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Care of the Battle Casualty in Advance of the Aid Station

Medical Science Publication No. 4, Volume 1

CARE OF THE BATTLE CASUALTY IN ADVANCE
OF THE AID STATION*

RUSSELL SCOTT, JR., M. D.

A review of the statistics dealing with the battle casualty in past wars has thrown increasing attention upon the extreme importance of the medical care given the wounded soldier during the first few hours after wounding. The mortality rate of the battle casualty after admission to a fixed hospital has fallen from 17 percent in World War I to 5 percent in World War II to 1.7 percent in the Korean War. In spite of these encouraging statistics, one out of every four wounded soldiers dies. The ratio of Killed in Action to Wounded in Action has changed very little since the First World War. The mortality rate at division and particularly battalion level has not paralleled the fall in the hospital mortality. For this reason, improvement of all facilities that speed the casualty to resuscitation and that bring resuscitation as far forward to the casualty as possible should be continued. In particular, intensive effort should be directed to the casualty in the most forward area.

To realize these aims it is of the utmost importance to appreciate what the optimal care of a battle casualty can and should consist of, under what conditions optimal care has been demonstrated to be possible, and what policies in training and supply must be adopted to insure the best care under any set of circumstances. It is necessary also to appreciate that variations in weather, terrain, tactical situation, efficiency of supply, etc., sometimes render optimal care difficult, but not impossible. We must therefore strive to modify our care as circumstances permit in order to give the best care possible at all times. As simple as this might appear, there is usually a significant delay in improving our care as circumstances allow. In order to have optimal care it is necessary for us to have a clear idea of what the optimal care of a battle casualty should be.

Before we go into the specific first aid procedures, let us formulate the broad aims and objectives of the early phase of resuscitation.

The broad aims and objectives of resuscitation are first to save life, then save limb and, at the same time, do the most good for the greatest


*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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number of casualties. To achieve these objectives we must understand the pathology of trauma so that from this knowledge we may emphasize the measures of resuscitation that are of real importance in saving life and limb.

Briefly, four major phenomena threaten life following wounding.

1. First, and most important, blood is lost and continues to be lost, not only to the exterior but into the damaged tissue at the wound or fracture. With blood loss there is progressive decrease in blood volume, fall in cardiac output, fall in blood pressure, decrease in renal blood flow and decrease in oxygenation of tissue.

2. Tissue is damaged. With tissue damage specific organs and systems are damaged, the media for bacterial growth are produced, and the latest laboratory work indicates that toxic products may be released from the damaged tissue and have a general systemic effect which in itself may cause death.

3. The defense against bacteria is broken, wounds become contaminated and bacterial evasion of the tissues and of the blood stream may occur.

4. Mechanical defects may develop, such as blockage of the airway, hemothorax, pneumothorax, cardiac tamponade or increase in intracranial pressure.

It must be understood that all of these four processes are progressive, synergistic, and will continue until measures are instituted to slow them down (first aid) and finally correct them (definitive surgery). As long as these processes are in motion, the casualty continues to deteriorate. In general, the intensity of early therapy and the time lag before the processes are finally brought to a halt determines the outcome of each casualty.

Aims of Resuscitation. It is important to appreciate that "resuscitation" includes the whole process of slowing down and stopping the pathological processes set in motion by wounding; first by simple local means, secondly by plasma or blood replacement therapy, and finally by operative intervention at the surgical hospital. In its complete sense, first aid in the field and surgery at the surgical hospital should be considered integral parts of resuscitation.

The specific aims, then, of resuscitation include:

1. Prevention of continued blood loss.
2. Prevention of additional tissue damage.
3. Prevention of additional bacterial contamination and suppression of bacterial growth.
4. Replacement of blood volume deficit.
5. Prevention or correction of mechanical defects in the cardiorespiratory and central nervous system physiology.
6. Relief of pain.


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7. The removal of damaged tissue and repair of specific organs.

