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Emergency Treatment and Resuscitation at the Battalion Level

Medical Science Publication No. 4, Volume 1

EMERGENCY TREATMENT AND RESUSCITATION
AT THE BATTALION LEVEL*

MAJOR MEREDITH MALLORY, JR., MC

1. Introduction

In discussing emergency treatment and resuscitation practiced at battalion level, a breakdown of casualties into three general groups is helpful in defining our problem. These are: Group I-those killed outright or severely wounded past any help, Group II-severely wounded requiring continuous medical support and supervision, and Group III-those requiring minimal attention until they undergo definitive surgery. Group I is fairly sharply defined and is important medically only in that hopeless cases during heavy casualty loads must not be allowed to distract medical attention from the more fortunate who can be helped by it. The example given later illustrates how this might happen. The medical effort expended on Group II is justified primarily by the moral obligation to prevent loss of life. The salvage value of these casualties is limited for direct military purposes, but of considerable importance to the gross national output; especially when we contemplate the heavy financial obligation assumed by the Government in the event of mortality.

Group III represents the source of greatest return for medical manhour expended. It is in this category that the human machine is repaired and the man returned to the duty for which he has been so expensively prepared. Although this is obvious to all and is implicit in the motto of the Medical Service, we sometimes partially lose sight of its immediate and direct consequence. This is that our medical capacity must satisfy the requirements of Group III category before any other with the exception of basic lifesaving measures necessary in Group II. This distinction must constantly remain in front of us if we are to tackle tomorrow's medical problem with the economy mandatory for all on the logistical team.

Groups II and III will tend to merge; indeed it is the primary aim of our forward care to preserve those in Group II until surgery is available (or else, by proper measures, such as tourniquet and splints,


*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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bring them out of Group II severity to the Group III level. Once a casualty is determined to be in the Group III class he then is promptly passed on to rear medical installations with but minimum treatment in the aid station.

The numerical proportions involved in these groups vary from war to war and battle to battle; however, an order-of-magnitude for the Korean war can be given. Roughly, out of 100 casualties, 25 will fall into Group I, 8 to 10 in Group II, and the remainder in Group III, with a number of the latter being borderline Group II. It is Group II, about 10 percent of all casualties, which composes almost the entire demand for forward medical care. Moreover, a brief look at casualty statistics by branch of service shows that the infantry is the major contributor, which means that forward medical care is essentially a matter of infantry support.

We will now go to a brief description of the circumstances in which forward medical care operates and the technics employed.

2. Physical Factors of Battle

Misunderstandings arise as to what should or should not be done in the infantry battalion aid station because of lack of consideration for the tactics involved. Table 1 portrays a concept of the variables which affect organized battle and its logistical support. Each combination of these variables forms a different circumstance occasioning great variation in the quality and quantity of medical care permitted in the aid station. It should be noted that the farther forward in battle the greater the impact of these variables on medical or other operations. To illustrate, the Korean war was fought under all three types of maneuver, in mountainous terrain, in generally temperate to cold weather, without analyzing each possible combination. It follows from the above that what should be done in the aid station cannot be stated inflexibly but will consist of doing a maximum number of desirable procedures according to limitations of a given situation.

Table 1.-Variables Affecting Logistical Support of Combat

Maneuver

Medium

Climate

Forward operations

Jungle

Very cold.

Retrograde operation

Desert

Cold.

Static operations

Mountain

Temperate

 

Plains

Hot. (Dry. Wet)

Hot. (Dry. Wet)

 

Airborne

 

River crossing

----------

 

Amphibious

----------


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Types of procedures recommended for aid station practice appear in the following discussion.

3. Technics

a. Shock. Shock, actual or potential, in the aid station means only one thing, the administration of fluids. Blood is the solution of choice with the solutions of albumin-size molecules next. It is, I believe, universally accepted that plasma infected with hepatitis virus is definitely contraindicated when the synthetics are available. The administration of fluids is based on rapid clinical evaluation alone as neither time nor equipment will permit more detailed observation. For purpose of resuscitation clinical judgment is sufficiently accurate. The combat injured are usually dehydrated so that glucose and/or saline can almost always be given advantageously to those requiring intravenous therapy. Venesection and cannulation should be a matter of routine practice for all patients for whom continuous fluids in large amount will be required. The value of these procedures in easing the handling of such patients in the rear surgical installations is difficult to exaggerate. Any intravenous therapy, once started, should not be intentionally discontinued until the patient reaches hospital care. Medical officers, fresh to combat, are usually unaware of the drastic requirement for blood and fluids occurring in severe trauma. Perhaps this is due to the relative rarity of trauma in combat degree in civil life and the fact that experience in handling it is simply not available.

b. Splints, Bandages, and Tourniquets. These technics, properly applied, do most to elevate a patient's category from Group II to Group III.

    (1) Splints. The factor of traction has been overemphasized in handling battle or ordnance-caused fractures, since, as severity increases, generally the traction requirement decreases. Rigid immobilization and protection of the injured limb is the primary consideration. Our present splints and technics are not entirely satisfactory in this respect. For instance, I have seen a considerable amount of unnecessary and harmful manipulation due to our inflexible, dedicated, and withal, rarely expert, use of the Thomas splint. The Navy plywood splint was very popular with battalion surgeons in my experience and a splint of this type as a supplement to the Thomas splint seems to be required.

