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Chapter III



Training of Personnel

General Considerations

Almost 2 years were spent in the United Kingdom in preparation for the care of casualties with bone and joint injuries expected in the campaigns to be conducted on the Continent. When the time came, these campaigns lasted only 11 months. Orthopedic care began, of course, with the arrival of the first troops in the United Kingdom in 1942, and the period between 6 June 1944 and 7 May 1945 was the summation of all the previous efforts.

This preparation had to be accomplished in the face of certain difficulties not apparent in the bare statement of the facts:

1. The period of training was not the same for all surgeons. Only a few hospitals were in Great Britain for the full 2-year period mentioned. Some arrived shortly before D-day and had only a few weeks of training; many others arrived long after D-day.

2. The training of physicians in special skills is difficult to accomplish in a limited period of time, particularly when they have had no previous surgical experience at all, though in times of great need there is no choice but to rise to the emergency. The results of the training of orthopedic surgeons before D-day were extremely good. Many medical officers who had had little or no surgical experience and who acted as ward officers in the first hospitals which arrived in the theater served with usefulness and even distinction as chiefs of orthopedic sections in hospitals which arrived later. This was a result of the training they received during the period of preparation.

3. A major problem was that even the most experienced surgeons in the theater had had, for the most part, no experience at all in the mass management of battle casualties with injuries of the bones and joints. The senior consultant in orthopedic surgery is a case in point. He had had a wide civilian experience. From previous experience in the Zone of Interior, he had had extensive experience in accidents which occur in training for combat. He had served overseas in World War I, though, as a matter of fact, this experience was less useful than his civilian and Zone of Interior experience. He had had, however, no experience at all in the mass management of casualties with bone and joint injuries as they were to be encountered in World War II. Furthermore, he assumed his duties in the United Kingdom Base only a few weeks before D-day, and he was therefore additionally handicapped by lack of knowledge of the location and personnel of the various hospitals which had been set up in preparation for the invasion.


Methods of Training

Medical Officers

The Medical Field Service School organized at Shrivenham, Berkshire, England, in 1943 was staffed by instructors who were handicapped, as already noted, by their own lack of battle experience. Instruction in the care of battle casualties and in plaster techniques was therefore, as a matter of necessity, chiefly theoretic. Medical officers who attended the courses came from evacuation and field hospitals and from divisional medical units.

No formal Army program of orthopedic training was instituted, but each unit was provided with a full file of theater circular letters and administrative memoranda, Army medical circulars, and the material in the Manual of Therapy1 prepared shortly before D-day. It was recommended that all of this material be used for instructional purposes.

As far as was practical, the large battle experience which the British had had and the techniques of care which they had developed were disseminated to American medical officers. Opportunities were provided to attend the meetings of the Orthopaedic Section of the Royal Society of Medicine, the semiannual meetings of the British Orthopaedic Association, and the monthly Inter-Allied medical meetings. Every 3 months, Sir R. Watson-Jones, Royal Air Force consultant in orthopaedics, and Air Vice-Commodore Osmond-Clarke conducted 5-day courses of instruction in fractures in the hospitals in and about London. These were enthusiastically attended by as many of the younger orthopedic surgeons in the American forces as could be enrolled.

Some American surgeons had the opportunity of working in British hospitals. British arrangements for the care of their wounded differed materially from those in the United States Army. The care of casualties was a function of the Emergency Medical Service, a civilian organization manned by civilian physicians. In England and Scotland, only a few Army, Navy, and Air Force hospitals were operated as service hospitals. The wounded British soldier, sailor, or airman was cared for by the medical corps of his special branch of service as long as he was overseas. As soon as he reached the British Isles, his care reverted to civilian physicians. This particular arrangement was made at the outbreak of hostilities because it was expected that there would be an enormous number of civilian casualties incidental to bombings. It also necessitated the withdrawal of far fewer physicians from civil life, in proportion to the population and the total available supply of physicians, than in the United States. Although the number of civilian casualties was smaller than had been expected, British civilian hospitals were generally understaffed and their personnel was generally overworked. Early in the war, therefore, a number of United States orthopedic surgeons in the European theater had the opportunity of participat-

1A proposed revision of the orthopedic section of the Manual of Therapy, in the light of the European experience, was drafted in June 1945 but was not officially published because the war in the Pacific ended within the next few weeks. It appears as an appendix in this volume (appendix B).


ing in the care of the British civilian population after bombing. This provided greatly needed help for the British, established invaluable contacts between American and British orthopedic surgeons, and gave American orthopedic surgeons excellent experience in the management of what were, in effect, battle casualties.

The response of untrained and inexperienced surgeons to such rapid training in orthopedic surgery was, as might have been expected, extremely uneven. Many instructors remarked that poor surgeons who worked with orthopedic surgeons of superior ability often failed to improve their techniques in either orthopedic surgery or the application of plaster, while poor surgeons continued to do poor debridements no matter what their specialty or training might be. Men in this group were inclined to excuse their inefficient performance on the ground that they were not trained orthopedic surgeons.

A fundamentally good surgeon, however, while he might do unsatisfactory work for a brief time, when once he realized the principles of debridement and the application of plaster, immediately improved his technique. There were many illustrations of the fact that a well-trained general surgeon can readily adapt himself to the needs of a specialty in which he has had no previous experience. One general surgeon, for instance, although he had never before seen the Smith-Petersen approach to the hip joint, once it had been described to him, extracted a foreign body from the joint and performed an extensive debridement as competently as if he had done the operation a dozen times.

