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Chapter 2, Part 3

Medical Science Publication No. 4, Volume II

TRAINING OF MEDICAL OFFICERS*

COLONEL JOHN M. SALYER, MC

There are many involved factors and conditions, some considered favorable and others unfavorable, operating presently as well as during World War II and the Korean War, that affect and influence the overall accomplishment of the Armed Forces Medical Missions. During and immediately following the conduct of overseas combat endeavors, all Arms and Services of the National Military Establishment have their full quota of problems falling under the categories of personnel procurement, training and job accomplishment. The Medical Services have had and will continue to experience for some time in the unpredictable future an overabundance of difficulties relative to medical officer procurement and training in preparation for specific overseas and Zone of Interior duty coverages.

In view of such almost insurmountable obstacles in the past, it is rather amazing that the medical and surgical accomplishments during the Korean War were so highly laudable and at times approached the miraculous. However, in only about 85 percent of traumatic cases, aside from most medical problems, were the early and overall final results as ideal as we in the medical profession could desire or anticipate. This generalization is offered with due recognition that the fatality rate of wounded men reaching medical installations during the Korean War was only 56 percent of that statistically established during World War II; this percentage is based upon the fact that 4.5 percent of such casualties failed to survive during the last war and this mortality percentage was decreased to 2.5 percent during recent military operations in the Far East. It is our desire that this percentage of survivors among our troops and those of our Allies, i. e., 97.5 percent, will be increased during any future "peripheral war" not conducted on an atomic level, as well as in any group of unfortunates that suffer the severe injuries that all too frequently result from the bizarre, mysterious, violent and destructive forces of nature.

During the past decade Churchill [1, 2] and others have made it clear in their writing and lectures on the subject of traumatism that


*Presented 26 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Medical Center, Washington, D. C.


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such civil injuries are not unlike typically destructive and highly contaminated battle wounds and as such should be similarly managed. These initial comments and some of the subsequent remarks do not appear to be more than remotely related to my subject dealing with problems relative to the training of young medical officers, but seem somewhat appropriate in a dissertation on this broad and somewhat controversial subject. These views and comments are entirely those of the author and as such are influenced by surgical concepts and the surgical problems encountered during and immediately following the last 14 months of the Korean War. Some viewpoints would seem applicable and/or related to other professional specialty problems and circumstances encountered during any overseas military campaign. Some of the unfavorable factors that have been rather obvious in the past and may affect the efficient operation and conduct of the Medical Services are as follows:

(1) The size of the Regular Army Medical Corps has not been sufficiently large to provide medical care throughout a combat operation such as we have just experienced in the Far East. Roughly two-thirds of the number of medical officers required have of necessity been provided by the implementation of the doctor draft law-professionally speaking, this is a workable but not an ideal solution. It is rather obvious that a physician called into the Service against his will may not have the necessary enthusiasm to do a superb job that a career medical officer should conceivably have.

No actual complaint is offered with reference to the care of the sick and wounded; as a general rule, doctors of medicine do a fine professional job and will work around the clock when fellow men are in urgent need of their professional assistance; fortunately this professional characteristic is just as true in the Service as it is evident in civil life. However, of great importance is the requirement for a larger Regular Medical Corps imbued with a career desire and the necessary distribution of highly trained specialists assigned in staff and professional positions, as well as administrators who in their own right should be categorized specialists. We have a sizable number of such medical officers but too many are presently departing for "greener pastures." Such a tendency, the Services, as well as the entire medical profession and our nation, can ill afford. These problems should receive the highest priority of consideration in our Federal legislative branches-Congress alone has the authority to make the necessary adjustments to keep the various Medical Services sufficiently attractive to keep them supplied with a highly trained and competent professional cadre of career personnel. Such a situation, if ever attained, would be for the best interest of all components of the medical profession.


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(2) The doctor draft system as presently in operation, i. e., periodically, does not supply the Services with the proper ratio of professional specialists. It is understandable, for example, that in one group of inducted physicians there may be far too many obstetricians and few, if any, anesthesiologists, otolaryngologists, etc. In this period of specialization it is most likely that there will always be a shortage of MOS 3100's or general duty medical officers-indeed they are, during a war, never available in sufficient numbers. The vast majority of these doctors who are the most adaptable for service with forward combat units will of necessity continue to be supplied from groups of recent medical graduates who have had little, if any, training beyond internship. Numerically and professionally speaking, a great need for such officers to meet specific military situations in the future is a distinct possibility.

