New Zealand Medical Services in Middle East and Italy
The arrangements made for the treatment of the casualties were based on the attachment of an ADS to each brigade to carry out the first-aid treatment whenever the brigade might be engaged in very mobile battle. At the MDS arrangements were made to carry out the more elaborate forward surgery. To enable this to be done, the page 286 newly formed MSU was attached to the active MDS with the role of operating on specially selected cases such as abdomens, chests, and heads. It had very elaborate equipment, similar to that of the head and chest units in Britain, which had been brought from England by the Second Echelon, and to this instruments were added for abdominal and general surgery.1 A truck had been specially fitted up in Cairo to contain the equipment as well as special lighting plant, suction, and tanks to hold extra water. The unit was self-contained. The OC, Major Furkert, was a skilled surgeon and Major S. Wilson was one of our ablest young surgeons in the Middle East Force. The whole staff was hand-picked.
In the ambulances themselves there were many capable medical officers and some quite capable surgeons. It was fortunate that this was so, as the Division under the circumstances of the battle had to undertake the full responsibility of the forward surgery. The field ambulance surgical teams dealt with the routine wounds, and the MSU had referred to it specially selected cases. This arrangement, however, lasted only a very short time as it was found that in the rush it was impossible to restrict the work of the MSU, and, as had happened before, in France and in the Desert, the specialist teams in the forward areas had to deal with far more general than special cases. The surgeons were, in any case, general surgeons so were well able to fit in with the conditions.
At that period wound treatment consisted in the surgical cleansing of the wound, the local application of sulphanilamide, the dressing with vaselined gauze and the use of enclosed plaster splints, the method recommended by Trueta. This treatment was carried out in the MDS, and generally no further forward surgery was necessary and the patients were staged along their journey to Egypt in the different units, being fed and bedded and having their dressings changed as required, though, with the plaster technique, change of dressings was infrequent.
The prolonged journey, however, was very exhausting to the more serious cases and the constant shifting aggravated any infection that might have been present. The first part of the journey by ambulance or truck across the desert to the railhead was particularly trying, and was associated with the constant danger of interference by enemy mobile columns. The surface was rough and at times the convoys had to be speeded up. The nights were cold, and at times there were insufficient blankets available. The adequate resuscitation of the serious cases was gravely interfered with by lack of water, especially during the period when the MDSs were captured. Some page 287 blood had been sent up to the forward areas but not to the divisional areas. Plasma had been supplied, four bottles, to each field ambulance, and citrate solution for locally drawn blood. There was also supplied a quantity of distilled water for use with the plasma, but the supply of this was somewhat restricted. Plasma was given in the MDS and the MSU, and some blood was given from local donors. Morphia was available, and fresh supplies were obtained from captured enemy stores.
The nature of the work performed in the ADS is shown in a very valuable report by Major Harrison, who was in charge of the only uncaptured medical unit, 4 ADS. This ADS treated altogether 448 casualties, 360 being New Zealanders. There were 15 deaths, 10 being New Zealanders, and casualties in the ADS itself were 1 killed and 9 wounded. Harrison stated that he limited his treatment to the ligation of arteries, amputation of shattered limbs, splinting of fractures, suture of sucking wounds of the chest, and aspiration of haemothorax. At times when casualties had to be retained for twenty-four to forty-eight hours, more extensive surgical procedures were carried out, such as excision of wounds, drainage of infected wounds, and removal of obvious foreign bodies. Treatment of shock was difficult owing to the shortage of water and hot-water bottles. Often there was a shortage of acriflavine lotion and once of morphia. Kramer wire splinting proved very valuable, and when supplies ran short they were replenished from captured enemy equipment. The majority of the cases dying in the ADS were badly shocked on admission, and practically all suffered from great loss of blood. Only one plasma infusion was given, and it was impossible to give transfusions after dark. The majority of anaesthetics given were sodium pentothal.
Harrison gave a classification of the wounded men as under:
(a) Parts affected:
|Face and neck||32|
(b) Complications and deaths:
|2||deaths (both traumatic amputations with marked shock and blood loss).|
|Head:||9||had fractured skull.|
|3||of these died.|
|Face and Neck:||4||fractures of facial bones.|
|2||involving air passages died; in one case the great vessels were severed.page 288|
|Chest:||6||sucking wounds of which one died.|
|5||other deaths from extensive damage.|
|Abdomen:||15||had intra-abdominal damage, several with portions of viscera extruding from the wound.|
|2||died in the ADS.|
|Buttocks:||3||had intra-abdominal damage, one dying.|
|Lumbar region:||All wounds superficial.|
This ADS had to treat the casualties from the attack by 20 Battalion on 27 November, and many of these were hit in the early afternoon and stayed out in no-man's-land until after dark, suffering more wounds as they lay, and were in a bad way when brought in. Twelve of them died shortly afterwards, either in the MDS, in Tobruk, or in some other medical centre. Their main wounds were as follows:
|Face and neck||2|
Major King's detachment, with the help of an RAMC officer, operated on twenty-two severely wounded Germans left behind by General Rommel. Two of these, having had tourniquets on for three days, required amputation of the legs. All the cases had been wounded two or three days before and had received little, if any, medical attention. The Germans concentrated on the minor casualties so as to fit them for further service and neglected the severe cases. Rommel's large mobile force was stated to have very few medical officers attached and no field ambulance.
Major King reported that as much surgery as possible was done at his unit because of the very questionable contact with the CCS over a rough desert track. He operated on all cases except abdomens. The small supplies of glucose saline and plasma were soon used up. No blood was used. Sterile tulle gras, prepared by the unit before the campaign, was available, each dressing being wrapped in cellophane from cigarette packets. Some German dressings were used—these were of fine paper. All available plaster-of-paris was used up in the splinting of fractures.
Major Furkert in his reports of the work of the MSU gave a clear picture of the conditions under which forward surgery was carried out during the campaign. During the period of capture water was cut down to a pint per head, and the lack of water undoubtedly increased the mortality, especially of the abdominal cases. Dehydration noticeably accelerated death by 4 December. An enemy filter was used for the theatre water, which was re-used indefinitely. No patients were washed and no linen was cleaned. Only once in a page 289 fortnight was water drawn, and without the unit reserve work would have been impossible.
Supplies of kerosene and spirit were very short, and both sterilisation and heating became difficult. There were insufficient blankets for the large numbers of wounded, and this caused some distress as the weather was cold. Selection of cases became impossible and few casualties were admitted who had been wounded less than twenty-four hours, and many wounds were three days old. But, in spite of this, fulminating infection was rare. Very few abdominal cases were seen. Shortage of ether, morphia, and plaster-of-paris was serious. Food consisted of vehicle battle rations, and shortage of water made the use of Red Cross comforts difficult. Evacuation to the CCS after the relief necessitated twelve hours' actual desert travelling.