War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
Administration of Transfusion Service
Preparations were made six months before the onset of war to set up a Blood Transfusion Service in Britain under the aegis of the Medical Research Committee, and a memorandum on the subject of shock was drawn up by the committee for general circulation both to the services and to the civilian medical authorities. The memorandum stressed the importance of the restitution of the blood volume as the primary need in shock.
The Transfusion Service was based on a main unit in Britain at Bristol, where blood was collected and stored and where experiments were sponsored which resulted in the production of blood plasma, both dry and wet, in large quantities. Here also crystalloid solutions such as glucose saline were prepared, and the unit became a huge factory for supplies of blood, plasma, and crystalloids, as well as apparatus. Simple and very efficient blood taking and giving sets were designed and sent to every theatre of war. Plasma and crystalloids were also sent abroad in large quantities and also made available in Britain for the heavy air-raid casualties. Blood transfusion units were organised and trained and then sent abroad.
In the Middle East Force a base unit was set up in Cairo at 15 Scottish Hospital, and here Lieutenant-Colonel G. A. H. Buttle, RAMC, organised the service for the African and Syrian campaigns, and supplied blood and crystalloids and sulphonamide drugs to both the base and the forward areas in the desert. Buttle's organisation developed the highest efficiency and can be said to have been the most successful part of the whole medical service in the MEF. Plasma was not available in any quantity for some time, and blood was relied upon almost entirely. The development of the transfusion service in the MEF was partly due to the difficulty of obtaining supplies of plasma from England, much of which was lost in transit. This forced Buttle to supply whole blood, and, as this proved eminently suitable, it became the normal transfusion.
The Australians under Lieutenant-Colonel Wood, as Transfusion Officer, had organised blood transfusion during the first Libyan campaign, and they utilised their own Soluvac apparatus, and also wet serum which had been produced in Australia and sent overseas. Some valuable reports of their experiences are available. They had to depend on drawing off the blood from donors on the spot. They pointed out the value of adding glucose to the blood, and demonstrated that this rendered the blood quite fit for use for fourteen page 96 days, and also much delayed haemolysis. The necessity for thorough cleansing of the apparatus and rigid aseptic techniques in the preparation of blood was stressed.
2 NZEF Experience
In the early campaigns of Greece and Crete stored blood was not available, and very little was given to the wounded men. In the second Libyan campaign blood was available at the CCS level, but in the divisional area very little blood was given and little plasma was available. Blood, however, was given when the casualties got to the CCS level, and later more was given at hospitals on the L of C and at the Base.
In this very difficult campaign with disrupted communications proper blood service in any case was impossible in the forward areas, and the conditions, which included long rough transport over the desert, militated against the proper treatment of shock. The transfusion service, however, had developed during this period and was fully active at the Base. The great benefit of blood transfusion was recognised, as was the necessity to give large amounts in the serious cases associated with marked haemorrhage. The other methods of resuscitation were being utilised, including adequate dosage of morphia, warmth, and hot drinks such as tea or cocoa.
Provision of NZ Field Transfusion Unit
Up to this stage the 2 NZEF had made no special provision for transfusion officers or units, nor were there any transfusion officers appointed till the Division returned to the desert to help to stem the victorious march of Rommel before Alamein. A transfusion unit was then formed from 1 NZ General Hospital under Major Stewart, who was pathologist to the hospital. The unit had the standard equipment and staffing of the RAMC unit and was attached to a forward operating unit, generally the active MDS. Our CCS was at that period supplied generally with an RAMC tranfusion unit.
The transfusion unit consisted of one medical officer, two transfusion orderlies, and two drivers, with one refrigerating truck and one stores truck. One of the drivers was a refrigeration mechanic. There was an insulated box, surrounded by a water jacket, capable of holding 110 bottles of blood. The temperature was controlled by a refrigerating pump using methyl chloride as a cooling fluid, and driven by a small petrol motor. This was all placed in the tray of the truck and fitted in any 3-ton truck.
