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Discussion on Consultants and Organization of Surgical Service

Medical Science Publication No. 4, Volume 1

DISCUSSION ON CONSULTANTS AND ORGANIZATION OF SURGICAL SERVICE*

MAJOR CURTIS P. ARTZ, MC

Various types of organization have been used on surgical services in forward units. Auxiliary surgical teams were utilized in World War II. The organization and working schedule should be made for greatest efficiency. Usually it is wise to divide the surgeons into two groups in order that each group may be responsible for a 12-hour period-one team for daytime surgery, the other for night surgery. The teams may shift from week to week in order that one group may be on duty during the day for one week, then during the night the following week. It is of greatest importance that each team have as a team captain a more experienced surgeon who is responsible for all patients admitted during his team's period of duty.

The chief of surgery should supervise and be responsible for all patients admitted, regardless of the team that is on call. Since he cannot supervise the preoperative, operative and postoperative phases of every patient's care, he should have as deputies two skilled surgeons who have had appreciable experience in the management of battle casualties. These captains of the surgical teams may then designate the operator for each particular case and assist the less experienced men with preoperative preparation, operation and postoperative care. Unless this type of plan is followed, surgeons with inadequate experience may be forced to handle severe cases that should be cared for only by more mature surgeons. Triage in the preoperative section is an important function of the captain of the surgical team. The chief of surgery and the team captains should visit the evacuation hospital occasionally to ascertain the results of the initial surgery.

When a new surgeon first arrives at a forward surgical unit, he must be carefully indoctrinated in the surgery of the severely wounded. The organization of a forward surgical service should be somewhat similar to the organization of a department of surgery in civilian medical schools. The chief of surgery serves as the professor and his two assistants are responsible for their two separate services. The surgeons who head the services have less experienced men on their


*Presented 20 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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staff for whom they are responsible. Only with an organization of this type can the training and experience of the surgeons be utilized in the most efficient manner. It is most unfair to the severely wounded soldier to permit a less experienced surgeon to care for him when the judgment of a more experienced surgeon is available.

During times when casualty loads are heavy, it is imperative that surgeons be given adequate time for rest. Usually a 12-hour schedule is optimum. On the other hand, if 8 hours are available for much needed rest, it has been found possible for a surgeon to be on duty during a 16-hour period. Adherence to a rigid schedule is most important, with definite periods of rest during times of increased activity.

Because of the type of injury and the limited number of surgeons, many operative procedures are performed without an assisting surgeon. Surgeons soon become accustomed to operating with one or two capable technicians. They must select the patients on whom they require another surgeon as first assistant. This is usually necessary in most abdominal wounds and chest wounds. Minor débridements may be done with the aid of one scrub technician. However, when a large amount of muscle is damaged and there is profuse bleeding, it is important that a capable assistant be available in order that the operation can be conducted with maximum hemostasis in the shortest possible time. All too frequently, inadequate assistance leads to unwarranted blood loss.

When multiple areas are involved, it is wise to use two surgical teams on the same patient. One team may perform an upper extremity amputation as another team débrides or amputates a lower extremity. The utilization of two teams decreases the time under anesthesia and proves most beneficial to the patient.

Since initial surgery in the severely wounded is so important, it would seem wise that the chief of surgery in a forward hospital be a more experienced Regular Army surgeon trained in the principles of resuscitation and combat surgery. So frequently the more mature, higher-ranking surgeons of the Army Medical Corps are assigned to rear hospitals. Because most of the surgeons in a forward hospital are obtained from civilian life and do not have extensive experience in the surgery of trauma, it would seem to be a good policy to have as a leader one of the more mature Army surgeons with previous combat experience. Only by utilizing surgeons with wider knowledge of initial care of the severely wounded man can we expect to decrease the morbitity and mortality of the injured mail. Improved medical care will come with increased emphasis on teaching the principles of forward surgery that are now known. The greatest need in the forward hospitals is dissemination of existing knowledge about resuscitation and combat surgery. One of the real responsibilities of the Regular


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Army surgeon is the care of the soldier wounded in combat. All surgeons in the Regular Army should be thoroughly trained in the management of the problems of trauma. Their subspecialty should be forward surgery. Physicians in civilian life do not have the opportunity to obtain knowledge and experience in the management of severely wounded patients. The problems associated with severe war injuries are peculiar to the Army Medical Corps and its surgeons should maintain a particular interest in this type of management. Young career surgeons in the Regular Army should always be given an opportunity to gain experience in forward surgical hospitals.

Utilization of Consultants

From time to time it is important that experienced, mature leaders in the field of surgery visit forward surgical installations as consultants. Their valuable advice is most stimulating to younger men who are managing battle casualties. The teaching done by these experts is invaluable. Too frequently, however, the consultant visits the rear hospital, the evacuation hospital and several forward hospitals in a short period of time. This permits him to spend only 1 or 2 days at each installation. His knowledge could be better utilized if he actually performed some surgery and, by first-hand experience, became extremely familiar with the problems of the particular institution he visited. A consultant should probably visit only three hospitals; and he might spend 2 weeks at each installation. During his visit he should care for some of the patients, assist surgeons, make regular ward rounds and share his knowledge with less experienced surgeons. The system used by many medical schools of having so-called "visiting professors" for a period of 10 days or 2 weeks is a good one. Such a program could be utilized with great efficiency in a theater of combat. "Visiting professors" in anesthesiology and surgery would lead to a closer bond between military and civilian surgery. As our nation becomes more frequently involved in conflict, it appears that our professors of surgery must stress the principles and concepts of forward surgical care.