New Zealand Medical Services in Middle East and Italy
REVIEW OF CRETE CAMPAIGN
REVIEW OF CRETE CAMPAIGN
After the experiences in Greece some confidence was felt in the use of the Red Cross for the protection of medical units, although there was still much doubt as to the extent the enemy respected it. The attack on 7 General Hospital and 6 Field Ambulance caused some loss of confidence again, though the enemy's behaviour in the campaign thereafter indicated a respect for the Geneva Convention.
The display of Red Crosses on the site of the hospital could not be described as inadequate. Red Crosses were painted on the three buildings, a large one in stones was laid out between the officers' mess and the sea, and one of similar size in cloth was spread out in the area occupied by the hospital expanding tents. The weather page 200 was mostly fine and the crosses could be seen from a fairly high altitude.
Yet captured enemy orders indicate that those who planned the attack on Crete may have been unaware that it was a hospital site. It may be that German intelligence reports were defective, as indeed they were in their estimate of the number of troops in the sector. Orders of 3 Parachute Regiment issued on 18 May describe the area as a “tent encampment” with a “hospital barracks” and “hospital huts”. The regiment was to land in the Galatas area, clear the ground around Canea, and capture the town. A full battalion was committed to attacking the hospital site, but only one company of parachutists actually reached the scene. Air Corps reports later reported the capture of 500 prisoners but omitted to mention they were hospital patients and staff.
The Germans verbally stated they had seen troops in steel helmets traversing the area before the attack. It seems to have been a German practice to forbid the wearing of steel helmets in medical units, and although this had no basis in the Geneva Convention, the Germans seem to have assumed that other forces should follow the same practice. Steel helmets were worn in the area, and troops did pass along the road running through the area to the beach. A study of German orders does not indicate that the area was required for further air or sea landings, which was one of the conclusions earlier drawn from the attack. The aim seems to have been to eliminate any opposition from troops expected to be in the neighbourhood of the camp. But this hardly excuses the sustained attack on 20 May on what must have been perceived to be a medical unit.
From all the evidence at our disposal it would seem that the German Air Force did otherwise respect the Geneva Convention when the medical units were distinctly marked by the Red Cross, when steel helmets were not worn, and when medical units were sited away from main roads and from any fighting unit.
There was insufficient transport for the conveyance of the wounded. Walking wounded had not only to walk between the dressing stations and the hospital, but most of them had eventually to walk across the island during the evacuation. Lying cases had to be left behind at the medical units, both because of lack of vehicles and the impossibility of embarking stretcher cases at Sfakia.
Constant machine-gunning of the roads after the invasion made conditions still more difficult and often caused serious delay; it was only by strenuous efforts on the part of medical officers and drivers that the essential work was carried out. At times lorries were found page 201 abandoned and were brought into service when urgently required. Patients had to be moved in the darkness to escape the bombing and machine-gunning of the roads. Some of the cars were damaged in this way.
It was found that, generally, the German airmen respected the Red Cross if it was effectively displayed, and this eventually led to the use by 5 Field Ambulance of transport furnished with large Red Cross markings. During the evacuation this method was used in the transport of wounded, with great success. It was stated that six ambulances, marked with small crosses only, were destroyed, whereas those marked with large crosses proceeded unharmed through the same area.
The Work of the RMOs
The RMOs, especially those attached to 5 Infantry Brigade, experienced great and unprecedented difficulties during the violent and confused attack, particularly in the Maleme area. They found themselves called upon to deal with heavy casualties, with very little in the way of equipment and medical supplies. Although attempts were made by the field ambulances to contact them by parties of medical officers and stretcher-bearers, these were unsuccessful and the RMOs had to carry on as best they could.
Fortunately, their medical supplies were supplemented by German supplies dropped by parachute, and these were found to be of excellent quality, both as regards drugs and dressings, even containing tubes of glucose saline and surgical operating equipment. The RMO of 21 Battalion stated that he obtained adequate supplies of opium by this means when his own supply of morphia was exhausted.
All the RMOs of 5 Infantry Brigade, with the exception of the RMO of 28 Battalion (who was wounded, losing an eye), were captured. They remained behind with the seriously wounded, including a large number of Germans, when their battalions withdrew. Many walking wounded were able to retire with the brigade.