    (2) Bandages. Although bandaging is important, our approach to this technic has been and remains unrealistic. Bandages do three things: (a) provide hemostasis, (b) prevent dis-


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      turbance of the wound by foreign objects, and (c) prevent bacterial contamination. Of these, only hemostasis is important in battle. A bandage that secures hemostasis provides incidentally sufficient protection from foreign material and bacteria. In respect to bacteria, all battle wounds are grossly contaminated and remain so until débridement. Too much effort is wasted in procurement of and training in a complicated array of bandages and bandaging technics.

      (3) Tourniquets. Application of adequate and timely tourniquets in battle is a vital essential at battalion level. Patients, whose wounds should place them in Group III often become Group II, and all too frequently Group I members through lack of an effective tourniquet. Present methods are time-consuming, inaccurate as to pressure exerted and often require excessive manipulation of the injured part (especially when applied by a single person). Self-application is virtually impossible. In the case of lower extremity wounds, which give rise to the most severe hemorrhage controllable by tourniquet, it has been my observation that too few doctors, much less their lay assistants, have a concept of the constricting pressure required about the thigh to abolish the flow of blood. Since the amount of blood lost after injury is probably related to time in an exponential fashion, most of it occurring the first few minutes, the tourniquet to be effective must be applied before the patient reaches the aid station. This requires that it be done in or very near the battle area. This further demands that the method be very simple and rapid and applicable by anyone-characteristics not possessed by the present means. Although we can improve application of tourniquets by increasing the training of the soldier, medical or other, this has two very undesirable features:

        (a) It is only a partial solution of the deficiencies noted above.

        (b) It will encroach on other more essential combat training. We need, critically, a better tourniquet device.

    c. Points in Handling Specific Wound Types.

      (1) Chest. Penetrating wounds of the chest (sucking) must be sealed airtight by the first medical officer to treat the patient. Any means, even to application of bare adhesive strips over the wound, are permissible as long as a good seal is obtained. Rubber sheeting over the wound sealed with Vaseline is another method. Simple gauze bandaging is most often not effective. A few deep sutures through the wounds to approximate wound edges may be necessary and can be done in the aid station. Although but infrequently necessary, the medi-


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      cal officer in any forward medical installation should be prepared to perform chest aspiration using a large needle, three-way stop-cock and large syringe. An evacuated intravenous bottle may also be used to produce suction (evacuated by boiling a small amount of water in it and sealing while filled with steam). These patients, often short of breath because of the reduced respiratory volume, need encouragement probably more than any other casualty. Their symptoms frequently exceed the immediate criticality of their condition.

      (2) Abdomen. Those with penetrating abdominal wounds require maximum rapidity in evacuation to definitive surgical attention. They should be retained in forward installations only long enough to support adequately the circulation for transport to the rear. Mortality on these patients varies directly with time-lag between wounding and surgery and is virtually 100 percent at 24 hours.

      (3) Central Nervous System Injuries. Patients with these injuries require immediate evacuation to neurosurgical care. Spinal cord injuries, in general, require the most immediate surgery of any injury, if salvage of cord function is to be a possibility. The recommendations as to position of patients with spine injuries have always appeared equivocal and contradictory. For injuries caused by ordnance probably the best solution is to minimize movement and evacuate the patients in the position they arrive in the aid station, prone or supine.

      (4) Extremity Injuries. Hemostasis should be secured by bandage and/or tourniquet. Fractures should be adequately splinted. In combined extremity and trunk injury it is imperative that hemostasis and splinting of the extremity wound be done properly so that the additive effect of the multiple trauma will be combatted and prevented from delaying early surgery. Extremity injuries, by themselves, should never occasion mortality except in the most unusual circumstance if adequate tourniquet procedures are available.

    d. Sedation. Patients with fractures and uncomplicated soft tissue injury may have morphine until adequate bandaging and splinting are applied. It is contraindicated in chest, head and belly wounds for obvious physiologic and diagnostic reasons. The single dose should not exceed 0.25 grain (one-half syrette) and each dose must be accurately and clearly noted on the Emergency Medical Tag. Pain is very infrequently a significant factor in injuries seen at forward levels. In extreme cold the administration of morphine should be even further curtailed.


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    e. Antibiotics. The requirement for early administration of antibiotics is recognized by all and needs no further discussion here.

    f. Triage. Selection of patients for type of evacuation (helicopter or ambulance) is essential, especially when movement and transportation are limited. The following wound types are listed in order of priority for rapidity of evacuation to surgical care.

Priorities for Evacuation

        (1) Spinal cord.
        (2) Uncontrollable severe hemorrhage (after blood and fluids have been started).
        (3) Abdomen.
        (4) Chest.
        (5) Head.
        (6) Extremity.

      Time of wounding is also an important consideration in triage. A fresh fracture occurring just outside the aid station door does not have the necessity for immediate treatment that a 24-hour-old moderately severe soft tissue wound of the thigh does.

