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New Zealand Medical Services in Middle East and Italy

Surgical Policy

Surgical Policy

During the operations in September a high proportion of abdominal wounds was observed as well as many chest wounds. The percentage of bullet wounds was noted to be unusually high. The Division was under command of the Canadian Corps, which had its own medical chain; in view of the expected breakthrough beyond Rimini, and also because of the proximity of 1 General Hospital to the forward areas, 1 Mobile CCS under Lieutenant-Colonel Clark did not set up on its arrival with the Division. This resulted in the loss of the services of a valuable unit with experienced personnel at a time when there was a definite shortage of such staff in our force. There had never been throughout the war any period of active warfare when there was not ample forward surgical work for all available units and personnel. The control of our CCS at this period was under the ADMS 2 NZ Division, whose more immediate interest was naturally in the functioning of the field ambulances. A CCS is normally under Corps or Army command but in the New Zealand force our CCS, like all our New Zealand units, was retained as a rule under the command of the DMS 2 NZEF. The 1st Mobile CCS page 614 surgical team was, however, attached to 4 Canadian CCS and then to 5 Canadian CCS, which in turn dealt with many of the more serious New Zealand casualties. The surgical arrangements at the Canadian CCSs were found to be somewhat different and, in our opinion, not as satisfactory as our own, but the work of the Canadian surgeons was of a high standard. The supervision of the patients in the pre-operative room was in the hands of the transfusion officer or the general duty officer acting as his relief. There was no surgeon available for diagnosis and sorting, though the operating surgeon often had a look at the patients. This threw a very great responsibility on the transfusion officer and, in our opinion, was not as safe and sound as our custom of having an experienced surgeon in attendance in the pre-operation room. This particularly applied to the abdominal cases, where diagnosis was often difficult and always of great importance and where the use of X-rays was often of value. An experienced surgeon could often take the responsibility of deciding against abdominal exploration. This was of more than theoretical importance as abdominal exploration carried a very definite mortality as well as morbidity.

After operation the cases were looked after by ward medical officers who carried out the treatment without reference to the operating surgeon. This had certain administrative advantages in rush periods but could not compare in surgical efficiency with the system where the operating surgeon supervised the after-treatment himself. The ideal in our opinion was for the operating surgeon to retain his control but to share it with a ward officer who could watch the case and report complications to him. If a senior surgeon was acting in the pre-operative room, he could make interim rounds of the post-operative cases while the operating surgeon was in the theatre.

The utilisation to the full of the surgical abilities of 4 Field Ambulance was a feature of the unit's activity at Viserba. The commanding officer made the following comments on this phase:

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 battle casualties received complete surgical treatment and were fit to be sent on direct to 1 NZ Gen. Hosp.

As facilities for nursing are better at a CCS, all non-urgent cases of abdomens and chests were sent to a CCS for surgery.

The principle adopted was to hold cases awaiting operation only up to the time involved in evacuating to a CCS, and there awaiting treatment. In other words, holding cases at the MDS awaiting operation, if by so doing the patient will receive earlier surgical treatment, than if he is sent on to a CCS immediately.

In conclusion, the equipment of the ambulance remains at the high standard previously attained. With the advent of winter it becomes obvious that an open MDS can function satisfactorily only in buildings; as the canvas, page 615 which is excellent under summer conditions, does not provide the necessary shelter and warmth.

On the other hand, the Consultant Surgeon 2 NZEF expressed the hope that the tendency to operate at the MDS instead of the CCS would not become more prevalent. His view was that, whenever circumstances permitted, forward surgery should be performed at the CCS, which was the unit specially equipped and staffed to do the work. The cases formerly thought to be of importance as regards early operation, for example, abdominal cases, were rightly sent back to the CCS and there was no reason why the CCS should not carry the main load of other heavy cases.