Again, the level or echelon at which each of the above measures may be carried out will depend upon many variables: the weather, tactical situation, terrain, efficiency of supply, and the ability and attitude of the medical personnel involved.

It should be obvious from this discussion that neither "first aid" on the battlefield nor surgery at the surgical hospital can be separated from resuscitation. The whole process of resuscitation should be considered to be an integrated program, beginning with first aid in the field and ending with surgery at the surgical hospital. We all know that military surgery is not just civilian surgery carried out in a tent; likewise, we must appreciate that combat first aid is not Boy Scout first aid carried out on the field of battle. If we are to lower the present battle mortality of 25 percent, every effort must be made to make the initial phase of resuscitation prompt, intensive, exact and thorough. One oversight or break in technic may well cost a life because of the long time lag involved in evacuation.

It would be impossible with the time and space allotted even to outline a complete course in first aid. The following section deals with the first aid measures believed to be the most important.

Optimal resuscitation begins with the aidmen in the field who attempt to slow down or stop the basic pathological processes that have been set in motion by wounding. This is done by initiating the aims of resuscitation.

1. Prevention of Continued Blood Loss

    a. Pressure Dressings and Pressure Points. The vast majority of bleeding wounds can be controlled by the application of a pressure dressing. In addition to the pressure dressing, the patient may be instructed to add additional pressure. In most instances bleeding can be controlled by such measures.

    b. Tourniquets. When a pressure dressing has proven to be unsatisfactory for the control of hemorrhage, a tourniquet should be resorted to. I use the word "resorted" advisedly, for the necessity of a tourniquet should occur only infrequently. It is of the utmost importance that all aidmen be well grounded in the use of the tourniquet. Often the tourniquet will not be applied correctly so that hemorrhage is not completely controlled, or the tourniquet may slip and bleeding recur so that a casualty will bleed to death while on the way to the aid station.

    During cold weather an extremity with a tourniquet applied is unusually susceptible to freezing and gangrene formation. During the freezing months the aidmen and surgeon should be unusually careful


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    not to apply a tourniquet unless it is absolutely necessary and should do so only when repeated efforts to control hemorrhage have failed.

    Once a tourniquet has been applied, any member of the medical team removing that tourniquet should exercise extremely good judgment, as bleeding may recur after the patient has passed through that period of observation. The removal of a tourniquet in cases where followup observation is impossible, such as during the period of evacuation, is extremely hazardous and should be avoided. The untimely removal of a tourniquet with recurrent hemorrhage, even when recognized and immediately stopped, has been shown to be serious. On occasion this error has thrown a casualty back into shock from which he could not be revived. However, when safe, the removal of a tourniquet reduces the chances of the casualty's losing an extremity. In casualties with extensive tissue damage where the need for amputation is obvious, the tourniquet can and should be left in place to avoid any chance of additional hemorrhage. This decision, however, should be made only by a medical officer.

    c. Immobilization. Splinting of a fracture is of real assistance in preventing further vascular damage near the fracture site, and thereby preventing additional blood loss, both to the exterior and into the damaged muscle. Immobilization of any portion of the body which has been wounded is a sound principle to observe in order to decrease the chances of recurrent hemorrhage. Should an arm or leg be wounded, it is advisable to instruct the patient not to use that extremity until a location has been reached where complete resuscitation is possible should bleeding recur.

2. Prevention of Additional Tissue Damage

    a. Splinting of Fractures. The proper application of a splint is the single most important factor in preventing additional tissue damage. Inadequate splinting, rough evacuation, or inadequate instructions to the patient as to how to manage himself during the period of evacuation, may result in additional tissue damage at the fracture site. The importance of prompt and adequate splinting cannot be overstressed. We should continue the motto of "when in doubt, splint them where they lie."

    b. Immobilization of Any Wounded Part. Regardless of location, with or without fracture, it is also important to impede further tissue damage. If a missile should be lodged in a leg and a casualty is allowed to walk, the metallic fragment may well produce additional tissue damage or hemorrhage. Every wounded casualty should be instructed not to move the injured part for fear of producing additional tissue damage. If the casualty is disoriented, measures should


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    be taken to restrict movement of the wounded part. Should a leg have extensive muscle damage, a splint will do no harm.