Owing to the nature of the fighting and the ground fought on, the regimental medical officers could expect little Red Cross immunity. By and large, Red Crosses were not displayed at RAPs as these aid posts were, after all, in the main in strictly combatant areas. Indeed, in such fighting the more the aid post was surrounded by armed troops the safer were the wounded. No deliberate attacks on the wounded were reported by the regimental medical officers who, with their staffs, all performed most gallantly at their posts and did everything in their power to assist the wounded.page 202
The collection of wounded in the forward areas was carried out only with great difficulty in the chaos brought about by the scattered landing of the paratroops. Nevertheless, the work was conscientiously and efficiently done, and the seriously wounded had the benefit of continued attention during the difficult period of early captivity.
Siting of Medical Units
Difficulty was experienced in the siting of field ambulances, dressing stations, and hospitals. Neither the force nor the individual units had had any experience of an airborne attack. The 7th General Hospital had been established before any such attack was seriously thought of. The lack of transport and the conditions of the terrain made the siting of the dressing stations near the main roads a natural decision. It thus came about that the main hospital (7 General Hospital) was erected close to the shore in an area peculiarly liable to both airborne and seaborne attack. One MDS was originally placed at a crossroads and then under a culvert on the main road, positions certain to be subjected to air attack. The selection of sites was thus made very difficult, as the dressing stations had to be kept away from main roads and also from any open space where paratroops could be readily landed. The dressing stations had also to be placed in positions where they could be defended by the combatant troops. The differences of opinion which arose between the senior medical officers with regard to the siting of the units exemplify the difficulties of the problem.
Fifth Field Ambulance set up a very efficient dressing station in the officers' mess building of 7 General Hospital and did excellent work there, although the ADMS considered the site unsuitable. The 189th Field Ambulance established a large hospital in buildings at Khalepa, a suburb of Canea, where it carried out operative treatment on a large number of casualties. The town, however, was subjected to heavy bombing and the unit was lucky to evacuate the site just before one of the buildings was demolished by a bomb.
Health of Troops
The men arrived in Crete very tired and with little personal equipment. There had, however, been no sickness in Greece and the troops rapidly recovered in the peaceful conditions and excellent climate of Crete, probably helped considerably by the facilities for sea-bathing that were available. In spite of a reduction in the rations, made necessary by the unexpected number of troops to be supplied, the health of the troops remained very good throughout the campaign. There was very little sickness and practically no endemic disease, except dysentery.page 203
Shortly after the arrival of the troops many of them suffered from a transient attack of diarrhoea, and towards the end of the campaign mild dysentery was also present, but not to any marked extent.
A British hygiene section had been stationed in Crete for some time before the arrival of the troops from Greece. A malarial survey had recorded widespread infection by malaria in the villages and measures were taken to control the spread of the disease. The 4th Field Hygiene Section under Captain Irwin began at once to investigate the local conditions and to carry out a mosquito survey in our area, finding several areas infested with mosquitoes. The troops had no individual protection – such as nets, cream, or sprays – yet very few cases of malaria occurred. Fortunately, the malaria season had not really commenced before the troops left Crete.
There were no cases of typhoid. Venereal disease had been very prevalent among the garrison troops, but the incidence in our troops in the short and active period that they remained on Crete was not high. There is no mention of any other disease.
Treatment of the Wounded
The casualties on Crete were very heavy, much heavier than in Greece,1 and thus threw a heavy burden on the ill-equipped New Zealand Medical Corps. Medical officers had, however, managed to save many essential parts of their equipment, such as surgical instruments, drugs, and dressings. They were helped considerably by equipment and supplies readily obtained from 7 General Hospital. The lack of transport and the difficulty of evacuating casualties by the one road, which was bombed and machine-gunned incessantly in daylight hours, made it necessary for the MDSs of the ambulances to carry out surgical work, sometimes of a major nature. The surgical team from 1 NZ General Hospital under Major Christie, which had been attached to the ambulances in Greece, was available in Crete; Major Christie performed excellent work and furnished a valuable report on the work carried out under such difficult conditions.