Built-in shelves and drawers were also used to keep the equipment handy and tidy, with specially made boxes to contain sets for typing transfusions and for bleeding. Transfusion stands were found page 97 essential. The transfusion unit obtained supplies of whole blood, plasma and saline, and glucose and saline, from the British Base Transfusion Unit, which organised the distribution by means of an executive forward transfusion officer. The personnel of the New Zealand transfusion unit was changed from time to time, but its establishment remained constant. Two New Zealand units were set up at one period in Italy. Units without attached FTUs carried out resuscitatory measures utilising their own personnel.
Treatment at Medical Units
This varied according to the medical unit and the circumstances at the time, the following procedures being normal:
At the RAP: The main factor here was rest, both general and also local at the site of the injury. Morphia and the recumbent position supplied the first want and dressing and splinting the other. Morphia was more efficient and safer if given intravenously. If given subcutaneously to a serious shocked case there was often lack of absorption till the circulation improved following transfusion, when a dangerous dosage from the repeated injection might arise. The adequate foolproof recording of morphia administration proved essential to prevent overdosage. Marks were made on the Field Medical Card and often on the patient's forehead. Plasma or serum was given when available, and at times even whole blood was possible. Fluid by mouth was of great value. This was generally given as large cups of hot sweetened tea, and the medical comforts supplied by the Red Cross enabled cocoa and other warm drinks to be given. The application of a tourniquet as close to the wound as possible in cases of traumatic amputation both stopped bleeding and also the toxic effects produced by the wounds. (The tourniquet otherwise was used sparingly.)
At the ADS: The treatment given at the RAP was again carried out, but more elaborately and with more efficient splintage. Efficient splinting was of particular importance throughout the course of treatment, but especially so during the course of evacuation, which was often carried out over rough desert or bad roads. Blood was often given if available, but plasma and serum were the more usual transfusions. Warmth and copious drinks were routine treatments.
At the AIDS: The treatment at this level depended on whether the MDS was being utilised as a forward operating centre -or not. In 2 NZEF the MDS almost always did act as an operating centre, and our NZ FTU was attached to it and supplied full facilities for resuscitation and transfusions. Adequate blood, plasma, serum, and crystalloids were available, as was a trained staff to administer them. At the Alamein period and afterwards beds were made available page 98 for the nursing of abdominals and other serious cases. As it became realised that wound shock in the cases with large flesh wounds and in traumatic amputation persisted till adequate excision of the damaged tissues had taken place, provision was made for these cases to be treated in the MDS as first priority.
At the CCS: Here all facilities were available including an FTU, operating team, nurses, and hospital beds.
The transfusion service of the Eighth Army units provided dry plasma for the RMO, dry and wet plasma or serum for the ADS, and plasma and blood for the MDS. Blood was sent out in ice-packed boxes holding up to twenty bottles each, and it kept well for twenty-four hours. Over 1000 bottles of both blood and plasma were issued each month to the Eighth Army, and over half was used in the Field Ambulances. In spite of transfusions at the Field Ambulances, it was found at the CCS level before Alamein that the case might be severely distressed on reaching the CCS and then was very difficult to resuscitate again. A month later arrangements were made to keep the transfusions going during the journey from the Field Ambulance, and this kept the patients' condition satisfactory. This enabled RMOs and Field Ambulances to transfer bad cases even when otherwise not quite fit for a journey. In abdominal cases it was found particularly that patients stood travel badly for the first six or seven days following operation. After the Mareth battle our CCS was detailed to go forward and very carefully shifted seven abdominal cases to another CCS alongside only half a mile away. Four of the cases died in the next twenty-four hours. Ever afterwards when the CCS shifted, the abdominal cases were left in their own tent with the same personnel to attend to them and to carry on the continuous gastric suction and intravenous glucose saline treatment. On an average, each abdominal case had 18 pints of intravenous fluid after operation.
Cases of burns, penetrating chest wounds, and maxillo-facial injuries travelled badly, and plasma or serum was administered during transport with great benefit.