3. Prevention of Additional Contamination and Bacterial Growth

    a. An adequate dressing should be placed on the wound as soon as possible. By adequate is meant a dressing that is large enough and thick enough to protect the wound in its entire extent. Often more than one of the conventional dressings will be needed.

    b. Antibiotic therapy in the field is also desirable under certain circumstances. In outpost positions, during assaults, or in any tactical situation where the casualty cannot reach the aid station until 4 or 5 hours or longer after wounding, antibiotic therapy by the aidman in the field is most desirable. This practice can be carried out with minimal effort by the use of penicillin syrettes. Antibiotic therapy at this early time is not only important in suppressing bacterial growth at the site of wounding, but also may be of particular value to casualties with abdominal wounds where the peritoneal cavity has become contaminated with fecal matter. Recent work indicates that in such cases bacteria may enter the blood stream and be deleterious to the patient's condition. Dressings, once applied, should not be removed so that wounds are exposed by the "look-see procedure" to satisfy the curiosity of the aidman or battalion surgeon. In the absence of continued bleeding or severe pain, removing the dressing to look at the wound accomplishes nothing and increases the chances of further contamination or hemorrhage. The unofficial policy or habit of looking at the wound at each level should be abandoned.

    c. Burns should be covered with dry sterile dressings at the earliest possible time. In many instances, because of the extent of injury, this cannot be accomplished before the casualty reaches the aid station. All personnel should be warned not to use Vaseline dressings at this early time. Adequate cleansing of the wound in advance of the surgical hospital is impossible, and the application of Vaseline dressings in the field usually contributed to bacterial contamination. A Vaseline dressing, however, is preferable to no dressing at all, and should be used rather than leaving the burn completely exposed during evacuation. The application of a dry sterile dressing in the field does not obligate the casualty to continued treatment by the closed method. At the surgical hospital the first aid dressing applied in the field may be removed and the patient treated by the open method if the surgeon in charge so desires.

4. Replacement of Blood Volume Deficit

The replacement of a deficit in blood volume is second only to the control of hemorrhage in saving life. With the new plasma ex-


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panders, found to be efficient in combating shock, the aidman has a relatively harmless aud inexpensive agent with which to resuscitate more completely the battle casualty at an earlier time. Prior to the advent of the plasma expanders, when pooled plasma was used, many surgeons felt the risk of hepatitis was probably too great to allow many aidmen to use their own discretion in administering plasma therapy on their own. With the new expanders the danger of hepatitis has been eliminated.

During the winter months it was found difficult and sometimes impossible to reconstitute the dried plasma. The loss of this expensive agent through breakage of the glass containers sometimes accounted for half of the plasma allotted to a given battalion. In addition, the glass containers were bulky for use on patrol, and the process of reconstituting the dried plasma required valuable time. Plasma expanders are now available in a light plastic container which can be easily carried by the aidmen. Plasma expanders so prepared are light, non-breakable, and can be kept warm under the clothing of an aidman prior to administration. Their contents can be given under pressure by manipulation of the bag or by placing the casualty on the bag to create pressure.

Also important is the more vigorous replacement of the blood volume deficit in the field of battle prior to evacuation. This is important for three reasons:

    a. First, the patient will be brought out of shock earlier and what deleterious effects shock has on the casualty will not operate as long.

    b. Second, the condition of the seriously wounded patient is improved for his journey to the rear, he is in a less critical condition, and his chances of surviving the litter carry are better. All of the casualties with multiple penetrating wounds of the extremities, peripheral vascular wounds and traumatic amputations in whom hemostasis has been established will be greatly benefited by vigorous replacement therapy shortly before and during the period of evacuation to the aid station.