The team was first attached to 5 MDS and then to 7 General Hospital to fill the place of a specialist surgeon killed by a bomb on 18 May. The team was then attached to 189 Field Ambulance hospital at Khalepa until it ceased to function. The force was lucky in having available at 7 General Hospital surgeons of sound training and experience, the senior of them, Lieutenant-Colonel Debenham, later becoming a consultant surgeon on the Western European Front.page 204
Fifth Field Ambulance was called upon to perform a considerable amount of surgical work, both at Modhion and at the site of 7 General Hospital. Sixth Field Ambulance attended to large numbers of wounded from Greece immediately after its arrival in Crete, and later assisted 7 General Hospital by relieving it of its burden of lighter cases and also by setting up a convalescent depot to look after the cases discharged from the hospital. It also treated wounded from the fighting in the Galatas area. Both units assisted the wounded during the evacuation with transport, dressings and rations, and, finally, at the evacuation itself. They nursed and shepherded along large numbers of wounded, some with relatively severe wounds, who normally would not have been permitted to make the trip.
The actual wound treatment varied according to the skill and knowledge of the medical officer and it was natural that some of the surgery was not up to the highest standards. The surgical team reports instances of wounds sutured at the field ambulances with unsatisfactory results. Luckily, there was available our own surgical team and the skilled surgeons at 7 General Hospital, who coped with the greater number of the heavier cases and who had knowledge of the best surgical wound treatment. The wound treatment carried out by our surgical team consisted of débridement, with removal of all soiled and damaged tissue – particularly muscle – with free opening of the wounds and with acriflavine dressings. The serious loss of serum was noted in the large wounds, and also the relative freedom from injury of the nerves and blood vessels.
Fractures: After the usual wound treatment the cases were splinted as follows:
Femur: The Thomas knee splint was used and our surgical team employed a special technique. From ankle to mid-thigh was enclosed by two Cellona plaster bandages. A strong calico bandage was laid on this, passing over a spreader below the foot and coming up on the other side of the limb. Three more Cellona bandages were put on over this. The limb, complete with its plaster casing and extension, was now placed in the Thomas knee splint, the calico attached to the end with rubber tubing – if available – the splint slung from the Thomas crossbar on the stretcher, the footpiece applied, and finally the foot of the stretcher raised to provide extension by the counter body-weight method. This illustrates how one surgeon worked out a combination of plaster and Thomas splintage, which as the Tobruk splint was to become the universal practice later.
Tibia: Plaster closed splint applied.page 205
Humerus: Plaster back slab with collar and cuff, or Kramer wire splints. In fractures of the lower end of the humerus, extension of the elbow below 90 degrees was carried out.
Amputations: These were usually carried out for gross destruction of bone and joint. No guillotine amputations were performed, short anterior and posterior flaps were used, and the site of election was selected. The ends of the wound were sutured, but the central part was left open for drainage. No tubes were used. Main vessels were doubly-ligated and the nerves were simply cut across in the upper part of the wound. In amputations of the lower limb the tourniquet was used, but in the upper limb only digital control of the brachial or subclavian was employed.
In the case of shattered limbs the surgeon employed a simple rubber band just above the lacerated end, to be left on during resuscitation to control haemorrhage, leaving undamaged all the tissue above, through which the amputation would be performed.
Head Wounds: These were excised and the wound closed by use of an S-shaped flap. A head tourniquet was used and an improvised table formed from a stretcher, with a bandage between the bars forming a head rest.
Chest Wounds: These were dealt with very conservatively by aspiration and air replacement. Open sucking wounds, if not already sutured at the field ambulance, were closed, but few of such cases were seen. Detached pieces of rib were removed. No open exploration of the chest was carried out, nor was it ever considered necessary.
Thoraco-abdominal Wounds: All such cases produced by the German explosive bullets were noted to be fatal.
Abdominal Wounds: These were not very frequent. They were all explored at once. The small bowel was generally damaged, the large bowel frequently escaping in a surprising manner, especially in transverse wounds. It was noted that resection of the small intestine caused a heavy mortality. The mesentery and omentum were often found damaged, producing an abdomen full of blood. The rectum was noted to be often injured in sacral wounds, and these cases were generally fatal from toxaemia and probable peritoneal infection. No such case survived, although one lived for five days after a transverse colostomy. The bladder was sometimes injured and catheterisation was always resorted to if any doubt existed, and an in-dwelling catheter left in if any bladder injury was present. No cases of liver, stomach, or splenic injury were encountered.
