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Chapter 2, Part 2

Medical Science Publication No. 4, Volume II

THE TRAINING OF TECHNICIANS FOR MEDICAL CARE
WITHIN THE INFANTRY DIVISION*

RUSSELL SCOTT, JR., M. D.

The extreme importance of the detailed care that a battle casualty should receive in the first few hours after wounding has been discussed. It was pointed out that while the hospital mortality of the wounded soldier has continued to fall, there has been no change in the overall battle mortality since World War I. Still about 25 percent of those wounded die. The importance of prompt, intensive, meticulous care and attention to detail in the initial care of the battle casualty cannot be overemphasized.

First, let us outline briefly the concepts which should be a part of our policy, training and indoctrination if we are to succeed in lowering the present battle mortality and give the combat casualty optimal care. I feel there are five general headings.

The first concept is concerned with the initial phase of training and indoctrination given to the aidmen.

a. This indoctrination should include the teaching that the aidman has a prestige that approaches or equals that of the chaplain, that there is a respect due to him and that his duty requires of him a loyalty to "cause" which few medical officers are ever in a position to achieve. This ideal should be part of his training.

b. Second is the indoctrination of the "team concept" of resuscitation. 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 by an understanding of the role they play in achieving the goal. For a team to succeed, and resuscitation is a team job, each member must have a clear understanding of the final objectives. The aidman must be made to feel that what he does or does not do will influence to a large extent the outcome of each casualty.

c. Finally, after the trainee has real understanding of his obligations to the wounded, an understanding of the broad scope of resuscitation, and the vital role he plays in resuscitation, he must be taught the specific medical knowledge that he will be required to use


*Presented 26 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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in the field. This of course includes control of hemorrhage, splinting, intravenous therapy, etc.

The second concept to be included in our policy is continued training after the initial period of indoctrination and teaching. Refresher courses and on-the-job training must continue at theater headquarters, while a unit is in reserve, or even in actual combat. We must further develop the concept that training is a continuing job.

The third portion of our policy, designed to increase the excellence of medical care, is to obtain the complete control of the enlisted medical personnel by the Medical Service both for training and subsequent assignment. At the present time the Medical Service is responsible for training, but then loses many of its best men through improper assignment by other departments within the Army. This defect must be corrected.

The fourth concept to be adopted is that all members of the Medical Service and all members of tactical units recognize and appreciate the great challenge placed on the aidman and battalion surgeon and be willing to support these individuals. No other members of the Medical Service are called upon to render unsupervised care to such a critically injured group of patients as are the battalion surgeons and aidmen. We, in the Medical Service, should recognize the need for the best trained men in the most forward area where the greatest test of ability is made and make every effort to see that only the most capable personnel are assigned to these vital positions.

The fifth concept is concerned with the fact that compromises in training and care will have to be made at various times. We must, however, be ever alert to recognize these expediencies as compromises and eliminate these compromises as the tactical situation, terrain, supply conditions, availability of personnel, etc., permit. The recognition and elimination of compromise is of course dependent upon a sound understanding of the goal of the Medical Service.

Let us now take up these five points in more detail.

Training

The training required to prepare an aidman should, as stated, include a sound philosophic approach to his responsibility as well as specific technical knowledge. The aidman must understand the broad objectives of resuscitation and know that his role is as vital as the role played by the battalion surgeon or the surgeon at the Surgical Hospital. He must not adopt the idea that once he has performed a few self-imposed duties his obligations to the patient and the team have ended. There was a distinct tendency for aidmen to fall into this


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habit and this was particularly true with splints and bandages. Often an aidman would see a fracture, apply an ineffectual splint and feel he had fulfilled his obligations. The same was true of bandaging. If the aidman was corrected for his error, the standard reply was "but I did what the book said" or some similar remark. He had done what the book said, that was, apply a splint in cases of fracture, but he did not have the final bit of training that makes an excellent aidman. The same is true of morphine therapy. Few efforts were made to evaluate the degree of pain or relieve pain by reassurance or immobilization of the wounded part. The aidman literally came to the wounded casualty with morphine syrette drawn.

These may seem like small errors but small errors, committed early, will be magnified later in the course of events and can cost lives.

We must not let our aidmen become stereotyped in their care of the battle casualty. We must develop the concept early in their training that the care of a battle casualty is individual and requires thought and consideration.

He must understand that at the completion of the basic training course his real period of learning has just begun and to become proficient he must remain alert, objective, and susceptible to suggestions from his battalion surgeon in combat or during refresher courses while in reserve. The development of such a philosophy among our aidmen is advantageous.