    The casualty with internal bleeding is another problem. Vigorous replacement therapy and delay to any extent should be reserved for an echelon where immediate surgical intervention is possible should abdominal bleeding continue or recur as the blood pressure rises to normal; in most instances this will be the surgical hospital. In the hands of a skilled, well oriented, mature aidman, certain types of casualties would be definitely benefited, however, by more vigorous resuscitation in the forward area before evacuation is begun. By vigorous resuscitation is meant the administration of 500 to 1,000 ml. of a plasma expander over a 10-minute period. A "delay" of more than 10 minutes by the aidman is, probably not justified. I avoid the


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    use of the word holding. Any delay in evacuation, however, should be reserved for those patients in whom complete hemostasis has been established. If any degree of hemorrhage continues, it would be unwise to expect an aidman to have the clinical judgment required to make a decision as to whether a patient's evacuation should be delayed for more vigorous resuscitation. If there is any question about continued hemorrhage, intravenous therapy should be started and a speedy evacuation to the aid station begun.

    Whole blood therapy, which was shown to be practical in the aid stations under certain circumstances, is probably not practical in advance of the aid station, at least in the hands of the aidman. As a rule, it is usually impractical to give more than 1,000 cc. of an intravenous solution to a patient before he reaches the aid station and plasma expanders can be used without reservation in this amount.

    c. Finally, it is important to recognize that certain types of wounds will eventually be accompanied by clinical shock unless intravenous therapy is instituted early. Such injuries as traumatic amputations and large evulsing wounds will eventually require intravenous therapy. Early intravenous therapy in such patients may well prevent clinical shock. This is the third reason that casualties will be benefited by intravenous therapy before and throughout the period of evacuation to the aid station.

5. The Prevention or Correction of Defects in Cardio-respiratory Physiology

At the time the battle casualty is initially examined, an effort should be made to determine whether the patient has signs of respiratory difficulty. If the patient has a sucking chest wound, this should be immediately closed with a Vaseline dressing. Many battalion surgeons instructed their aidmen to have the casualty exhale completely an instant before the Vaseline dressing is applied. This will force the major portion of free air out of the thoracic cavity thereby reducing the "dead space" caused by the free air within the thorax and will result in a larger vital capacity following closure of the chest wound.

The patient should be examined about the face and neck for wounds. If there is partial occlusion of the airway, this may be relieved by manipulating a shattered larynx or positioning the head in a particular manner. Instructions to the patient concerning how to hold his head or how to lie on the litter may be lifesaving during the period of evacuation. With bleeding about the nose and mouth, the patient should be instructed to lie in a manner that will allow the blood to drain to the exterior and not pass into the throat and cause aspiration and suffocation. The treatment of a hemothorax or cardiac


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tamponade is beyond the ability of the aidman and should be reserved for a medical officer.

6. Relief of Pain

    a. Immobilization of the wound is one of the greatest factors in relieving or preventing pain. This may be accomplished by splinting in the case of suspected or known fractures and by instructions to the patient as to how he should prevent movement of a wounded part during evacuation.

    b. Reassurance and explanation to the patient is often beneficial. Many casualties expect pain, or in the excitement of battle, a fear of death or deformity actually magnifies in their own minds the amount of pain they are experiencing. A simple explanation that their wounds do not threaten life or limb and that a small amount of pain can and should be tolerated will quite often give gratifying relief to the casualty.

    c. Morphine Therapy. Several known facts should be taken into consideration by the aidmen before administering morphine. These facts are:

      (1) A very small percentage of battle casualties actually have pain severe enough to warrant morphine therapy. This is particularly true of casualties in shock. Patients in shock may be restless, hyperactive, and appear disoriented. The untrained will interpret this as a response to pain when the reaction is actually on the basis of cerebral anoxia. As stated, a large portion of the patients who claim to have pain are merely anxious and can be relieved of this anxiety by adequate psychotherapy founded on mature judgment of a sincere and well trained aidman or surgeon.