Desert Campaign, Alamein to Tunis
The organisation of the transfusion service of the MEF during the desert campaign from Alamein to Tunis proved very efficient. Adequate supplies of blood, serum, plasma, and crystalloids were sent up from the base unit in Cairo to blood depots under the charge of special transfusion units, whose officers functioned as distributing agents to all the forward medical units. At the same time they gave advice and valuable information on military matters page 99 to the scattered units. The blood depots were generally placed at the headquarters of an MAC or on an aerodrome, so that refrigeration was available at the places where blood arrived from the Base and where it could most easily be distributed. The transfusion officer paid daily visits to all units, not only supplying the blood, but also removing any surplus supplies and used apparatus needing servicing at the Base.
Experience of NZ FTU, Alame'm to Tunis
This has been well summarised by Major D. T. Stewart and Captain C. P. Powles, both of whom were in charge of our FTU at different periods. They gave the results of their experience in the operations from Alamein to Tunis. They utilised the standard transfusion apparatus and were supplied from the Base Transfusion Unit at Cairo, under Lieutenant-Colonel Buttle.
The percentage of casualties transfused varied from 3 to 16 per cent, 6 to 9 per cent being the average figures.
An analysis taken from records of 246 cases shows that:
21 per cent had had prior transfusion in ADS or RAP.
11 per cent had had prior whole blood transfusions in ADS or RAP.
One third had subsequently died.
Stewart and Powles came to the conclusion that blood transfusion was definitely of great value and saved many lives. Nevertheless the mortality in transfused cases was high. The most important lesson was the value of large transfusions both in the forward areas and at the Base. Those at the Base had to be given slowly.
During the Alamein battle from 24 to 31 October 1942, 2 NZ Division had 1428 casualties. Two to six per cent of these were transfused at the MDS with an average of 2·6 pints of blood and 2·1 pints of plasma. On 1 November there were 573 casualties, of which 8·5 per cent were transfused at the MDS. There were sixteen beds available in the resuscitation tent and two each in the three theatres. During the Mareth battle there were 1004 casualties handled by the Field Ambulances, and nearly 8 per cent of these were transfused with 305 bottles of blood and 174 of plasma. Twenty donors were bled locally.
At that time the supplies normally available from the transfusion service were whole blood, dry plasma and distilled water, wet serum or plasma, glucose (5 per cent) and saline (0·3 per cent), sodium citrate (4 per cent), sodium bicarbonate (4 per cent) in 100 c.c. bottles for intensive alkali administration, and sulphonamides.page 100
There were many problems encountered during this campaign. There was a loss of plasma into the damaged tissues produced by movement during evacuation, which could be overcome by setting up travelling transfusions in ambulance cars. The absence of roads in the desert, and the long distances the wounded had to be transported over rough desert, led to great difficulties. The short water supplies also led to dehydration, especially shown after wounding. Mine and booby-trap injuries were very severe, producing much tissue destruction. Wounds in the desert were especially severe, and as a result larger quantities of blood were required than in the fighting near Enfidaville.
Total Amount of Blood Required
It was generally estimated that 10 per cent of casualties required transfusion and that 2 to 3 pints was the average amount given. That would mean 20–30 pints per 100 casualties. The Americans stated in North-West Europe that they needed 1 pint for every two wounded men. In Italy it was finally estimated that 9–12 per cent of wounded required transfusion and that every 100 wounded required 40 bottles of blood, 50 of plasma, and 100 of glucose saline.
Taking of Blood for Transfusion
The need for the provision of blood transfusion for the wounded was recognised at the beginning of the war and all New Zealand servicemen were blood-typed when called up. The particulars of their blood group were stamped on their identity discs. Only members of the O/4 group were used as universal donors, rechecking of the group being carried out for safety. Prospective donors who had had malaria, infective hepatitis, or syphilis were eliminated. Blood from other groups was only very occasionally used to supply fresh blood for patients of the same group. Normally a bottle of blood was taken from each donor. The blood was drawn off by means of a needle from an arm vein. Veins along the radial aspect of the forearm were utilised whenever possible, and the needle was introduced up to the hilt.
