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Chapter VII

Contents

CHAPTER VII

Emergency Measures

Lyman A. Brewer III, M.D.

The management of the casualty with a chest injury from the moment he was wounded until his arrival at a forward (field or evacuation) hospital was directed to the same end as was the management of all other wounded: To state it bluntly, it was to keep him alive until he reached an installation in which his wounds could be evaluated and suitable measures of resuscitation administered to make a safe candidate for surgery. There was often, however, a particular urgency about the care of thoracic casualties because their wounds seriously interfered with the physiologic function of respiration and had a secondary, often equally serious, effect on cardiac function.

MANAGEMENT ON THE BATTLEFIELD

Emergency care of the wounded was begun on the battlefield by company aidmen. The thorough training of these medical corpsmen, and of the battalion surgeons who received casualties from them, in the proper emergency measures to be applied in thoracic wounds is not susceptible of statistical analysis but was an unquestionable factor of real significance in the steadily improving mortality and morbidity of these wounds. Medical corpsmen were fully alert to the dangerous possibilities of chest wounds, particularly sucking wounds, and to the importance of their correct initial management. Forward surgeons were agreed that the number of patients with these wounds who arrived in forward hospitals without proper occlusive dressings steadily decreased during the war and was, on the whole, gratifyingly small.

Corpsmen were always instructed to do no more than was really necessary in any type of wound. In chest wounds, battlefield care was limited to several simple measures:

1. Open wounds of the chest (so-called sucking wounds) were closed in one of several ways (figs. 18 and 19). The simplest method was to occlude the wound with a gauze dressing, preferably petrolatum-impregnated, large enough and applied tightly enough to stop the characteristic blowing sound. Petrolatum-impregnated gauze was preferred to plain gauze for the first layer of the dressing, partly because it provided a more nearly airtight closure and partly because it could be more easily removed.


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FIGURE 18.-Emergency packing of sucking chest wound by medical corpsmen.

The wound was not tightly plugged. The dressing was simply laid over it, and well beyond it, on all sides. It was held in place by adhesive straps. This simple measure usually proved entirely satisfactory. It eliminated the risk of an open pneumothorax during transportation to the rear and at the same time provided a means for escape of air under tension, so that tension pneumothorax could not develop.

Early in the war, it became the policy in the Mediterranean Theater of Operations, U.S. Army, to dress practically all wounds of the chest as if they were sucking wounds, as indeed many of them could become with changes of position (vol. II, ch. I).

2. Paradoxical motion of the chest, caused by multiple injuries of the bony thoracic cage (the so-called stove-in chest), was controlled by the snug application of a bandage.

3. Patency of the airway was maintained by urging the wounded man to cough. This measure was particularly urgent if his breathing was noisy or there was a rattle in his throat. Coughing could be encouraged if the corpsman could take the time to support the chest manually during the act.

4. A casualty who had difficulty in breathing when he lay recumbent was transported in a sitting or semisitting position if his condition and his other wounds permitted. The recumbent position often materially reduced the vital capacity.


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5. Morphine was administered only if the patient was in real enough pain from thoracic or other wounds to make its use necessary (p. 244). A dose of gr. was considered the maximum.

6. Associated wounds were given the required attention. If their severity warranted it, they were given precedence over chest wounds not associated with respiratory difficulties.

7. Early in the war, it was the policy to sprinkle sulfanilamide in all fresh wounds. As the war progressed, this measure was recognized as useless, if not actually harmful, and it was gradually abandoned.

FIGURE 19.-Emergency management of sucking chest wound on battlefield or at battalion aid station. A. Occlusion of wound with cloth, plain gauze, or petrolatum-impregnated gauze. B. Approximation of wound edges with adhesive tape. C. Approximation of wound edges with safety pins. D. Manual approximation of wound edges. E. Positioning of patient on pad or pack so as to cover opening in chest wall. F. Temporary mattress suture of wound. This measure could be used only at the battalion aid station, as corpsmen were not provided with suture material and were not trained to insert sutures.