Shock and Haemorrhage: Treatment consisted of the application of warmth by hot bottles, the relief of pain by morphia (gr. ½) and the splintage of fractures, the elevation of the foot of the stretcher, page 206 and the giving of fluids by mouth, rectally, subcutaneously, and intravenously. Some Baxter vacolites were available at the MDS.
Dried plasma in limited amounts was available at one field ambulance. It was necessary to cut down on the vein and use a cannula. Blood was not used, though transfusion sets and citrate were available at 189 Field Ambulance. The intensity of the surgical inundation precluded its use. The suggestion was made that a special blood transfusion team, consisting of a medical officer and two orderlies, should be attached to the Division, with supplies of dried plasma, a portable refrigerator, and a few pints of blood ready for use.
Gas Gangrene: Only one fulminating case was seen by Major Christie, with infection spreading up to the umbilicus; death occurred twelve hours after admission to hospital. Several cases of limb wounds showed gas in the tissues. These were treated by excision of muscle and muscle groups, and freely opened to facial planes. No amputations were necessary for this condition. Serum was given.
Lieutenant Ballantyne saw several severe cases at 6 ADS and cases were seen later after evacuation of prisoners to Greece.
Sulphonamides: A dosage of 2 grammes, followed by 1 gramme in two hours and then four-hourly for forty-eight hours, was given by the mouth to seriously wounded cases. No sulphonamide was used locally on the wounds.
Foreign Bodies: These were removed when readily accessible or large, but otherwise no time-consuming search was made.
Severity of Wounds: It was noted that the German wounded had much less severe wounds than our own men. The German aerial bomb, trench mortars, explosive machine-gun and cannon-gun shells inflicted more severe wounds than our .303 bullets. The Schmeisser bullet was as severe as a machine-gun wound, if fired at close quarters.
The Leaving Behind of Medical Personnel
In Crete this problem again arose and on a much more serious scale than in Greece. Altogether, there were eight medical officers and 176 other ranks of the NZMC left behind as prisoners in Crete. Four of the medical officers were attached as battalion medical officers and elected to stay behind in their RAPs with the wounded under their care. One of these officers, Captain Stewart, later said: “Unfortunately on 23 May Hetherington and I, under the stress of events, both decided to remain, not realising until we met later in the day that we were only half a mile apart, and as we had information that Longmore was a prisoner of war, probably page 207 unwounded, one of us would have sufficed. Of course, too, our judgement was biased by the belief that exchange of protected personnel would eventuate early allowing us to rejoin our own side”. (This belief was based on the Geneva Convention.) Three medical officers attached to field ambulance dressing stations also chose to remain with seriously wounded men. The ADMS NZ Division was also captured, having delayed his departure to set up a dressing station for walking wounded; he could not be contacted before the engineers blocked the road.
It was not until the later stages of the battle that it was known at Creforce Headquarters that so many medical personnel were remaining with the wounded. An order was then issued by the DDMS Creforce that no more medical officers or other ranks were to remain behind unless detailed by their commanding officer to do so; but it is very doubtful if this order reached more than a limited number of those for whom it was intended. Medical officers, padres, and men unselfishly sacrificed their liberty in their anxiety for the welfare of their patients.
In the hurried retreat to the southern coast close contact between medical units and with headquarters was difficult, and danger arose of two medical units both leaving personnel in the same area. This happened when, at 5 Field Ambulance MDS, two medical officers on their own initiative remained behind, and the nearby 7 General Hospital also left behind medical officers and personnel – a needless duplication. The medical officers generally acted without orders from higher authority, as they felt their individual responsibility keenly, and no definite ruling was available. Circumstances were such that instant decisions had to be made.
These officers showed a noble spirit of self sacrifice and are to be commended for their altruistic zeal, but the policy determining their actions should be clearly laid down by higher authority to prevent unnecessary loss of valuable personnel. Such was the lesson that was learned in the campaigns in Greece and Crete. The British and Australian Medical Corps suffered in the same way, and their officers made the personal sacrifice in a similar unselfish manner.