      4. Management

      In applying the technics above, in battle circumstances, to the three casualty groups specified, it is clear that efficiency will not be obtained without premeditation and organization. I would like, now, to mention matters of arrangement, equipment, procedures and training.

        a. Arrangements. The aid station must be arranged to handle a large volume of wounded and not just to handle sick call or occasional patients. This arrangement should be as elaborate as is possible to devise in a given situation. It should provide for orderly flow and segregation of casualties in the station. Each person should know precisely his place and job in the casualty stream. Litter supports to place the litter at table height must be procured and the medical equipment laid out nearby to be readily available. A system must be devised with the battalion S-1 and S-4 to handle the stragglers, hangers-on and materiel that swiftly accumulate about the aid station in heavy fighting. Neglect of this item of arrangement can cut the effectiveness of an aid station by many times.

        b. Equipment. The equipment presently organic to the aid station contained in Dispensary Medical Set, Field; Medical Field Set, Combat; and Medical Field Set, Supplemental Supply; is, in general, appropriate. Instruments to accomplish vein cut-downs, tracheotomies and chest aspiration should be immediately available. These can be made up in formal sets packaged sterilized or can be merely a collection of instruments requisitioned as needed in addition to that in the field sets. Refrigerators and electrical generators are very


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        desirable but are logistical problems. Iceboxes may have to be improvised for the storage of blood. In general, the more frequently the aid station moves, the less equipment it will carry. The best solution is to have a minimum of organic equipment and augment it whenever additional equipment is indicated. It is the province of the Division and Army Surgeon to see that all necessary and appropriate technics and materiel are employed in the battalion aid station.

        c. Procedure. The basic principle of procedure is that the medical officer must not involve himself in anything that he can train someone else to handle. He must occupy himself with the severely injured patients, leaving the moderately injured to his assistants. As indicated above, he should be prepared to institute any emergency measure to save life, such measures to include thoracentesis, tracheotomy, venesection, and placement of deep sutures to secure hemostasis. In one case we moved an anesthetic machine from clearing station to battalion aid to intubate a head patient in respiratory arrest, the battalion surgeon and others administering artificial respiration for 1 to 2 hours while waiting for its arrival. The patient was intubated and moved 30 miles by ambulance to a MASH with anesthetist attending and survived the journey, although he eventually succumbed from his hopeless wound. It is difficult to be too radical in an aid station. Errors arose frequently from "too little" and never from "too much." We do not teach the handling of acute severe trauma well in our medical institutions, judging from results observed in Korea. Happily a short period of on-the-job training usually sufficed. Improved and more uniform treatment would result, however, if this problem were attacked earlier in our medical education.

        d. Training. It goes without saying that training must be constant and unremitting from a short course for the doctor in division before he goes forward to become a battalion surgeon to the training he himself administers to his subordinates to enable himself to be free of the multitude of details of bandaging, splinting and sorting of the uncomplicated patients. The personnel replacement stream for medical officers should be liberal enough to allow for a short period of formal and on-the-job training in division. This time can be secured by cutting Zone of Interior training where much is taught that has limited value. Personnel assigned to division will have their life's total combat experience in the succeeding few months that they serve with that division. They need only be trained for this narrow restricted experience and a large part of it can be given in the division where specific points relative to local problems of medical support can best be emphasized.


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      5. Personnel

        a. 0fficer. Two officers are required in each infantry aid station, either two MC's as with the Marines, or one MC and one MSC as in the Army units. In my opinion, the MC-MSC (or possibly Warrant) combination is best, provided this is utilized to make available battlefield commissions for qualified enlisted personnel from the aid platoons.

        b. Enlisted. The enlisted medics (MOS 3666) generally available in Korea were of excellent caliber. In fact, one wonders if we do not invest too much capability in unskilled tasks such as litter bearing. The one emolument here, of course, is that litter bearers are then available to act as aidmen. However, by accepting lower-quality personnel it might be feasible from the standpoint of manpower economy to augment our present litter bearer units. Though the proportion of aidmen required may be open to argument it is certain that these people must be trainable to act with initiative and effectiveness by themselves in administering first aid. They must be able to bandage, splint, apply tourniquets and give fluids intravenously without supervision and assist in all the many other medical responsibilities of the aid station. Their present training is satisfactory except for a tendency to include too many technical nonessentials. Continued on-the-job training by interested medical officers should further technical education and can create some extraordinarily effective medical assistants out of many of these soldiers.

      6. Conclusion

      Our present theory and practice of medicine in the aid station is well conceived and effective in general application. We might seek improvement in detail as follows:

        a. Devote specific attention to securing a better method of applying tourniquets.

        b. Give specific instruction in medical school in battlefield and disaster emergency therapy and resuscitation.

        c. Re-evaluate certain of our bandaging and splinting doctrines.

        d. Reapportion training time of the medical officer so that a maximum occurs in the combat zone where his medical practice will be located.

        e. Examine the feasibility of utilizing lower-quality personnel for the menial, non-technical jobs in medical soldiering in combat.