Local chemotherapy-At the beginning of the war, as described elsewhere, powdered sulfanilamide was part of the contents of the first aid kit, and the wounded soldier was taught to begin his own chemotherapeutic treatment, whenever he was able, by dusting his own wound with the powder. If he could not, the corpsman was taught to do it for him. Similarly, until almost the end of the war, sulfanilamide tablets were included in the first aid kit, and if the wound did not involve the abdomen, the soldier, if he was able, took them according to instructions as soon as he was wounded. Later, it


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came to be realized that dusting an undebrided wound with sulfanilamide and covering it with gauze was no more than a gesture, and an ineffectual one at that.

MANAGEMENT IN BATTALION AID AND COLLECTING STATIONS

When the casualty arrived at the battalion aid station, he was observed by a medical officer, whose functions were:

1. To examine the dressings over the wound, making sure that they were properly applied and readjusting them as necessary. If they had become stiffened by blood, they had frequently ceased to be airtight and had to be changed. Dressings over large sucking wounds were examined with particular care. Unless circumstances required it, however, dressings which had been applied satisfactorily were simply inspected; they were not changed.

2. To administer morphine if it were really needed for pain and if it had not been given by the company aidman (p. 244). Intravenous administration was preferred in patients in shock.

3. To begin a plasma transfusion if the patient were in shock or seemed to be verging on shock. From the most forward point, care was taken not to overload the circulation of a thoracic casualty.

At the beginning of the war, it was the practice of some medical officers to dust the wound with sulfanilamide crystals at battalion aid stations. The practice was never uniform, and eventually it was discontinued. It was never useful.

When penicillin became generally available, in the spring of 1944, it was given in the battalion aid station or the clearing station, in the amount of 20,000 units intramuscularly every 3 hours.

At the collecting station, the next point of medical care within the division, the same procedures were employed. Dressings were inspected carefully, but they were not adjusted or changed unless circumstances required it (fig. 20). It was often difficult to persuade inexperienced medical officers to obey these instructions.

MANAGEMENT IN THE CLEARING STATION

Once the casualty reached the divisional clearing station, he was subjected to triage (sorting) to determine his further management (p. 202). His disposition depended upon the character and severity of his injuries and the urgency of surgery for them, his physical status, and the number of other casualties and the urgency of their wounds.

A casualty whose wounds were slight and who could probably be returned to duty promptly was held in the clearing station. Early in the war, a casualty who was in shock, regardless of the kind of wound he had sustained, was treated for it at the clearing station, and his disposition was determined after resuscitation. Later, it became the policy to send all patients in shock,


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FIGURE 20.-Adjustment of surgical dressings on ambulatory chest casualties at collecting station. A. Adjustment of dressings on anterior wound. B. Adjustment of dressings on posterior wound.


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regardless of the kind of wounds they had sustained, to the shock ward of the adjacent field hospital and to determine their further disposition there.

Whether or not he was in shock, a casualty who required urgent surgery, which the majority of casualties with thoracic injuries did not, was always sent to the field hospital. Otherwise, he was evacuated to an evacuation hospital for initial wound surgery.

The clearing station was the farthest forward point at which whole blood was available for transfusion. The policy was to administer it here to patients who, it was thought, would then be safely transportable to an evacuation hospital.

TRANSPORTATION

From the time he was picked up on the battlefield, the wounded man was transported to the rear as rapidly as possible until he reached the clearing station, where the plan of management he required was determined upon. The timelag from injury to triage varied according to the combat activity of the division, the number of casualties, and the terrain over which they had to be moved. Sometimes, it was a matter of minutes. More often, it varied from 2 or 3 hours to 15 hours or more. Occasionally, when the tactical situation was particularly difficult, it was 24 hours or more.

Casualties with superficial wounds of the chest were permitted to be ambulatory. All other thoracic casualties were carried. They were usually moved by litter from the battlefield, though during the fighting in the Apennines, as already mentioned, they were frequently brought down the mountain by mules. Movement from the battalion aid station to the collecting station, depending upon the tactical situation and their relative locations, was by litter, by jeep with improvised litter racks, or by ambulance. Transportation from the collecting station to the clearing station was usually by ambulance. The clearing station and the field hospital were so closely adjacent that casualties were moved from one to the other by litter carry.

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