As stated above, it is quite understandable that the supply of this group will continue to be short and that doctors rather far advanced in specialized training may have to be utilized as general medical officers on a rotation basis from time to time; this mode of professional coverage had to be adopted periodically during the Korean War. This system, obviously, is not conducive to the best in esprit and morale. Only seldom do we see a medical officer, whether he be a regular or a reserve, who is completely willing to relinquish his specialty temporarily as well as some of his knowledge and skill and serve with troops whether they be on a training or combat mission; however, it has been a distinct surprise to many that surgeons, urologists, obstetricians, only to mention a few specialists, have done such outstanding jobs at division level and forward to hospital installations during the Korean conflict.

Regarding Training Prior to Overseas Assignment

It is proper and logical that medical officers should have a short military medical indoctrination course such as is now offered at the Medical Field Service School. We will all admit that a medical officer should know how to properly don and wear his military uniform and how to properly execute the military salute which, of course, is always executed in the position of attention and never with a cigarette or pipe in the mouth; such proper military conduct creates better respect and relations with military associates-both enlisted and officer personnel-and will never detract from the prestige of the Medical Corps. Some understanding of military discipline, command principles, medical supply methods and field sanitation is necessary. It may be noteworthy to relate that some knowledge of the conduct of proper military discipline and authority will prevent suffering and may save lives-reference is made to a military force located in a cold


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climate where cold injuries may be either negligible or numerous. In the same vein, death rates will be high and unwarranted discomfort great among prisoners of war if some should ever be so unfortunate as to be taken into captivity by a ruthless enemy and have no remaining semblance of military discipline promulgated by officers and noncommissioned officers among the groups of captured personnel.

Physical Training

There is little need for any prolonged period of physical training for medical officers prior to overseas or Zone of Interior assignments; this point is made in the interest of professional personnel utilization economy. To date no means or methods are employed to maintain perfect physical fitness of officers while en route to distant overseas stations-thus most medical officers arrive without any subjective or objective evidence of prior indulgence in physical culture routines. I desire to leave this thought with some of you who may at some future date have military assignments and duties that may in some way either directly or indirectly control some phase of officer training and/or assignments. This simple concept regarding the utilization of physicians, who indeed are scarce in the true sense of the word, seems mandatory and their early and appropriate assignment to professional duty without unnecessary delay is of the essence. This fact will be much more evident if other peripheral wars develop, not to mention the professional personnel shortages that will be critical if World War III should occur.

Noteworthy Surgical Problems Related to Professional Training

Only an occasional young medical officer, at the time of overseas assignment, is even remotely well informed as to the proper early care of war wounds. This generalization applies to surgeons who, so to speak, have had excellent "stateside" surgical training in our fine military hospitals as well as in the largest and best university hospitals. Many of our outstanding surgeons, both civil and military, are cognizant of this grave teaching deficiency in our graduate training program and they, along with various surgical societies and organizations, are making plans to improve this deficiency in our postgraduate surgical training programs.

Surgeons who had had average to excellent surgical training by civilian standards, but with only meager knowledge as to adequate care of war wounds, over and apart from the surgical concepts and principles alluded to by the Theater and Army Surgical Consultants during indoctrination lectures after reporting for assignments, were in most instances able to serve a short preceptorship with surgeons


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who had been similarly taught or had learned the unfortunate way-i. e., that inadequate surgical care such as inept débridement of wounds or the improper application of a plaster cast can cost the patient his limb or perhaps his life. A surgeon assigned to an Army Surgical Hospital would often progress from a very inadequate wound surgeon to one that could perform excellent surgical work independently within a period of 3 to 4 weeks. Such was more often the rule when the surgeons had had excellent prior surgical training and were receptive to realistic appraisal of the early and late results of their surgical work by themselves, their fellow medical officers and by surgical consultants who were in almost daily contact with hospitals that were most active in the care of the battle wounded.

Early Indoctrination as to Surgical Concepts and Policies

Reporting surgeons were given detailed information as to the policies on the early and late care of battle wounds and the natural and/or untoward sequelae thereof were stressed in informal lectures by the Theater and Army Surgical Consultants as well as by periodic professional information in staff publications from major headquarters. Chiefs of Services in the various hospitals, as well as division and corps surgeons, also contributed to this professional policy indoctrination program. Dissemination of such knowledge related to patient care was especially directed to those officers being assigned to forward medical units in divisions as well as to surgical hospitals, "so-called mobile," and to evacuation hospitals. First aid measures, triage, selective evacuation and distribution of the wounded and the initial surgical care following or concurrent with resuscitation measures in priority I and priority II patients were stressed repeatedly in great detail. Only some of the more important instructional points relative to the overall treatment of battle wounds will be discussed briefly.

