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Chapter V



Mass Management of Casualties With Bone and Joint Injuries

Methods of mass management of casualties depended upon the type and mission of the particular hospital, the kind of injuries to be handled, and the size of the casualty load, as well as upon the cumulative experience of the staff. In evacuation hospitals, no segregation was attempted, other than the assignment of priorities according to the necessities of the special cases. Patients with severe abdominal, chest, and vascular injuries seldom reached evacuation hospitals. As a rule, they were diverted to field hospitals, to which patients with only bone and joint injuries were seldom sent unless they were in a state of shock or had associated injuries which required immediate attention. The principal function of evacuation hospitals was the performance of initial wound surgery (debridement), which was essentially the same for all patients received in them.

When peak loads were being handled, regardless of the type of hospital, as many operating teams as were available worked at the same time. Surgical efficiency was greatest when shifts could be limited to 12 hours, but in times of stress both temporal and physical limitations frequently had to be exceeded.

Transit Hospitals

Adjacent to ports of embarkation for the invasion of the Continent were about a dozen hospitals designated as transit hospitals. They consisted, for the most part, of station hospitals, though a few general hospitals were included. The mission of these hospitals was triage of returning wounded and the performance of such emergency surgery as had not been done on the far shore or on returning landing ships, tank (LST's), and other ships. For all practical purposes, these transit hospitals functioned as evacuation hospitals. Only those patients were held who could not be safely evacuated. Patients who could be evacuated were sent, as rapidly as possible, to general and station hospitals farther north. As evacuation hospitals were set up on the Continent, these transit hospitals reverted to their regular status. Many of them later moved to the Continent themselves and were replaced by units more recently arrived from the Zone of Interior.

The report of the 217th General Hospital is cited as typical of the organization and work of a general hospital which served as a transit hospital during this period. The original plan was that this hospital receive casualties soon after injury. They were to be transported from the far shore by air and brought to the hospital from an airfield 8 miles away. At this airfield, a field hospital had been set up for the direct reception and care of any emergencies


that might have arisen in transit. With these exceptions, the patients were to receive initial treatment at the transit hospital. Then, if they were transportable, they were to be taken within 48 hours to a general hospital, where they would be retained. This general hospital, while it served as a transit hospital, was thus to act essentially as an evacuation hospital.

The first patients with bone and joint injuries to arrive at the 217th General Hospital after the initial assault on the Normandy beaches were received in the afternoon of D-day. Five transport pilots were admitted with compound fractures caused by small-arms fire as they had gone in low to drop supplies to paratroopers. A paratrooper was also admitted who had fractured his ankle when struck by the door load during evasive action of the plane over the drop zone.

The next casualties with bone and joint injuries arrived on the afternoon of D-day plus 4. They were a mixed group of 20 wounded, consisting of American officers and men, a French civilian, some German prisoners of war, and several Mongolian-Russian slave laborers. Thereafter, patients arrived daily in increasing numbers until, in July, the maximum received in a single day from the airfield was 740. Air evacuation from the far shore had begun to function within a week of the landing on 6 June.

The transportability of the patients received at the 217th General Hospital varied according to the severity of their injuries and the treatment they had previously received. Some had received thorough surgical care on the far shore and were immediately transportable. Others arrived wearing their original field dressings. The untreated patients had usually been injured from 24 to 36 hours before their arrival, but it was entirely possible, and by no means infrequent, to receive patients who had been wounded in France on the same day on which they were injured. These variations were caused by differences in the number of hospitals available near the front, the casualty load in these hospitals, and the proximity of air evacuation strips to the frontline.

Most transit hospitals, like the 217th General Hospital, received only a few patients in the first day or two after D-day, and for the next few days received only a limited number of seriously wounded patients. At the 38th Station Hospital, for instance, only 4 of the 107 patients received 8 June were severely wounded. Most of the chest and abdominal injuries were apparently being cared for on the beachhead by field-hospital platoons whose normal staffs were augmented by surgical teams from auxiliary surgical groups.

The pace in the transit hospitals then began to step up. The 110th Station Hospital received 1,000 patients in a 20-hour period 8 June. By 12 June most of the transit hospitals were fully occupied. As a rule, between 250 and 500 patients were received in each convoy, with the percentage of urgent surgical cases varying according to the proportions of walking wounded and litter patients.

The average stay at the transit hospitals was 36 hours or even less, which was well within the 48-hour maximum planned. Wounded were evacuated by


hospital trains to the general and station hospitals farther inland, most of which were fully engaged by 2 weeks after D-day.

Routine of Management

The management of casualties with bone and joint injuries received in moderately large to large numbers at a transit hospital was often as follows:

Triage was conducted in the admitting section for all patients. Those whose wounds had already been debrided and immobilized, and who were in obviously good condition, were sent to a medical ward, not to an active orthopedic ward. The other patients were sent to a single orthopedic ward which had previously been designated by the chief of section, and, when it was filled, to another ward intended to take care of any overflow. All the beds in these wards were empty, except for occasional nonevacuable patients who had been moved to one end of the ward.