The job responsibility of the aidmen can be outlined by simply restating the aims of resuscitation. The aidmen should be prepared to:

    1. Prevent blood loss by-

      a. Tourniquet.
      b. Pressure points or pressure dressings.
      c. Immobilization.

    2. Prevent additional tissue damage by-

      a. Splinting of fractures.
      b. Immobilization of the wounded part.
      c. Proper instructions to the patient.

    3. Prevent additional bacterial contamination and bacterial growth by-

      a. Proper dressings.
      b. Antibiotic therapy.

    4. Replace blood volume deficits by intravenous therapy.

    5. Prevent and correct defects in cardio-respiratory physiology by-

      a. Closing sucking chest wounds.
      b. Proper instructions to the patient concerning position of head and body during evacuation.


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    6. Relieve pain and fear by-

      a. Immobilization and instructions.
      b. Reassurance.
      c. Morphine.

    7. Arrange for proper transportation and protection from the elements by-

      a. Evaluating the type and severity of injury.
      b. Knowing the modes of evacuation available.
      c. Proper instruction to the patient and litter bearers.

In analyzing the job responsibility, certain duties are of greater importance than others and should receive the greatest portion of attention in a training program.

Control of Hemorrhage

The control of hemorrhage is probably the most important single job of the aidman. Specific points concerning the application of pressure dressing and tourniquets and the arresting of hemorrhage through the use of pressure points are familiar to most aidmen. However, most aidmen fail to appreciate the importance of attention to details and follow-up observations. Once a tourniquet or dressing is applied, the aidmen fail to appreciate that the tourniquet may slip or that with a rise in blood pressure bleeding may recur. These principles of follow-up care must be emphasized.

The fact that the simple movement of an injured extremity may dislodge a clot and produce additional hemorrhage should be impressed on the aidmen. Each aidman should be familiar with the fact that even a small hemorrhage, while a tourniquet is being readjusted, may result in death in the critically injured casualty.

The aidman should understand that if he does not produce complete hemostasis of visible hemorrhage by one method, he should try another and another until hemorrhage has ceased.

In the control of hemorrhage the aidman should not only be taught what to do initially but should know how to look for and correct inadequate hemostasis initiated by other aidmen.

In the realm of hemostasis the aidman must be taught to be prompt, thorough, and ever mindful that what he does or does not do may cost a life.

The importance and technic of locating fractures should be impressed. All too often fractures are missed and serious hemorrhage or additional tissue damage results from movement during evacuation. The principle of "when in doubt, splint them where they lie" should be stressed.

The technic of splinting is usually understood by most aidmen. They fail, however, to appreciate the importance of adequate splint-


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ing and therefore fail to carry out adequate splinting while under the stress of combat. The thought process of the undertrained aidman seems to be that once a splint is applied, regardless of how ineffective it may be, his duties have been fulfilled. He should appreciate that in some cases a poor splint may be worse than no splint at all. The aidman should be impressed with the importance of rechecking his splints or any other aidman's splints as often as the opportunity presents itself. At every echelon the sight of a splinted extremity should make the aidman ask himself: "Is the splint immobilizing the extremity and has the blood supply been unharmed?"

Relief of Pain

The role of immobilization in the relief of pain should be stressed. Although this fact is readily accepted by the aidman, he seldom uses it himself and this information is rarely passed on to the patient or litter bearers.

Reassurance is an extremely helpful method of relieving pain. The aidman should be indoctrinated to appreciate how much fear and anxiety a casualty suffers and how this anxiety will magnify in the patient's own mind the severity of his pain. The aidman should understand that to be able to give adequate reassurance, the patient must have confidence in him and that confidence is founded on his ability.

If immobilization and reassurance fail, the aidman must then have the ability to evaluate the patient to see if contraindications to morphine therapy exist. The indications and contraindications for morphine therapy were discussed in the section on first aid. During one survey of battalion medical care in Korea, it was determined by interview that battalion surgeons felt that only 60 percent of their aidmen used good judgment in giving morphine to men who needed it and in refraining from administering it to casualties with contraindications to morphine therapy. The answer that only 60 percent of the aidmen are qualified to give morphine does not necessarily mean that the remaining 40 percent cannot list the indications or contraindications, but the latter figure represents those who do not exercise good judgment in giving morphine under field conditions. This is the group of aidmen who approach the casualty with morphine syrette drawn. It was generally felt that the figure of 40 percent was being reduced by persistent teaching from the battalion surgeon during combat and while in reserve after the men had had combat experience.