Early Wound Care

The principles and concepts regarding wound débridement and the non-suture method of handling such wounds, as a general policy with limited exceptions as mentioned below, were stressed in considerable detail. This all-important surgical measure, which theoretically implies the complete excision of devitalized tissue and foreign matter as completely as clinical surgical judgment will allow, was stressed repeatedly to all medical officers who were to be given assignments in medical installations providing early wound care. The important aspects of wound management were stressed to all surgeons at the time they arrived in Japan, again in Korea, and often in the operating rooms along with technical demonstrations. It was most encouraging


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to see surgeons who had had creditable former surgical training become adept wound surgeons within a very few weeks; however, an occasional surgeon seemed never to grasp the full significance and appreciation of the necessity of an adequate débridement and such officers were ultimately transferred to medical installations where initial wound surgery was seldom done. Perhaps it is noteworthy to relate that recommendations were made to the effect that the following types of wounds, and only these, were to be considered eligible for primary closure at the time of initial adequate débridement:

    1. Wounds of the face, neck and mucous membranes lining naso-oro-pharyngeal spaces.

    2. Simple lacerations of the scalp.

    3. Craniocerebral wounds.

    4. Conversion of sucking wounds of the chest by suture of intercostal fascia and muscle bundles.

    5. Partial closure of abdominal wounds to prevent evisceration and

    6. Closure of synovial membrane or joint capsules.

    7. For the past 2 years primary closure of hand wounds was definitely not recommended-viable avulsed skin was to be left intact and loosely tacked at the former site to partially cover important anatomical structures such as tendon sheaths and tendons. Primary closure of wounds of the hand under war or mass civilian disaster conditions should always be discouraged.

Those medical officers who were most likely to be assigned to medical units forward to the surgical hospitals in Korea were informed, on their arrival in Japan, that their primary duties during active combat would be to provide first aid, resuscitation measures such as the establishment of adequate respiratory exchange, shock therapy before and during evacuation, the alleviation of pain and apprehension, the institution of antibiotic therapy and the administration of the routine tetanus toxoid booster injections; the necessity for timely, early evacuation and distribution to appropriate surgical or evacuation hospitals was stressed.

A definite point about which there is always some controversy should be mentioned. It is in regard to the most logical echelon level at which initial wound surgery should be performed. It is the contention of the author that initial surgery of any significant magnitude should never be attempted forward of the mobile surgical hospitals. There are many cogent reasons for this recommendation, some of which are as follows:

1. Competent anesthetists and highly trained surgeons are seldom assigned to units forward to first-priority hospitals-only seldom can


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the most minor of war wounds be débrided under conditions other than well controlled general anesthesia.

2. As a rule, adequate x-ray facilities are not available for proper localization of radiopaque foreign bodies.

3. Sterile supplies and equipment in sufficient amounts, as well as specialized equipment for proper preoperative care and postoperative complications, are usually not adequate.

4. Improvised operating rooms are poorly lighted and difficult to maintain in a dust-free state.

5. Nurses who are so necessary in the conduct of the operating room, operative procedures and in the care of the seriously wounded patients are not available.

6. If medical officers are involved in the surgical care of patients, they are not available to conduct their specific delineated duties at the forward echelon-this fact is especially obvious when casualties are numerous.

Other points, many of which were of paramount importance, were stressed in discussions with medical officers regarding the care of wounded men. Time limitations permit little more than the listing of some of these concepts as related to patient care:

Records. Adequate field medical and clinical records should be maintained-concise significant entries should be a must requirement. All echelons providing professional care should be "clinical record conscious." A revised clinical record form is urgently needed; a notebook type with spaced item headings and of good serviceable and durable paper would provide a much more satisfactory record which could be maintained intact with some semblance of stability and order.

Narcotics. The overmedication with narcotics, especially in wounded men who are in impending or frank hemorrhagic or wound shock, is a problem that must always be guarded against. The value of small dosages intravenously supplemented on occasions with barbiturates has been advocated by Beecher (3, 4), Dripps (5), and other noted authorities in the field of anesthesia.