      (2) Morphine may be deleterious in certain types of casualties.

        (a) Casualties with head wounds should not receive morphine because morphine can alter the neurologic response of the casualty and make physical examination and evaluation before operation difficult.

        (b) Patients with chest wounds and impaired respiratory physiology may have slowing of respiration and additional difficulty with adequate oxygenation of their blood.

        (c) Patients in shock with poor peripheral blood flow may accumulate morphine in the peripheral tissues and receive an overdose once shock has been combated and adequate tissue profusion is restored.

      (3) It has been clearly shown that a dose of one-sixth to one-fourth grain is as effective in relieving pain as a one-half grain dose and has less side effects.


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        (4) Morphine may cause nausea and vomiting, which can be deleterious to the patient.

        (5) Morphine may increase the hazard of anesthesia.

    In view of these facts, a real consideration should be made before morphine is given and any aidman administering morphine should have a thorough understanding of the indications and hazards as well as contraindications to morphine therapy. Many capable medical officers and civilian consultants feel strongly that the Medical Service should recall the one-half grain morphine syrettes and replace them with one-fourth grain syrettes.

    7. Transportation and Protection from the Elements

    It is important for all personnel dealing with the battle casualty to appreciate that exposure to the elements is deleterious to the casualty. It is important that adequate numbers of blankets (four to five) be available when a casualty is to be transported outside of a heated vehicle during the winter months. This can be made possible by instructing all members of a litter team to carry one blanket in addition to their normal load while on patrol or during an assault.

    It is also important for all members of the medical team to appreciate that movement of the casualty is often deleterious, particularly while a patient is in shock. We should abandon the motto that "the shortest litter time is the best litter time" and put in its place "the smoothest litter carrier is the best litter carrier." This is particularly true after bleeding is controlled and intravenous therapy has been started when the need for speed is not urgent. It was observed at the Mobile Army Surgical Hospital that the movement of casualties from the preoperative ward to the x-ray table, not 50 feet away, can cause some patients to go back into severe shock. In two cases this resulted in death. The concept of preparing a patient for evacuation and then carrying out a smooth litter evacuation must be well understood by all members of the Medical Service.

    The evacuation of casualties with head injuries is an individual problem. The ease of movement is more important following head injury than in any other injury. It was the feeling of some neurosurgeons attached to the Mobile Army Surgical Hospitals that a patient with an open head wound, received during the hours of darkness when helicopter evacuation was impossible, had a better chance to survive if he were held at the aid station until dawn to be evacuated by helicopter, rather than have a traumatic evacuation, via ambulance. Once evacuation is started, the patient with a head injury should be positioned on his stomach to prevent aspiration should he vomit.


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    A smooth period of evacuation is not only important for the "general condition" of the patient in shock or with a head injury but, as stated, prevents additional tissue damage in extremities that have fractures. In dealing with problems of evacuation, it is the duty of the battalion surgeon to be ever alert for means of improving the speed and ease of evacuation from the fields of battle or in taking resuscitation to the casualty. This may be done in a number of ways.

      a. By securing additional litter teams from labor pools of indigenous personnel.

      b. By requesting additional vehicles, such as tanks and armored cars, to be used to pick up casualties under enemy fire.

      c. By requesting that the battalion commander have litter trails or tramways coustructed where indicated.

    The construction of a "forward aid station" on the main line of resistance has enabled a medical officer, without unnecessary risk, to advance and set up an aid station on the main line of resistance in bunker positions. The bunkers are constructed to accommodate six to eight litters of patients and are usually within easy access of any portion of the battalion sector. In addition to this forward aid station, some battalions developed the concept of a "mobile aid station." The mobile aid station group usually consisted of the battalion surgeon or assistant battalion surgeon and two to three aidmen from the aid station. It was their function to move forward of the main line of resistance and meet incoming patrols with casualties or to move laterally to concentrations of casualties who did not have easy access to the forward aid station. In one sector a 3/4-ton truck was converted into a heated, lightproof compartment and could be dispatched to any area night or day for the reception and treatment of wounded under adverse weather conditions. This was of great value on winter nights when a message was received that a number of wounded would arrive at a specific location distant from and inaccessible to the forward aid station.