Preservation of Blood
Refrigerators were used by the base units where the blood was withdrawn and by all the FTUs. A box holding 110 bottles was fitted into the refrigerator. Kerosene refrigerators were used by the FTUs. Ahead of the FTUs blood was packed in boxes with straw and ice, only small quantities (four bottles) being sent up at a time. Blood was found to keep satisfactorily for up to two page 101 weeks in spite of the long transport. It was thought that old blood given did not give good results and in some cases might have caused death, but although a maximum of twelve out of the forty-seven deaths reported by Stewart might have been related to the transfusion, only two showed jaundice or anuria; the others simply did not respond.
After a week a filmy clot sometimes arose at the junction of the plasma and cell layers. A wastage of 20 per cent of blood took place at one period, but later was reduced to 10 per cent. This depended naturally on the number of casualties requiring transfusion at the time.
Little blood was used from donors on the spot. Wet plasma was found to be satisfactory, but occasionally became turbid and had to be discarded.
Technique in Giving Blood
Positive pressure was used and care was taken to prevent air embolism, especially as the bottle was getting empty. Small quantities of air, however, seemed to cause no trouble.
Reactions in the field were very uncommon, well under 1 per cent, and were of minor nature. Orderlies readily acquired the skill to give and look after transfusions.
It was pointed out that the use of whole blood was both more satisfactory and more economical than the use of serum or plasma. A case was recorded of a traumatic amputation just below the hip where operation was carried out with transfusion taking place in both arms, and eight pints were given before the finish of the operation. The patient recovered. Another case was recorded with an abdominal wound associated with vasoconstriction, where marked collapse had taken place after warming the patient. This was relieved by three pints of plasma.
Position at End of North African Campaign
At the close of the North African campaign the treatment of shock had been developed considerably, and blood, plasma, and serum were freely available. The researches of Lieutenant-Colonel Wilson at Alamein had made a valuable contribution to our knowledge, and Lieutenant-Colonel Buttle had developed a highly efficient organisation for the supply and distribution of blood and all other supplies, even up to the RAP, The treatment appropriate to the different types of wounds had been determined, and FT units were available to shoulder the greater part of the work in the field units undertaking forward surgery.page 102
Whole blood had been proved essential when there had been much bleeding, and serum had been of value when blood loss was not so great, and in burns and blast injuries, as well as a supplement to blood. Movement had proved deleterious, especially following operation in abdominal cases. The FTU had become a normal part of the forward field units, and the close co-operation between the Field Transfusion Officer and the Field Surgical Officer had become well established and remained so throughout the war.
Relative Worth of Blood and Plasma
Differences of opinion arose, especially at the beginning of the war, as to the value of blood and plasma in restoring the blood volume. Many held that the restoration of the volume and not the haemoglobin content of the blood was the cardinal factor. This led Brigadier Whitby, head of the British Transfusion Service, to concentrate on the provision of plasma and serum, which had the advantages of simplicity in handling and stability for long periods. Supplies of plasma were not available, however, in the MEF, largely because of enemy action against shipping, and this led to the use of whole blood in this theatre of war. This was carried out so efficiently by Lieutenant-Colonel Buttle and his unit that sufficient blood was available for all purposes, and the plasma available was utilised for the treatment of burns and as a supplement to whole blood. The great value of blood in wound shock was appreciated so much by the forward medical units that it led to modification of the original view in England that it was volume alone which was required. There were at first two schools, one favouring blood and the other plasma, and these met at Tunis when the Eighth and the First Armies joined forces. The First Army had ample supplies of plasma and appreciated its value, whereas the Eighth Army had quite fixed ideas that blood was definitely to be preferred to plasma, and their efficient base transfusion unit at Cairo had always furnished adequate supplies.
When the two armies amalgamated to form the Central Mediterranean Force, the value of both blood and plasma was appreciated, but the pre-eminence of blood was established for all cases with serious bleeding and a low haemoglobin content.
In Italy a British base transfusion unit was set up at Bari, and this supplied the British armies during the campaign. It worked under considerable difficulties, but carried out the work efficiently and never failed in the supply of blood. Field transfusion units carried on in the same manner as they had done in North Africa, page 103 and more units were available. The personnel kept up the high standard and were helped and stimulated by the constant research work undertaken by British and Canadian research units.