The dressing cart was in the center of the ward, with the plasma units already open. The traction cart was available. A table was conveniently set up with request forms for X-ray examinations and laboratory tests. Additional nursing and other personnel had been assembled for the care of the patients, including two litter teams for taking patients to the X-ray department and the operating rooms. Finally, the kitchens had been warned of the need for extra food, some of which had been brought to the ward. As soon as patients began to arrive, additional workers were sent to the designated wards, including a physical therapist, a Red Cross worker, and an enlisted man ordinarily assigned to the orthopedic clinic.

The advantage of admitting all casualties with bone and joint injuries to a single ward or to two adjunct wards at the same time was twofold:

1. The other wards were kept free of the movement of patients.

2. The fact that the recently arrived patients were all in one place, with all necessary facilities at hand, facilitated their examination by the chief of section and the ward officers.

As soon as each patient was put to bed, his pulse, temperature, and blood pressure were taken and recorded. He was also given sulfadiazine (2 gm.). X-ray and laboratory blanks were filled in with his name, serial number, and other necessary information, and the hospital number was filled in on the 55C record form. By the time this was done, the patients had been allotted in groups of 3 or 4 to the medical officers on the orthopedic service.

A brief history of each case was taken. A complete examination was made, exclusive of the wound, and the findings were recorded. As soon as these details had been completed, the patient was presented to the chief of service and the ward officer, who made whatever additional examinations were necessary and decided what laboratory work and X-ray examinations were required. Finally, a tentative plan of treatment was formulated.

Patients who needed emergency care or who were to be operated on were designated by pieces of red flannel, pinned conspicuously to the bed covering


on their beds. Patients who did not need surgery were given hot drinks and sandwiches at once.

The first patients who were examined and who required surgery were sent to the operating room and cared for there by designated officers from the orthopedic section. When all patients had been examined and evaluated, the chief of service and the ward officer themselves went to the operating room to continue the necessary surgery.

Wounds were not uncovered on the wards. They were first uncovered under sterile conditions in the preparation room, where an enlisted technician, in cap and mask, made a sterile preparation of the wound, after anesthesia had been induced. Preparation before induction of anesthesia would have been too painful. The entire procedure was repeated in the operating room by the surgeon after he had prepared his hands. The skin was then prepared chemically by an instrumental technique. The wound was draped and the operation started after the surgeon and assistant had rescrubbed their hands and put on gowns and gloves.

Most of the extremity wounds which required operation at transit hospitals were managed by wound excision or debridement, with the application of plaster of paris.

The patients who were operated on, depending upon their number, were put on one or two wards, where they could be easily kept under observation by experienced medical officers and nurses. The ward officer on the designated wards might well operate the entire night, but for the next day or two he would be assured of no admissions.

Finally, 48 hours after the reception of the first patients, the ward was emptied in a mass movement, beds were made up, and facilities were again prepared to receive fresh patients.

General Hospitals

The United Kingdom, owing to the stability of its hospital sites, was designated as a base center after the invasion of the Continent. In addition to the general hospitals which operated in it, seven hospital centers had been set up, each one under its own commanding officer. This arrangement was a notable step in increasing the efficiency and improving the results of professional care, and it also resulted in a significant saving in orthopedic personnel.

The routine of management of mass casualties in general hospitals and hospital centers varied from installation to installation. The important consideration was that some general plan of management be set up. At the 803d Hospital Center, the following routine was found efficient:

Casualties arrived at this hospital center by ambulance or hospital train, after having been brought from the Continent by air or boat and having spent 24 hours or more in a transit hospital, before being distributed to various installations in the United Kingdom.


As soon as they arrived, they were subjected to triage by the chief of the surgical service, assisted by the chief of the orthopedic section. It was thus determined immediately what types of injuries had to be dealt with and which wounds required priority of treatment. These were matters of great practical importance when 200 to 300 patients were received at the same time.

The patients were first divided into three groups: (1) Those who needed immediate attention; (2) those who could wait a brief period for treatment; and (3) those whose wounds were not urgent at all.

Patients were next segregated according to type of injury. Those with fractures of the long bones were sent to wards equipped with facilities for traction. Those who had undergone amputation and those with hand injuries were sent to special wards designated for the management of those injuries. Those with multiple injuries, whose condition was more or less critical, were sent to the shock ward, which was equipped for the combined management of abdominal, chest, bone, and other injuries, in addition to the treatment of shock.

At the 802d Hospital Center, a plan similar in principle but somewhat different in detail was followed:

All casualties with bone and joint injuries were sent directly to the orthopedic section, unless other wounds required some departure from this practice. Then, when the casts had been removed and the nature of the injury clearly defined, the following channels of distribution or courses of treatment were adopted:

1. Seriously injured men with compound fractures were sent to the orthopedic wards, which were equipped with Balkan frames, elaborate dressing carts, and supplies which permitted wound management by a scrupulous aseptic technique. These wards were staffed by young medical officers who were on 24-hour call. As far as possible, the nurses most skilled in the care of orthopedic injuries were also assigned to them.

2. When skeletal traction was not required, the patients were transferred in plaster casts to various other sections of the hospital, depending upon the necessities of the case, such as the need for plastic surgery, neurosurgery, or genitourinary surgery. The orthopedic surgeons followed the patients on these wards and continued treatment at the convenience of the officer who was in charge of the major problem.