As regards the other ranks of the NZMC, a large number likewise remained behind with the medical officers to tend the wounded, but many were unable to be evacuated, either because of their loss of contact during the retreat, or, at the end, because it was impossible to evacuate the whole force. Priority had been given to combatant troops, a decision which could not be questioned. It is open to question, however, whether a complement of medical personnel should not always accompany the combatant troops to which they are normally attached as they provide a highly specialised service essential to the well-being of the troops.page 208
The problem of the shepherding of the walking wounded across the island and giving them medical attention during that period was fraught with considerable difficulties. The majority of the slightly wounded had to make the trip on foot, travelling during the night on a road crowded with a rather disorganised medley of troops and refugees and a variety of vehicles, and lying up under the olive trees during the day. The force orders were that road traffic should cease during the day, but it was impossible to enforce the order strictly, particularly during the last days of evacuation. There were thousands of Cypriots, Palestinians, and Greeks making their way across the island, and this added to the confusion due to the number of separate forces involved. It was extremely difficult in the weary march across the mountains for the wounded, and even the personnel of the medical units, to keep contact. The best that could be done was to set up medical dressing and rest posts at intervals along the route, where the wounded and the staffs could be collected together again to have wounds attended to and rations supplied.
Large dressing stations were set up by our New Zealand units as well as by British and Australian medical units, especially near the coast, where the men could be collected and helped during the embarkation. The steep and narrow road down the cliff to Sfakia led to great difficulties in embarking wounded men and also brought about a serious delay, with the result that many, who would otherwise have been accommodated on the ships, were unable to be picked up in the time allowed.
The embarkation would have been speeded up – had it been realised at the time – if a larger proportion of medical personnel had been detailed to help the wounded down the cliff; this would have had the added advantage of allowing a large number of personnel of the medical units to be embarked when extra space in the ships was available. It was so very much a question of the speed of the embarkation, as the naval ships had to be as far as possible out of bomber range before daylight.
The troops who were policing the embarkation had an exceedingly hard task, since in the darkness they had to check all troops for their priority, as laid down by GOC Creforce. The large number of Greeks and Cypriots who had to be turned back also caused serious delay. Slips were issued to wounded by the medical units at the staging posts and, as far as possible, order was maintained and the men checked.
In considering all the circumstances the percentage of the force evacuated was satisfactory, and the number of wounded men, some of them seriously wounded, who got away from Crete showed the virility and sturdiness of our own and other Commonwealth troops.
LESSONS FROM CRETE
The Crete campaign taught our army valuable lessons and made a lasting impression on those who had the honour to take part in it:
Graded Men: The most important outcome, as far as our New Zealand force was concerned, was the attitude thereafter of the senior officers of all units towards the use of graded men in the Division. The severe strain thrown on men marching across the rough and hilly road so impressed itself on these officers that they considered that, in future, none but Grade I men should ever be accepted in any divisional unit – even if normally transport would be available. Men with foot disabilities, who had been detailed for duty in the ASC and other units with transport, were considered especially unsatisfactory in the Division. This attitude was so prevalent that the name “Creteitis” was given to it. It perhaps brought about some unnecessary transfers of personnel with minor disabilities from the divisional units. Fortunately, never again during the war was the Division faced with a similar problem, so the over-anxiety regarding the use of slightly disabled men proved to be unnecessary.
The Geneva Convention: It was recognised as a result of the experiences in Crete that the only adequate protection for a medical unit was the generous display of large and distinct Red Cross markings. It was proved that the Germans respected the Geneva Convention provided that the medical unit was not sited in an area suitable for airborne landing. The wearing of steel helmets was recognised by the Germans as a sign of combatant troops, and therefore they had to be discarded by medical staffs.
Value of Surgical Teams Attached to Divisional Units: There is no doubt that the attachment of a surgical team from 1 NZ General Hospital to the Division in Greece was of inestimable value in the campaigns in both Greece and Crete. The presence of a senior surgeon, with an all-round surgical experience and a special knowledge of orthopaedic surgery, enabled knowledge of the best treatment of the wounded man to be passed on to those working with him, and in addition his own operative ability and judgment were available. He himself noted the difference between the cases passed on from the ambulance in which he had been working and those coming from its fellow.