The importance of early surgery in large muscle wounds was clearly recognised. In abdominal injuries more time was given to pre-operative treatment so as to ensure full resuscitation. The danger of overdose of morphia was countered partly by intravenous injection. The evacuation of the serious casualties was postponed till serious danger of increasing shock by movement was past. This especially applied to abdominal, chest, and burns cases. There had been no marked change in the ordinary routine developed in North Africa. Blood was still pre-eminent in the treatment of wound shock.
NZ FTU in Italy
In Italy the function of the NZ FTU, the type of cases treated, and the blood used were as follows:
Functions: (1) To act as a divisional blood and plasma bank. Transfusion stores were drawn from the Corps' blood bank located at a CCS—from there they were distributed to ADSs which, in turn, supplied to RAPs in the usual manner. Small insulated boxes holding four bottles were supplied to ADSs for storing blood and sending it forward to RAPs. (2) To take over at the MDS the resuscitation of those casualties who were not fit to be evacuated further, or not fit to undergo the necessary surgery; also to maintain the general condition during surgery, and to carry out such intravenous therapy as might be indicated in the post-operative period.
The NZ FTU was generally attached to the active MDS, the NZ CCS having a British FTU attached. A considerable amount of work was done during the active periods of the Division at the Sangro, Cassino, Florence, Rimini, and in the Po Battles. Blood and other supplies came from the British base unit at Bari, and, apart from some trouble with infection, mainly of glucose solution, no difficulties arose. The average dosage of blood remained at about 3 pints, and plasma and serum were freely used. There was some trouble with the vis-caps of the giving sets. The need for the relief of the transfusion officer and the training of the orderlies was recognised.
For the Sangro battle a blood bank was available at Vasto. On only one occasion was it necessary to bleed donors, when 23 pints were taken. The average transfusion given at the MDS varied from 3·3 pints for limb injuries to 2 for abdomens and heads and 1·4 for chests. Some blood was used up to twenty-one days old.page 104
In March 1944 it was observed that ‘the casualty, arriving at the MDS, being considered not fit to travel further, was brought in for resuscitation before resuming the journey to the CCS, a distance of 10½ miles over a road with a deteriorating surface. Following up the resuscitated wounded showed that, in spite of a travelling transfusion, the journey reduced or removed the benefit that had accrued from treatment on the standard lines at the MDS, unless the required surgery had been available before evacuation to the CCS, abdominal and head cases excepted. Men with large limb wounds, chest injuries which produced sufficient shock to prevent evacuation without resuscitation, did better if they had the necessary surgery and eight to twelve hours’ rest than if they were temporarily resuscitated and speedily evacuated.'
Quantity of Blood Used: Over the period 20 November 1943 to 31 March 1944, being the period from the Division's first campaign on the Sangro River to the relief of the Division in Cassino, 1245 bottles of blood were handled by 2 NZ FTU.
The use of penicillin increased the scope of the FTUs, but the giving of blood and plasma still remained their main function.
There was some difficulty with the apparatus at times, but the base unit at Bari, in spite of difficulties, continued the excellent service we had become accustomed to in North Africa.
Transfusion Service at Base Hospitals
The problems and requirements of the base hospitals differed from those in the forward areas. The base hospitals made their own arrangements for blood transfusion and generally appointed a member of the staff as transfusion officer. In our own hospitals the pathologist was so appointed. Each hospital arranged its own supply of blood, but serum and plasma were supplied from the base transfusion unit. Severe reactions following blood transfusions were not uncommon, especially in patients who had had prior transfusions. This necessitated the use of fresh blood and careful retyping and cross-typing. The previous transfusion had brought about an alteration in the blood characteristics.
The work carried out is shown by the following account of the experience of the New Zealand base hospital at Helwan during the period of the desert campaigns.
Transfusion at a New Zealand Base Hospital
This was organised and carried out by the pathologist, who set up a blood bank and arranged for the collection of blood from donors, mainly from the base camp, and also serviced the apparatus. Although all 2 NZEF personnel had been blood-grouped on page 105 enlistment, check grouping was carried out before utilisation of blood from the donors. An error of only 2 per cent was found in 1000 2 NZEF donors.
