by applying firm pads and tight bandaging. Fractures were rendered more comfortable by bandaging the lower limbs together, or, in the case of the upper arm, by bandaging to the body. Morphia by mouth was sometimes administered generally in doses of ¼ grain. No attempt was made to provide any elaborate treatment, and the casualty was transported to the RMO at the RAP as rapidly as possible. This was carried out by the best available and practicable method. Jeeps and Bren carriers, and at times ambulance cars, were used, but sometimes hand carrying was necessary.page 65
Tributes were paid to the unit stretcher-bearers by all who saw them at work in the care of the wounded. They were subjected to many dangers, but these were disregarded as they saw to the safety and treatment of the casualties. There were many casualties among the stretcher-bearers themselves, and at times their work was arduous in the extreme. Jeep drivers, continually going to forward companies over roads subject to heavy fire, were also unflinching in their duty, and were the direct means of saving many lives.
Regimental Aid Post
The treatment given varied considerably according to the campaign and the conditions. Frequently in the desert little could be done beyond rearranging and applying dressings, splinting fractures, and giving cigarettes and chocolates. At times hot drinks were not available for all the casualties. Rapid evacuation was the main consideration.
In Italy much more could be done and the patients made more comfortable, their wet clothes removed, more elaborate wound treatment given, and splints applied. The type of treatment given for the different conditions was as follows:
(a) Control of Haemorrhage: This was usually controlled by direct pressure by pad and firm bandage, the shell dressings being very suitable for this purpose. The tourniquet was very rarely required and was strongly deprecated except in the case of traumatic and inevitable amputation, when it was applied as close to the wound as possible. One RMO of long experience never used a tourniquet except to place it ready for use in case of emergency during transport. He stated that there was never any need to tighten the tourniquet. Another RMO felt that the tourniquet should only be used if all else failed. Opinions were sometimes strongly expressed that the tourniquet should be discarded as it undoubtedly did much more harm than good. It was also pointed out by experienced RMOs that the most serious bleeding had been from axillary and femoral vessels for the control of which the tourniquet was useless. Artery forceps were rarely required.
It was not uncommon to meet with profuse venous oozing, or frank flow, and sometimes spurting from small arteries—these were the most frequent cause of severe blood loss. Cases presenting haemorrhage from a partially severed large or medium-sized artery were rare. In the infrequent case of complete traumatic amputation of a limb the severed arteries had contracted and sealed the end. In partial traumatic amputations the bleeding was from veins or small arteries in most cases.page 66
When the bleeding was profuse control was obtained by the application of artery forceps to the main bleeding vessels and these incorporated in the pad and bandage pressure dressing, and here the use of crepe bandages was a boon in obtaining better pressure.
In those cases where the bleeding had been profuse the limb was immobilised in splints before evacuation and morphine was given. For internal haemorrhage that was clinically suspected or certain, reliance was placed on morphine and rapid evacuation to the ADS for further disposal.
(b) Splinting of Fractures: This was carried out in the simplest method that would give adequate immobility of the limb. Conditions varied so much that at times little could be done, while at others much more elaborate measures were possible. A great deal depended on the proximity of the ADS, and the ease of transport and speed of evacuation, as to whether much time should be spent in handling and applying very elaborate splinting. If casualties were numerous time could not be devoted to elaborate splinting, and the simple measures of binding the arm to the chest and the legs together were utilised.
Even in battle adequate splinting, without recourse to extempore measures, was, however, always possible. The adequacy depended only on time—whether or not it was wiser to retain the patient in an area of danger while time was spent on splinting, or whether to evacuate him at once if transport was available. Time spent on adequate splintage was indeed well spent, the patient being able to be sent through to the operating centre without further interference to the wound before coming to operation, and travelling more comfortably, with relief of pain and in a much better frame of mind.
In the infantry, with the necessity of planning for the minimum of gear owing to the frequency of establishing the RAP on foot without transport being immediately available, it was usual to use the Thomas splint for the lower limb, and Kramer wire for the upper limb with bandage fixation of the limb to the body.
These splints proved very satisfactory in every respect, quick and easy to apply, giving complete immobility, and the comfort in handling and in transport, sometimes over very rough country, was marked, and the patients arrived in good shape.