The loss of a specialist surgeon attached to 7 General Hospital made the team doubly valuable, and a second team would have been most welcome. The problem of whether the forward surgery should be done in the ambulances or at the CCS did not arise here, as there were no official casualty clearing stations and the general hospital was itself a field unit, so that there was little or no distinction between any of the medical units, each one in turn dealing page 210 with whatever work came into its area. The 5th MDS carried out a good deal of operative work. The surgical team operated with both 7 General Hospital and 189 Field Ambulance hospital. British and Australian units also dealt with a considerable number of casualties, including New Zealanders.
Improvisation: The New Zealand units landed in Crete with minimal equipment and supplies, but nevertheless carried out their work under most difficult conditions with quiet efficiency. They showed their ability to improvise, to collect together essential implements, and to work in makeshift quarters. The younger RMOs did a great deal of work single-handed, one RMO putting through nearly 700 cases during the campaign. The lessons learned by those who escaped were of great value to the Medical Corps later in the Desert campaign.
Blood Transfusion Team: The impossibility of carrying out blood transfusions during a rush of casualties, without there being any special team available for that purpose, was recognised. Transfusion sets were available in 189 Field Ambulance hospital, but no transfusions were given. Our surgical team attached to this hospital recommended that a team of one medical officer and two other ranks should be established and attached to the Division, and that equipment, such as portable kerosene-operated refrigerators, should be obtained.
Transport: Naturally, in Crete the supply of transport was of paramount importance and the necessity in modern warfare of having adequate means to transport the wounded from the forward areas to the operating centres only too obvious. Even if it had been possible to embark stretcher cases from Sfakia, ambulances to carry them were not available. It is remarkable how well the medical work was carried out with a minimum of transport.
Dispersal of Medical Stores: The stores of 7 General Hospital were all kept in one tent – in which it was stated that ether was also kept – and unfortunately this tent caught fire during the attack on the hospital. The dispensary tent was also burnt, so that nearly all the medical supplies were destroyed. The dispersal of all essential equipment and stores should be carried out under any circumstances, and especially where damage by the enemy is likely to occur.
There was every reason to be proud of the New Zealand Medical Corps in Crete and of the fact that the medical administration was under our own command. All sections of the Corps did excellent work, including the sisters during their brief stay on the island, and the men of the medical units showed their ability to sacrifice their liberty in the interests of their patients.
Second Libyan Campaign: Medical Units and Lines of Evacuation
The line of evacuation was at first back along the route of advance to Conference Cairn, thence to the railhead
|29 Apr||Suda Bay||500 (On Ionia—walking wounded ex-Greece)|
|5 May||Canea||602 (On Aba—sick and wounded ex-Greece)|
|16 May||Canea||561 (On Aba—sick and wounded ex-Greece)|
|24 May||Suda Bay||60 (on destroyers bringing medical supplies)|
|25 May||Suda Bay||50 (on destroyers)|
|26 May||Suda Bay||150 (on destroyers—from Naval Hospital)|
|28–29 May||Sfakia||230 (on destroyers)|
|29–30 May||Sfakia||550 (On Glengyle)|
|31 May-1 Jun||Sfakia||80 (Final embarkation)|
|23–25 May||270||Maleme area, with RMOs 5 Bde—22 Bn, 160; 21 Bn, 50; 23 Bn, 60.|
|26 May||200 (?300)||7 Gen Hosp caves with British MOs|
|26 May||20||Near Canea, with 5 Fd Amb rear party|
|26 May||100 (?150)||Near Canea, with Lt Ballantyne, 6 Fd Amb|
|27 May||200 (?300)||Kalivia, with part 2/1 Aust Fd Amb|
|28 May||46||Neon Khorion, with Lt-Col Bull|
|30 May||40||Imvros, with Australian MO.|
|Prisoners of war||525|
|5 Field Ambulance||1||1||(2) 63|
|6 Field Ambulance||(1) 6||8||(2) 83|
|4 Field Hygiene Section||17|
|1 General Hospital||17|
|Regimental medical officers||(1)||(4)|
|(1) 7||(1) 9||(8) 180|
|Killed (incl. died of wounds)||36||598||634|
|Prisoners of war||74||2143||2217|
Of the prisoners of war, 15 officers and 510 other ranks were wounded, and of these 1 officer and 36 other ranks died of wounds.
|5 Field Ambulance||8||146|
|6 Field Ambulance||8||179|
|4 Field Hygiene Section||1||30|
|1 General Hospital||21|