War Surgery and Medicine
EVACUATION FROM THE FORWARD OPERATING CENTRES
EVACUATION FROM THE FORWARD OPERATING CENTRES
The conditions experienced during the first two Libyan campaigns rendered evacuation of abdominal cases very difficult. It has already been pointed out that the immobility of the CCS made it necessary to perform abdominal surgery in the Field Ambulances. This still left unsolved the question of evacuation after operation from a unit which was essentially mobile and whose main function was the collection and evacuation of casualties. The terrain added to the difficulties as there was only one good road available and the distances were often great. Evacuation across the roadless desert was very rough and extremely trying for the seriously wounded man. The abdominal cases had to be shifted back shortly after operation to the CCS and then to the base hospitals, and it is not surprising that they did badly. The forward surgeons had at first no accurate knowledge of the progress of these cases after evacuation. It was gradually realised, however, that early evacuation after operation was deleterious, and efforts were made page 258 by the forward surgeons to hold the cases for some days. There were difficulties in doing this as no hospital beds and no trained nursing personnel were available in the Field Ambulances. During the second Libyan campaign our Mobile Surgical Unit was able to provide more skilled nursing but, unfortunately, could not function normally.
During the pre-Alamein period conditions had improved markedly and the lines of evacuation were short, but there were difficulties in retaining and nursing the cases in the Field Ambulances. Air evacuation, however, became available for special cases, including the abdomens, and this appeared at first a satisfactory solution of the problem of post-operative management.
It was soon realised, however, that the abdominal cases were dying shortly after arrival in Cairo in spite of the smooth travelling by plane. Major-General Monro, Consultant Surgeon MEF, drew attention to this, and in consequence a conference of senior British and New Zealand medical officers was held at a New Zealand Field Ambulance to discuss the matter.
The decision was reached to hold the abdominal cases at the Forward Operating Centre normally for a period of ten days following operation, and to provide hospital beds and nursing orderlies for the Field Ambulances to enable the cases to be adequately looked after during that period. This decision was immediately implemented and beds and nursing orderlies were sent up with the NZ CCS surgical team to our active MDS. These were the first beds used in the Field Ambulances in the Western Desert. There was an immediate improvement in the results, and whenever possible thereafter abdominal cases were always held at the site of operation if conditions allowed of it. Evacuation by air later was still arranged and ambulance car evacuation utilised as little as possible, especially in the desert.
During the Tunisian campaign the NZ CCS was commonly working alongside British CCSs as part of a Forward Operating Centre. Shortly after the battle of the Wadi Akarit the NZ CCS had orders to go forward, handing over their patients to a British CCS nearby. This necessitated only a very short trip by ambulance car to beds already prepared for the cases, amongst which were several abdomens normally expected to recover. The cases, however, did very badly, some dying a short time after moving, and this so impressed us that an immediate decision was made never to transfer our abdominal cases to any other unit, but to leave behind a section of our CCS to hold and nurse them for the normal period before evacuation.' Patients can be moved miles before operation, but afterwards any movement should be measured page 259 in feet.' The British consultants were immediately informed of the unfortunate result of shifting the patients and took steps to prevent a repetition.
During the advance to Tripoli two or more operating units travelled with the New Zealand Division and took it in turns to set up and operate. When they moved off to rejoin the Division, they left a company of a Field Ambulance with trained nursing orderlies to nurse the cases till they were fit to be evacuated. Cases evacuated in the first few days rarely did well and usually developed septic wounds. Captain Douglas noted that in static conditions, with skilled nursing and mental and physical peace and quiet for the patient the mortality was at its lowest. His figures were: cases operated on while the surgical teams were stationary, 23, with 6 deaths; cases operated on while the teams were ambulant, 11, with 5 deaths.
It was recognised also that the cases differed as regards their suitability for evacuation and that the more serious and toxic cases should be kept longer. The general tendency was to lengthen the period in the forward unit.
In Italy attention was drawn by Lieutenant-Colonel Rodgers, RAMC, who carried out an investigation of cases at the base hospitals, to the association of wound sepsis and burst abdominal wounds with intra-peritoneal infection. This led to the retention of cases in the forward areas if any signs of wound infection were present, partly for the prevention of bursting of the wound, but also for the general treatment of abdominal infection.
All surgeons in forward areas, and those at the Base handling the patients after evacuation, were in agreement that the patient who did not run a straightforward course should not be evacuated till any doubt as to his future had been cleared up. Patients dying at the Base all died of sepsis. It was agreed that peritoneal infection was accentuated by movement, and experience at the Base showed this all too clearly. The infected patient had a difficult uphill fight and often just pulled through. Shift him and he died. The number of patients of this type was quite insufficient to clog the Casualty Clearing Station, so there was no real reason to shift them. It was clearly shown that, unless one was perfectly happy about a patient with an abdominal wound, then that patient should be held, even against administrative urging. It was finally determined to retain all abdominal cases in the forward areas till their condition was satisfactory in every way, throwing the full responsibility for recovery on the forward surgeon. Undoubtedly this led to a lowering of mortality at the Base and did not lead to any corresponding increase in the forward areas.page 260