Replacement of Blood Volume Deficit

Interviews with aidmen actually serving in combat emphasized the inadequate background that most aidmen had concerning wound shock and replacement therapy. As part of the survey mentioned above,


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40 aidmen who were serving in combat were interviewed. A representative conversation would go as follows:

    "How many months have you been an aidman in combat?"
    "Five months."
    "Do you consider yourself qualified and able to start plasma on your own?"
    In almost every case the answer was "yes."
    "Have you ever started plasma or albumin in Korea or in the ZI?"
    "No" was the routine answer.
    "Why have you not started it?"
    "I have seen no casualties that needed it."
    "What types of serious wounds have you treated in advance of the aid station?"
    "Men with one or both legs blown off, abdominal wounds, chest wounds, but none of these men needed plasma."
    "What type of men do you feel need plasma?"
    "Those in shock."

These aidmen had the impression that shock was a condition diagnosed only by a medical officer with a sphygmomanometer and that it could not have been determined by them in the field by the nature of the wound, nor could the condition of the patient be determined by simple diagnostic signs. Occasionally an aidman would state that he could have helped some particular casualty with plasma but would offer as an excuse that he did not carry plasma or that the time lost in starting plasma would do more harm than the plasma would do good. This, I believe, is not true.

Seventeen aidmen were questioned at length about their experiences. On initial questioning only 1 of the 17 believed that he had seen a patient in advance of the aid station in whom replacement therapy was indicated. With closer questioning, 9 of the 17 men described one or more serious injuries (traumatic amputation, chest or abdominal wounds) which they had treated in advance of the aid station. After recalling these patients, the nine aidmen were still under the impression that plasma was not indicated in casualties with these types of wounds. Further questioning revealed that of these nine aidmen, six had treated casualties who died before they reached the aid station; three patients with traumatic amputations, two patients with multiple fragment wounds of the abdomen, and one with an injury not described. In only one of these six fatalities did the aidman in charge believe that plasma was indicated. It was obvious from these interviews that only the best trained aidmen recognized even severe wound shock and felt confident to treat it.

The aidman should be taught that shock, in one form or another, can exist without hypotension and that wounds of a certain type and


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magnitude sooner or later will be accompanied by shock and that casualties with these types of wounds will be benefited by early intravenous therapy even though clinical shock may not be present at that time. Traumatic amputations and large evulsing wounds fall in this group. Intravenous therapy in this group of patients with incipient shock would be nothing but helpful. In our training programs the aidman should be taught specifically which type of wounds, when encountered in the absence of "clinical shock," would be benefited by intravenous therapy. This training program could be carried out by academic lectures and by the demonstration of the specific types of wounds with colored pictures.

In addition to recognizing the types of wounds that will eventually produce shock and that would be benefited by early intravenous therapy before "clinical shock" developed, the aidman of course must be able to recognize clinical shock. Few aidmen, as pointed out above, were able to do this.

This weak point in their training could be overcome in three ways:

1. By an intensive training program on the signs and symptoms of clinical shock.

2. By establishing an Army policy for each battalion surgeon to notify each aidman when he had made an error in not giving a casualty intravenous therapy. (This policy was carried out by some of the battalion surgeons in Korea with encouraging results.) This suggestion is of extreme importance because in any training program it is impossible to train each aidman as well as we would desire. It is essential to follow through with supervision and training in combat.

3. By establishing an Army policy to have, when feasible, all aidmen replacements remain at the battalion or regimental aid station for a period of "on-the-spot" indoctrination into the clinical signs of shock and practical experience in intravenous therapy. If a large group of replacements came at one time and were needed forward, it would be possible to recall them in groups of two or three for instruction.

It was the belief of some observers in Korea that at least one aidman on each patrol, on each outpost position and with each assault unit should have thorough training in the technic of intravenous therapy. This would mean that approximately two of the five aidmen assigned to a given "line company" should be so trained. It would be preferable of course if they were all well trained in intravenous therapy, but the training of 40 percent (two out of five) of the aidmen in intravenous therapy may push our training facilities to the limit. It has been suggested that such an aidman could carry a special MOS and rank and that the Table of Organization of a medical company call for a given number of men with this MOS.


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How could such a man be trained? In addition to the basic indoctrination on intravenous therapy and shock given to all aidmen, such a man should have practical experience in doing venipunctures. The trainee would begin first on rubber tubing in his classroom, second on soldiers in reception centers, serology laboratories or blood banks, and finally on patients in Army hospitals needing intravenous infusions. The trainee should receive practice in doing venipunctures with the tourniquet on and off the arm so that he is accustomed to dealing with collapsed veins so often found in a patient in severe shock.

Undoubtedly such a training program would cause extra work and stress to the regular members of the installations used for training, but the results obtained would pay worthwhile dividends.

Tremendous numbers of venipunctures are performed each day in countless numbers of Army installations throughout the world. There is no reason why this broad classroom cannot be employed for our own benefit.