Nerve injuries were always given priority of treatment whenever some graver injury did not prevent it. Patients with injuries of the sciatic or other major nerves were transferred, in the original plaster casts, to a neurosurgical center or to a hospital equipped for neurosurgery, unless there was some contraindication or some necessity for further evaluation. Peripheral nerve surgery could be provided at two of the hospitals which made up the 802d Hospital Center.

Certain plastic procedures had to be performed immediately. Exposed tendons, for instance, had to be covered, and orthopedic management had to be modified to suit the requirements of pedicle flaps.


Patients with compound injuries of the hand were eventually transferred to the hand-surgery section, but only after they had been studied on the orthopedic section.

3. Patients with injuries of the rectum and other injuries which required colostomy were retained on the orthopedic wards, where their wounds were treated by general surgeons. Whenever possible, patients with injuries of the rectum were managed in a special septic section, with special precautions against infection.

4. Patients who did not require traction, plastic surgery, or other special treatment and who were not acutely ill were immediately transferred to the convalescent ward, where a rehabilitation program could be pursued with the elaborate facilities provided. From this section, they were transferred to convalescent centers, rehabilitation hospitals, or, in some instances, directly to duty.

Each ward officer could usually care for a total of 72 patients and was likely to average 15 to 25 new patients with each mass admission. It was his responsibility to see them all as soon as they entered the ward to determine their priority for surgery; to evaluate their general condition; to observe them for possible complications, such as wound infection; and to continue the administration of penicillin or a sulfonamide if it had already been begun. Otherwise, an order was written for the administration of one agent or the other.

After all patients had been distributed and examined, the chief of the orthopedic section visited each ward in turn, examined each patient to check the ward officer's evaluation, and then made the operating-room schedule, listing the patients in the order of priority for surgery.

Each newly admitted patient who required surgery was taken to the operating room as soon as possible. In all general hospitals, there were complete facilities at hand for any indicated procedure. Three operating tables were usually employed for orthopedic surgery. Each was set up with a complete set of orthopedic instruments, as well as with sets of instruments for skin grafting. Fracture tables, plaster of paris, full traction equipment, and portable X-ray equipment were also provided in the operating room. As a rule, not more than 6 orthopedic operations could be done at each table in the course of the day, 3 in the morning and 3 in the afternoon. Ward officers worked in the operating room either in the morning or in the afternoon, spending the rest of the day in the care and supervision of the orthopedic patients on their wards.

Personnel assigned to each orthopedic operating table consisted of 4 trained orthopedic technicians, 2 surgical technicians, a sterile nurse, and a circulating nurse. As many shortcuts were employed as possible. Trained enlisted personnel performed the preliminary procedures, removing splints, preparing the surgical field, and frequently applying the plaster casts after operation. When these men were well trained, as they usually were, and were adequately supervised, this system was perfectly satisfactory and saved a great deal of time for professional personnel.


By the time a patient had left the operating room, a good deal had been accomplished for him. Bones had been set in the best possible alinement and were maintained in reduction by whatever method was indicated. If sepsis was not present, the wound had been closed either by delayed primary closure or skin graft, or by a combination of these methods. Not infrequently, the patient required no more active management of any kind until he was ready to be evacuated to the Zone of Interior.

Under this or some similar scheme of management, if from 200 to 300 casualties were received at a time, all of them could be operated on or otherwise disposed of in about 4 days.

Principles of Management

Whatever plan of mass management was followed in a general hospital, the principle of segregation of like cases was always followed whenever appropriate specialists were available. If they were not, there was no point in separating the orthopedic service, even in name, from the general surgical service. The best plan, in these circumstances, was to direct the patients who required specialized care to centers in which trained orthopedic surgeons were available. This policy was quite generally followed, except in the occasional instance in which a commanding officer failed to recognize that orthopedic surgery is quite as much a specialty as neurosurgery or radiology.

Segregation had two great advantages, as follows:

1. It was of great aid to a newly wounded man's morale to be assigned to a ward in which patients with injuries similar to his own were being cared for. A newly admitted man with a midthigh amputation, for instance, was much less perturbed when cared for with 30 to 40 similar amputees and could see how well they had already become adapted to their disability.

2. Ward officers assigned to special wards soon became skilled in handling special types of injuries, even if they had had no particular training directed toward this end in civilian life.

When mass admissions required the united effort of all hospital personnel, it was particularly important that their potential capabilities be used to the fullest possible extent. This principle was violated when trained orthopedic surgeons were assigned to ward work instead of operating-room work; when the chief of surgery made out the operating-room schedule without consultation with the chief of the orthopedic section, who might not know what was being done in his section, or by whom, until just before operation; and when ward officers were assigned to work in teams, which often prevented them from assisting at operation on their own patients. In enlightened hospitals, these practices were not followed. Ward officers were assigned in the operating room to their own patients and were encouraged to follow them into the recovery wards, even though other officers were detailed to these wards. Even in wartime, some semblance of physician-patient relationship could thus be maintained.