    Within the aid station more aggressive resuscitation by the medical officer should he carried out. To mention but a few examples: An intravenous cutdown may be instituted to insure that intravenous therapy will not be interrupted in a critically injured casualty; thoracentesis can be carried out to relieve a mediastinal shift; closure of sucking chest wounds, tracheotomy and intensive blood replacement therapy may be carried out at this level. These procedures will be discussed under the section on resuscitation within the aid station and details will not be given at this time.

    A brief consideration of the supplies and equipment required to carry out effectively the aims of resuscitation is in order. Only the


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    equipment of the aidman and aid station pertinent to the care of the battle casualty will be considered.

    An aidman should have available the following equipment:

      1. Aid bag.
      2. Tourniquets-either rubber or strap, probably two to three in number.
      3. Carlyle pressure dressings with supplemental ace bandage, roller gauze and adhesive tape.
      4. Arm sling.
      5. Morphine syrettes (gr. 1/4).
      6. Penicillin syrettes.
      7. Scissors.
      8. Plasma expanders in plastic containers.

    Such items as bandaids, merthiolate, hydrogen peroxide, cough syrup, APC's and swabs were found useful but not essential.

    Within the aid station certain items are essential for adequate care at this level:

      1. Adequate light-flashlights or Coleman lanterns.
      2. Tourniquets, hemostats, Carlyle dressings and ace bandages for the control of hemorrhage.
      3. Thomas lantern and wood splints with roller bandage for proper immobilization.
      4. Scalpel, hemostats, suture material for performing a venous cutdown or closing a sucking chest wound.
      5. Tracheotomy set.
      6. Several 100 ml. syringes with No. 15 and No. 18 gauge needles to perform thoracentesis.
      7. Procaine in sterile ampules for immediate injection.
      8. Morphine in syrettes.
      9. Penicillin in syrettes.
      10. Tetanus toxoid.
      11. Plasma expanders in plastic containers for administration under pressure if needed.
      12. Sphygmomanometer and stethoscope.
      13. Oral airway for unconscious patients.

    The physical setup of the aid station will vary greatly depending upon the tactical situation, time available to construct the aid station, casualty flow and weather conditions.

    In general, one should select a site for constructing an aid station which will give the surgeon adequate room to move as freely as possible from patient to patient. When the casualty load is heavy, it is advantageous to have the aid station divided into areas: a receiving area for sorting, a shock area, a splinting area and an area for patients waiting evacution.


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    Another important consideration of the aid station is protection from the elements. This is essential for the wounded casualty. When the tactical situation is fluid, a house or tent will suffice; when the line becomes stable, a tent which has been "dug in" or a large bunker is satisfactory. As stated, on occasion a closed, heated, 3/4-ton truck may be used as a mobile aid station.

    Conclusion

    In conclusion, we may say that any significant reduction in battle mortality will be made by saving lives now lost within the battalion.

    Most of the improvements and improvisions which increase the excellence of early care will be made possible through an understanding by the battalion surgeon and his aidmen of the ultimate goal of resuscitation and the role they play in achieving this goal. For a team to succeed, each member must have a clear understanding of the final objective.

    Our training must stress the broad scope of resuscitation so that each member, both officer and enlisted, will realize that his actions play a vital role in the outcome of each casualty.

    It is of the utmost importance that all members of the Medical Service and all members of the tactical units recognize and appreciate the great challenge placed on the aidmen and the battalion surgeon and be willing to support these individuals. No other members of the Medical Service are called upon to render unsupervised medical care to such a critically injured group of patients as are the battalion surgeons and aidmen. We must all recognize the need for the best trained men in the most forward area where the greatest test of ability is made and orient our policy and training to achieve this end.