It was felt, however, that the success of the splinting depended to a large extent on the fact that RMOs were able to use POP1 bandages around the splints rather than the ordinary bandages. page 67 It was easier to apply these—the finished result was better for the preservation of immobility and relief of pain, the splints were no more difficult to remove than those using soft bandages, and the patients benefited from this method. Except for very occasional periods it was always possible to do any splinting necessary, and the type of splint seldom varied, the Thomas splint being equal to any lower limb indication, and the Kramer wire, reinforced with POP bandages, for the upper limb; and on those occasions when the supply of Thomas splints was exhausted it was possible to use the wire, with POP, for the lower limb as well, with good results.
It was a routine to splint all large soft-tissue wounds in the limbs as well as those involving bone; much benefit came from this decision and practice.
In those cases where plaster was used round the splint it was very important to have marked in large letters on the exposed part of the splint that it was a temporary travelling splint only and had to be removed as soon as the patient reached the operating centre, even though there was no constriction.
Pentothal was sometimes used for the application of splints in difficult cases.
(c) Relief of Pain: Morphine was the routine treatment. It was first administered by hypodermic injection, apart from the oral doses given by stretcher-bearers. The dosage varied, the ordinary dose being ¼ grain, and sometimes ½ gr. doses were given. There was a tendency at times to repeat morphia dosage too frequently, and this led to dangerous complications, as in shocked cases with sluggish circulation morphia was slowly absorbed and action was much delayed. When resuscitation was carried out there was a sudden increase in absorption and strong morphia action resulted. Warnings were given concerning over-dosage, and the dosage given was recorded clearly on the Field Medical Card, and also often on the patient's forehead in grease pencil, the exact dose and time of administration being given. Intravenous administration was found to be much more efficient, and smaller doses were given, ⅛ gr. generally, and repeated if necessary. The danger of accumulated dosage was much less than when given subcutaneously.
Syrettes were available for personnel in tanks and armoured vehicles, but not for the infantry. The dosage was ½ gr., which was considered too large, and one RMO instructed his stretcher-bearers to give only half the dose. He made a strong plea for the supply of syrettes to all ranks and for ¼ gr. dosage. Bottles of morphia solution were very useful to the RMO, especially if away from his RAP.page 68
Morphia was only required for the more serious casualties associated with severe pain and restlessness, and for bleeding that was profuse or suspected internally. It was contra-indicated in head cases so as not to mask the signs of cerebral injury.
(d) Relief of dehydration: There was always lack of fluid, and dehydration was sometimes very marked, especially in those cases associated with considerable loss of blood. This was met by the regular provision of hot drinks, generally sweetened tea, which was liberally provided for all cases fit to take it, with the exception of the abdominals. In the desert campaigns scarcity of drinking water at times prevented the giving of adequate quantities of fluid.
(e) Resuscitation: In both Italy and in the Western Desert evacuation was generally so well arranged and the distances to cover, both in miles and in time, were so short that there was no great necessity for routine urgent resuscitation in the RAP. The patient was better served by rapid dressing of wounds and control of blood loss and rapid evacuation to the ADS, where facilities for resuscitation were so much better and the patient freed from the atmosphere of being still in the line. Rapid evacuation to the ADS, with the patient warmly wrapped in blankets, of which there was always an abundance, and hot-water bottles, was generally greatly to be preferred to resuscitation in the RAP.
However, in those cases where it was not wise or expedient to evacuate at once, as when the patient had been a long time wounded before it had been possible to bring him back to the RAP, and was in poor condition—or when the line of evacuation was too dangerous at the time—resuscitation could always be carried out, much the more easily in Italy than in the desert, as in Italy the RAP was generally established in a building of sorts, so that warmed blankets and hot-water bottles and hot drinks were available and ready for any casualty.
Plasma or blood could readily be given, at the risk of inadequate asepsis at the site of transfusion, but one was never informed of any sepsis having occurred at the site of needling. A good supply of plasma, both wet and dry (this latter more commonly in the later stages of the war), was always carried, and blood was sometimes available through the excellent offices of the Transfusion Service, and was given on rare occasions. In the main the standby at the RAP was plasma, and for ease of transport and convenience, as well as for the prevention of waste, the dry plasma was preferred. The distilled water was changed frequently if not used.