Following the initial training of our enlisted personnel, how can the Medical Service keep this level of proficiency high? One point that should be appreciated is the need for the best trained man in the most forward position where the greatest test of ability is made. There is a real tendency at all levels to hold back the best trained men and send forward the greenest men; such a policy is in error.

Additional training of course is essential, and several methods are available. One valuable training aid is to hold enlisted personnel at the echelon to the rear of the echelon where they will eventually be assigned. This is valuable for several reasons.

1. It gives the aidman a period of refresher training before entering combat.

2. It gives him a sound understanding of what is to be done for the casualty at the echelon to the rear and shows him how he can better prepare a casualty for evacuation and treatment at the rear.

3. It will show him the common mistakes made by the aidmen in the forward area and how these mistakes can cost lives.

4. It indoctrinates him into the "team" concept.

5. Finally and most important of all, it shows the aidman that there is nothing magical about the aid station and that he can actually initiate all the phases of resuscitation except débridement.

If at the time an aidman is assigned to a battalion, he is needed critically in the forward area, he may be pulled back at a later date for this period of indoctrination.

Another valuable period of training is the time during which the unit is in reserve. This is valuable for newly assigned personnel because they receive on-the-spot indoctrination by the surgeon they will work


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with. It is valuable for the aidman who has served in combat because much of the instruction that he now receives will take on new meaning, and in some cases, will be understood for the first time.

Another important training aid is to notify an aidman by a confidential (personal) note or phone call each time he makes a mistake or shows poor clinical judgment. If done in the right manner, this does not cause ill feeling and will aid materially in raising the efficiency of the medical team.

The belief that the Medical Service should secure the complete control of its enlisted personnel is probably of equal importance to any of the other five concepts. Because of limited time and space, only a brief statement will be made enumerating some of the discrepancies that can and do take place in the assignment of enlisted personnel.

Within the replacement depots the MOS of line personnel is sometimes changed to that of a medical aidman to fill a given quota. At one period during the Korean War (February 1952) a survey revealed that of 40 aidmen serving in combat only 9 had had the required course of training, 23 had had 4 weeks of first aid, 8 had had 1 week or less of medical training, and 3 had entered combat without training. This, I believe, is not a reflection on the Medical Service but on the method of assignment. The Regimental, Division and Army Surgeon had to do the best they could with the personnel that finally filtered through to them.

By interview other discrepancies became obvious. Enlisted men who had had experience in dispensaries as litter jeep drivers or similar non-clinical experience were readily given the MOS of an aidman without additional training. Such practices were carried out in replacement depots and not by the Medical Service.

We all appreciate that at times personnel needs do change and inadequately trained personnel must be utilized. After the period of improvision, changes should be made. An effort should then be made to reorganize and get the right man in the right job. It is my opinion that the problem could be better handled by the Medical Service than by any other Corps within the Army.

For completeness, let us state briefly what clinical responsibility is expected of the enlisted personnel at echelons to the rear of the aid station. The collecting station indulges in more holding, however, and some few aidmen will be responsible for the observation of these patients. These additional duties can be adequately learned by on-the-job instructions from the surgeon.

The clearing station will have holding wards, and active nursing care is needed. At this level minor surgery is carried out and enlisted personnel will be expected to set up for and assist in this surgery. While these added duties can be learned by the aidmen through on-the-


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job training, the presence of operating room technicians would be preferable. It is the opinion of many, however, that when personnel shortages exist within the division, the clearing station should receive the least trained personnel as their work will be supervised, and the best trained aidmen should be sent to the infantry company where their superior skill will be put to the greatest use.

At the Mobile Army Surgical Hospital the full range of surgical procedures and technics are carried out, all of course under the closest of supervision.

At this level the technician is expected to catheterize and pass nasogastric tubes, be familiar with oral-gastric, nasopharyngeal and chest suction equipment. He should be familiar with oxygen equipment. He should be able to set up for and assist at major surgery. Finally, he must be able to do nursing care on the postoperative ward. Again, all of these duties are under close supervision and much on-the-job training is possible. With the supervision and on-the-job instructions that the technicians in Korea received, it was rare that they did not reach a high degree of proficiency.

Conclusion

In this discussion and in the talk on the early care of the battle casualty, we outlined the extreme importance of the role played by the aidman in determining the ultimate outcome and mortality rate of the battle casualty.

From the statistics presented it appears obvious that the next significant reduction of the present battle mortality must be made by the personnel in the most forward area. The paramount importance of the proper selection, training and assignment of these individuals must be kept foremost in our planning. We must continue to recognize the absolute necessity for having only the most capable personnel in the forward area where the greatest test of ability is made and where our next great contribution to the battle casualty must be made.