Surgical Delay. The surgical lag should be kept in mind. Ideally, the seriously wounded should be receiving initial surgical care within 6 hours after injury. If surgery is required as an integral phase of the resuscitation process, then it should be instituted much earlier.

Plasma Volume Expanders. The limited value of substances such as dextran was usually pointed out in the indoctrination discussions, and the fact that there is no substitute for whole blood in the replacement therapy for patients suffering from severe wound and/or hemorrhagic shock should be common knowledge. The red blood cell


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rules supreme in the transport of oxygen to all tissues of the body-no substitute for the erythrocyte has yet been discovered.

Intra-arterial Versus Intravenous Transfusions. Until the end of the Korean War intra-arterial transfusions were advocated and frequently employed in the treatment of severely wounded men and no doubt this method saved many lives-perhaps only because of the rapidity by which blood was given by both routes simultaneously. It is doubtful if intra-arterial blood administration provides immediate assistance in the oxygenation of cerebral and cardiac tissue since the whole blood given is not oxygenated. Late in the war it was recommended that radial arteries should never be employed for intra-arterial transfusions as the danger of ischemic loss of a hand, fingers, or perhaps an arm is a distinct possibility. The posterior tibial, the femoral or an artery proximal to a mangled extremity were recommended if the intra-arterial route for whole blood transfusion was considered necessary.

Amputations. Sites of election are never considered when doing war or mass casualty surgery-the circular procedure commonly referred to as the guillotine method is performed at the lowest possible level to be considered as an adequate débridement.

Plaster Casts. Never did we have enough trained orthopedists to assign to all forward hospitals; however, general surgeons, by and large, provided excellent initial surgical care for patients with open fractures-namely, adequate débridement. The splitting of plaster casts and all underlying circular bandages down to skin level was a MUST after plaster cast application. This policy saved many limbs as well as occasional lives.

Arterial Injuries. The fine results in the care of such injuries has been reported elsewhere at this meeting. Perhaps this aspect of specific wound care brought forth greater periodic teaching efforts than for any other type of injury. Visitations and rather lengthy periods of duty by Lieutenant Colonel Carl W. Hughes and Major Edward J. Jahnke from the Walter Reed Army Medical Center were made available for the express purpose of providing expert surgical care for such traumatic problems. Many surgeons were given detailed instructions as to technical details on laboratory animals as well as in the operating rooms of the busy surgical hospitals.

Thoracic Injuries. Conservative measures as a general rule in the early care of such problems were constantly stressed. This policy paid off as evidenced by the overall fine results obtained.

Liver Wounds. All medical officers were constantly encouraged to control hemorrhage by appropriate suture methods and the very important employment of ample and dependently placed rubber drains-such drains are removed gradually at a late date. Management with-


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out adequate dependent drainage or the early removal of drains invites disaster in the form of severe early and late complications.

Bowel Injuries. It goes without saying that injured segments of colon are exteriorized, if at all possible, through a stab wound apart from the laparotomy incision. If anatomically impossible to exteriorize, repair of the defect and a defunctioning proximal or a diverting colostomy are performed-preferably a double-barreled colostomy. This policy was a MUST as it was in World War II. Much suffering and disability from extreme complications and/or fatalities are the rule when such a policy is not strictly followed. Small bowel injuries are closed or resected and bowel continuity re-established-exteriorization of the small intestine is seldom warranted.

I have mentioned only some of the prevailing principles and concepts in war or civil disaster wound care that should be clearly established in the minds of members of the medical profession whose lot it is to provide initial surgical care for those unfortunate individuals who are injured by the many destructive forces that could descend upon large segments of our population. I am sure we will continue to have better results in wound care as new and better biologic, therapeutic and technical methods and concepts are unfolded.

Surgical Consultants Program

In the Far East we have been very fortunate and highly pleased with the policy of having frequent consultant visitations by outstanding civilian authorities as well as from equally capable consultants from the Medical Services of the Armed Forces. This consultant program has been as successful and as popular in the other major Services' specialty branches as it has been in the fields of surgery and its related subspecialties.

Consultants, by and large, have been extremely well selected. They make, on the average, 30-day tours about the Theater and present formal and informal lectures and teaching clinical ward rounds with the respective specialty consultants assigned to the Theater and to the Field Army. These consultants have contributed a great deal toward the fine professional results that have been obtained during the Korean War and each of them has remarked that he too has gained much from his contacts with Service personnel and the professional problems with which the Military must deal during a very complicated and extremely destructive war such as has been experienced in Korea. An added professional stimulus and a decided boost in the morale of our medical officers has almost always resulted during and after their contacts with consultants such as visited and worked with us during the Korean War. The expenditure for such a fine consultant program


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should be of little concern to providing authorities when "professional dividends" are so regular and of such profound value.

