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Discussion of Papers on Preoperative Treatment of Battle Casualties

Medical Science Publication No. 4, Volume 1

DISCUSSION OF PAPERS ON PREOPERATIVE TREATMENT OF BATTLE CASUALTIES*

LIEUTENANT COLONEL CARL W. HUGHES, MC

About all that I can add to what Colonel Lindsey has had to say about evacuation is further praise for the helicopter pilots. Actually, some nights when it was so dark that the bats wouldn't fly, one would hear a Bell helicopter coming in the distance. When they flew on such nights we knew that they were bringing in very severely injured patients. The helicopters often had to land by use of jeep, truck, and ambulance lights.

I want to emphasize further the thought brought out by Colonel Lindsey regarding the use of surgeons in the forward aid stations and clearing stations. I had occasion to see a number of trained surgeons come in to the theater each expecting to be given a hospital assignment where he could utilize his training by doing operative surgery. It seemed extremely unfair to the surgeon to send him up forward to work in an aid station or clearing company. Early, I felt it was a waste of a trained surgeon. Now, I am convinced that the use of a trained surgeon in the forward station was far more beneficial to the patient than many of us realized.

I have little to say on triage except that I would like to clearly emphasize my feeling for the need of a trained, experienced person in each hospital to supervise triage, to follow through surgery, and be available for consultation postoperatively. Such a man need not necessarily perform surgery but his presence would be extremely important.

Dr. Howard mentioned the priority of a bowel and popliteal artery injury saying, of course, that the bowel injury takes priority for surgery. I readily agree with Dr. Howard, but I only want to make the point that when one does have such injuries it is quite often possible to utilize two surgical teams and do both operations at once.

Major Artz made it clear, and I readily agree, that we cannot separate surgery from resuscitation since surgery is a part of resuscitation. I would, however, question the necessity of passing a plastic catheter through the femoral vein into the vena cava in order to give


*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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intravenous fluids. I realize that such a catheter in the femoral vein must be placed in for a short distance in order to keep it from being accidentally pulled out. If placed into the vena cava I wonder about the possibilities of thrombosis and embolism. Normally, I feel that one should be able to do a percutaneous puncture of the femoral vein or the femoral artery and avoid most cut-down procedures. We were fairly successful in using the femoral vein and femoral artery for transfusions and failed to get into any difficulties, except that when the needle or the patient moved about too much, there was apt to be a hematoma at the needle puncture site.

As far as intra-arterial transfusion is concerned, I would like to mention that very good use can be made of the exposed artery which is often seen dangling from the extremity of injured patients, particularly those with traumatic amputations. The artery, being constructed as it is of stronger tissue than the muscle, is often dangling and visible and can be readily recognized and utilized by inserting a Webster cannula or a size 13 or 15 needle directly into the artery to replace the blood by way of the artery from which it was lost. We used this method a number of times as well as intra-arterial transfusion into the femoral artery. We did feel that using the exposed artery was an excellent method of transfusing. I feel that most of us in the theater tended to underestimate the need for blood in many patients even though some received 40 to 50 pints of blood. Many of them still had need for blood when taken to surgery.

Major Artz mentioned the use of the urinary output as an indication of the condition of the patient. We also used this method of evaluation but found it was more indicative of the condition of the patient with abdominal injury than those with extremity wounds.

We made it a habit to give intravenous glucose whether blood was going to be required or not. If blood was started and glucose could be started concurrently, the patients received both and if necessary blood was also given in more than one port. I raise the question as to how valuable intravenous glucose was to these patients who had been in shock, whether or not it played any part in decreasing the number of patients developing renal shutdown.

Mention has not been made here of the use of norepinephrine. I think most of us realize that it does not have much, if any, place in resuscitation. However, we have used it in some cases preoperatively and found in some instances that it did improve the blood pressure. Some feel that when a patient is in profound shock that the vasoconstrictor mechanism has undergone its maximum vasoconstriction and the use of norepinephrine is then ineffective. We did find norepinephrine of value postoperatively. I am speaking of the postoperative period as a part of resuscitation. We have used norepine-


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phrine during that period until the patient became refractive to it and died in spite of additional blood and plasma expanders.

We found some patients who, during preoperative resuscitation, apparently reached their point of maximum benefit and passed that point of maximum benefit before we realized it and became worse instead of better. This seemed to be especially true of patients with abdominal injuries with bowel wounds who were no doubt developing peritonitis or had well advanced peritonitis at that time.