For planned transfusions in hospital, especially for late cases which had already had previous transfusions, blood of the same group was used as often as possible, and both check-grouping and cross-matching was done. A form was filled in by the donors, giving full particulars for identification as well as the history of malaria, infective hepatitis, and venereal disease. Kahn's test was carried out in any case with a VD history, and syphilis meant exclusion, as did a history of any allergic disease. Bristol-type needles were used, being introduced up to the hilt, and veins along the radial aspect of the forearm utilised, splints being used as required. A record form was used giving full details of the transfusion. Plasma and serum were also always available.
During a period of twelve months the total admissions to the New Zealand hospital at Helwan were 11,500. Five thousand of these were surgical cases and 1350 were battle casualties. A total of 221 transfusions were given to 150 patients, 103 of these being battle casualties. Four hundred and fifty pints of blood and 50 pints of plasma were used. The majority of the battle casualties transfused were septic cases, mainly compound fractures and septic joints. No abdominal wounds were treated. The secondary anaemia present was associated with sepsis and secondary haemorrhage, mostly small and repeated. The clearing up of sepsis and the healing of the wounds were both helped greatly by blood transfusion. In the septic cases care was taken to use fresh blood under twenty-four hours old. Blood was kept in store for the treatment of secondary haemorrhage, for which full restoration by giving up to 3–4 pints of blood was carried out. In septic cases the blood was given slowly, not more quickly than a pint in three hours. In some cases very large quantities of blood were given, the maximum being 27 pints in thirty-one days to a case of repeated serious secondary haemorrhage from the axilla. The case recovered. Reactions were common in the first eight months, but less common later. They were largely of little severity and, unless severe, did not necessitate stopping the transfusion. Cases with septic wounds and prior transfusions were more liable to severe reactions. There was one fatal case and another with anuria recovered. The plasma available was reserved for burn cases. Crystalloid transfusions were given, often in large quantities, the moistness of the tongue being used to determine the amount of fluid required.
In Italy the base hospitals continued the work in the same way, utilising fresh blood for the late cases.page 106
Experience of 2 NZEF (IP)
The blood transfusion service in the Pacific offered a problem in that hot, humid atmosphere, where the keeping properties of stored whole blood and wet plasma were limited. High humidity, more obvious on refrigeration, softened the vis-caps and permitted contamination along the moist thread of the screw-capped bottles. For large-scale operations it was quite feasible to transport supplies by air to the forward areas from non-malarious areas, but when the operations were limited there was a considerable loss by wastage, as it was very difficult to estimate beforehand possible demands in jungle warfare. It was agreed that stored blood should be used within a week. Reliance was placed mainly on dried blood plasma, and when whole blood was indicated donors on the spot were used, due precautions being taken to exclude possible malaria. Apart from the malaria risk it was, of course, not good practice to take blood from forward troops, and more so in the islands because there was a tendency for nutritional anaemia to occur amongst the troops.
Recommendations for the Future
An organisation similar to the British one in the Second World War.
Increase of field transfusion units, and especially of personnel. Two officers to be attached to each unit for relief purposes.
Research units to be formed in each theatre of war to investigate specific problems and stimulate scientific thought throughout the Corps. Pathologists, biochemists, as well as research personnel, to be available for these units.
Investigation to be carried out in first twenty-four to forty-eight hours after wounding, when the majority of the deaths occur.
Provision of larger bottles to hold two pints of blood or plasma. Provision of standard bottle holders for ambulances.
Large transfusions of blood and serum to be given to injuries associated with severe bleeding, and given quickly.page 107
Post-operative transfusion to be given much more frequently and transfusion personnel to be set aside especially for that purpose.
Glucose salines to be given early in all severely wounded cases, especially abdominals, to prevent anuria.
In wounds involving much muscle and in traumatic amputations early operation is imperative in spite of, and largely because of, lack of response to resuscitation. The same sometimes applies to abdomens.
In heads, chests, and blast injuries only tranfuse to replace blood definitely lost, and replace slowly.