The issue transfusion apparatus was admirable, being simple to work and very efficient in action, and the RAP sergeant was trained in the setting up of the apparatus, so that all was ready for the insertion of the needle in the minimum time.page break page 69
Resuscitation was far better carried out at the ADS, but in those cases where evacuation was for some reason or other delayed, then the RMO could do a great deal. If decision was taken to resuscitate at the RAP, then it was important not to evacuate the patient too soon after the resuscitation had been begun, but to wait until he had recovered as far as seemed possible before evacuation was undertaken, even if the circumstances that had delayed evacuation had passed.
(f) Primary Dressings: The routine consisted in wide exposure of the area, cleansing by soap and water of the surrounding areas of skin, and the application of an antiseptic such as iodine. Rough toilet by removal of gross contaminants and foreign bodies from the exposed wound was carried out and then a powder insufflation of sulphanilamide powder by means of an insufflator made in the Engineers' workshops. An average of 5 grammes of sulphanilamide powder was used in a large wound and lesser amounts in smaller wounds. Then a vaseline gauze, or tulle gras dressing, and pad and bandage was applied.
For small wounds the field dressing on issue to all ranks proved ideal, and for larger wounds one or more shell dressings as were required. These supplied pads, but much more bandage was necessary in cases of bleeding in order to obtain sufficient pressure, and crepe bandages were very useful for this purpose.
(g) Injection of Anti-tetanus Serum: This was given in doses of 3000 units to all wounded men. All members of the force had been originally given doses of tetanus toxoid.
(h) Records: The AF 3118 (the Field Medical Card) was carefully filled in with all essential details of the wound and the treatment, and the envelope containing the card was tied to the patient's clothing. Details of morphia dosage given were especially noted and warnings given of any threatened complications such as haemorrhage.
The Advanced Dressing Station
This was still essentially a first-aid treatment centre and evacuation post. No operative treatment was carried out except as an absolute emergency.
Dressing of Wounds: If this had been adequately carried out at the RAP nothing more was required unless there had been some fresh bleeding or the dressings needed adjusting. The same dressing routine was used as in the RAP.
Haemorrhage: Control by pad and bandage was again relied on as the routine. The remarks concerning the tourniquet page 70 still applied and operative exposure and ligature was undertaken only in very exceptional circumstances.
Splintage: This was normally applied to all fractures and also often to severely wounded limbs without fracture. For the arm Kramer splinting or plaster was generally used. For the lower limb the Thomas splint was applied for fractures of the thigh and knee, elastoplast extension to the leg being often used if time permitted, and was much to be preferred. Otherwise the boot was used for fixation, either utilising bandage or preferably special heel clamps. As long as extension was not aimed at little disturbance to the foot was caused, provided skin traction was substituted at the MDS or CCS. If extension was attempted, however, sores were caused on the dorsum of the foot and at the ankle. For the leg Kramer splints and plaster were used.
PLAN OF ADS RECEPTION TENT, 6 NZ FIELD AMBULANCE, CASSINO
Amputation: Traumatic amputation was at times completed at the ADS, but operative treatment was left till the patient reached the forward operating unit.
Resuscitation: Measures used were similar to, but more elaborate than, those described under treatment at the RAP. Warmth was provided by means of blankets, and warm fluids were given by the mouth. Wet and soiled clothing was changed. Plasma and serum were generally available and were given to serious cases. Blood was at times available in small quantities and was given to cases with marked bleeding.page 71
An in-ambulance drip transfusion was utilised during evacuation to the MDS, special supports being made to clamp on to the stretchers. Plaster bandages were used to keep the needle in place and the arm steady. Morphia was given as required.
Records: There was usually time to write full details on the Field Medical Card, and special types of cases were sorted out. It was generally possible to do a primary sorting of cases—a great help to the next units on the line of evacuation. Cases were sorted into:
Abdomens, bleeders, and sucking chests.
Amputations, fractures with swelling and bleeding, joint injuries, large flesh wounds, especially with swollen limbs and situated in the buttock, thigh, or calf.
Heads, eyes, jaws, and spines.
An indication was generally given that further inspection and dressing was unnecessary, or that complications were feared and inspection required.