Theater Medical Societies and Periodic Professional Meetings

Professional societies organized in the interest of professional training and interspecialty exchange of scientific knowledge have been created and conduct periodic meetings regularly with very satisfactory attendance by professional personnel from all local and somewhat distant United Nations units as well as from our own Army, Navy, Air Force and Marine organizations. Doctors and other professional personnel with worthwhile and timely subject matter for presentation are invited to participate on such prearranged and well publicized programs. The itineraries of visiting consultants are always so planned that such consultants may appear as guest speakers at the regularly scheduled meetings of the more popular societies such as the I Corps' 38th Parallel Medical Society of Korea, the Korea Communications Zone Medical and Dental Society which meets monthly on three consecutive days, namely, at Pusan, Taegu and Taejon, and the Southern Honshu Medical Society which usually conducted monthly meetings in Osaka, Japan. Periodic specialty group meetings are scheduled from time to time with personnel from all Medical Services of the Armed Forces as well as native physicians from the particular locale in which the meetings are conducted. It is noteworthy that Japanese and Korean doctors have been duly invited and are attending in increasing numbers-some have participated very creditably on the programs.

Professional Journals and Memoranda

The Far East Medical Bulletin, a monthly publication, in which brief professional articles of distinct value as to timely subjects and professional trends in policies are published, was read by most medical officers in the Far East. Professional personnel are invited and encouraged to contribute material for consideration by the Editorial Board for publication in this bulletin and in the past such response has been very generous.

A Symposium on Military Medicine in the Far East Command, a supplementary issue to the Surgeon's Circular Letter, was published in September 1951-this concise publication containing material of a technical and professional nature has been distributed throughout most nations of the world. It is still the "professional bible" for our medical officers in the Far East. A few revisions have been made and these are published and distributed as often as necessary.


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Professional Library Facilities

A well-stocked lending professional library is located in Tokyo, Japan. Textbooks and journals are mailed to any professional person in the Far East and may be retained for a period of 4 weeks. Such library service has permitted many medical officers to prepare successfully for participation in specialty board examinations. It is noteworthy that on a single occasion as many as 21 candidates from the Armed Forces Medical Units in the Far East have taken the first part of the American Board of Surgery Examination. If excellent library facilities had not been available, these eligible medical officers would seldom have had the courage to participate. All medical installations having five or more medical officers assigned were provided with an acceptable basic textbook library and are furnished the most popular professional journals.

Summary and Conclusion

Again I should like to stress some of the better circumstances and viewpoints under the general heading of professional conduct and training that made it possible for the Theater and Army Surgeons to provide medical services that were so generally successful during the Korean conflict:

Doctors of medicine as a general rule, and regardless of their respective specialty, are very adaptable and have an ardent desire to perform a creditable job, especially if their duty assignments are related in a general way to the overall medical effort and linked directly or indirectly with the prevention of disease or the care of the sick and injured. We can be thankful indeed that medical officers no longer are required to serve as Registrars, Post Exchange Officers, Mess Officers, etc. The wise and timely elimination of such periodic duty assignments which resulted in the increase in the size of the Medical Service Corps prior to and during World War II and later with the inauguration of the very popular and successful graduate professional training program, has done much to preserve the integrity of the Medical Corps and perhaps prevented a "Corps suicide."

References

1. Churchill, E. D.: Panic in Disaster. Annals of Surgery (Editorial), December 1953.

2. Churchill, E. D.: Management of Wounds (Initial and Reparative Surgery). Symposium on Treatment of Trauma in the Armed Forces, Army Medical Service Graduate School, Walter Reed Army Medical Center, March 1952.

3. Beecher, H. K.: The Relief of Pain. Symposium on Treatment of Trauma in the Armed Forces, Army Medical Service Graduate School, Walter Reed Army Medical Center, March 1952.


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4. Beecher, H. K.: The Early Care of the Seriously Wounded Man. Journal of the American Medical Association, January 1954.

5. Dripps, R. D.: The Anesthetic Management of the Seriously Wounded. Symposium on Treatment of Trauma in the Armed Forces, Army Medical Service Graduate School, Walter Reed Army Medical Center, March 1952.