One of the greatest difficulties with new surgeons who were without military experience or previous training was making them understand the fundamental principles of debridement. There were two chief errors, (1) a tendency to excise skin and superficial layers of tissue, and (2) a failure to make bold incisions through the fascial planes, so that the deeper layers of tissue could be adequately debrided. A wound treated in this superficial manner was seldom ready for closure within 5 to 7 days after wounding. Wound closure at that time was the objective of reparative surgery. With proper supervision, these errors could be corrected, but they would have been corrected more rapidly if the consultant system had been somewhat more flexible.

It was an excellent plan, when possible, to attach officer and enlisted personnel from new hospitals to older hospitals for instruction before they were permitted to receive patients. Another excellent plan was to attach a small number of officer, nurse, and enlisted personnel to an older hospital for a few weeks in exchange for a like number of personnel from a new hospital. In this manner, it was possible for the group from the older hospital to supervise and train the staff at the new hospital, while at the same time key personnel from the new hospital received intensive training at the old hospital.

Still another plan was to attach one or two teams from an auxiliary surgical group to each new hospital for the first few weeks after it opened. Finally, arrangements could sometimes be made with nearby established hospitals for personnel from new units to visit them frequently, observe the wounded as they arrived, and study the techniques of surgical management. The plans just


described were very frequently used in evacuation hospitals as they arrived on the Continent.

Nursing Care

Nursing care of bone and joint casualties was of high quality, though the policy of certain hospital chief nurses of rotating nurses through all services in the hospitals was regrettable. Orthopedic surgeons, like all other specialists, frequently complained that few nurses remained on their sections long enough to become really proficient in the care of these casualties. Repeated requests were made for key nurses and key enlisted men to be given permanent assignments, without rotation, and in some hospitals this practice was carried out as well as circumstances permitted. In others, the recommendations were ignored.

Enlisted men who served as ward attendants had been carefully trained in their duties before D-day. A few had had additional training at the Derwin Training School for cripples in England. The more instruction these men received, the better, naturally, was their work. Some of them became extremely proficient in setting up traction and in caring for patients immobilized in plaster.

Plaster Technicians

Plaster of paris was used so extensively in bone and joint injuries, both in evacuation and in general hospitals, that surgeons and ward officers could not possibly take care of it themselves. It was always desirable for the surgeon to apply the plaster of paris after operation, but frequently this was impossible, and it had to be applied by enlisted technicians under his supervision. After several months' experience in this work, these enlisted men became extremely proficient and were able to change casts, as well as apply them, under the supervision of medical officers, thus saving a great deal of professional time and effort for other purposes.

The ideal arrangement was the assignment of technicians specifically for these duties, but such arrangements were often accomplished after considerable delay and much argument. In one general hospital, for instance, which served as a transit hospital at D-day, the orthopedic staff consisted of a chief of section, an assistant chief whose only orthopedic experience was a year in the Army, and three ward officers with no orthopedic training at all. The enlisted assistants were supposed to be any of the several men assigned to the operating room who happened to be available when the need for plaster arose. It was with the greatest reluctance that an enlisted man was finally assigned for full-time duty in the plaster room and was given an assistant who could be called upon when necessary. This reluctance soon disappeared before the weight of facts, and eventually five men were assigned full time to plaster duty in this particular hospital.

The most efficient arrangement was to assign 5 enlisted men to the plaster room-3 to be on duty from 7 a. m. to 7 p. m. and 2 to be on duty from 2 p. m.


until the day's work was completed. It was sometimes necessary for them to remain on duty until 7 a. m. This arrangement permitted an overlap of personnel during the afternoon, when the work was likely to be heaviest, and provided technicians around the clock. It also established a good working relationship between the day and night hospital staff.

When men assigned to plaster work were not applying casts or changing them, they prepared supplies and kept abreast of the daily heavy needs. The best plan was to put a single man in charge of the preparation of plaster bandages, though when casualties were heavy this arrangement was not always practical. Enlisted men assigned to plaster work frequently also took care of the braceshop and the preparation of external appliances for shoes. This was not as desirable an arrangement as having trained craftsmen in charge of this work, but it served the purpose when they were not available.

Professional Conferences

It was strongly recommended that each hospital set up some type of professional meeting or conference at which all orthopedic problems could be discussed and policies of management could be clarified and modified. Theoretically, and under the conditions which existed, there was no better way to improve the work of general surgeons and of others not trained in orthopedic surgery. The presentation and discussion of special cases were particularly valuable. This method, however, was not as practical as it might seem on the surface. Before D-day, when there was ample time to hold such meetings, the orthopedic material was not available. After D-day, when casualties were heavy and surgeons often had to work on long day or night shifts and sometimes around the clock, there was no time for such meetings. Finally, when the hospital was not receiving patients, it was difficult to arouse interest in any sort of professional meeting among medical officers who were tired and needed rest.

Between D-day and V-E Day, three formal conferences were held with the British and Canadian consultant staffs, and similar conferences were held with the French and Belgian medical services. The personnel in attendance included both civilian and military authorities of high rank. There was always, in addition to formal exchanges, free interchange of ideas and professional techniques between the American and other Allied forces, with great advantage to both.

A meeting of the junior consultants in orthopedic surgery in the United Kingdom was held in London in December 1944, and a second meeting was held in June 1945. A meeting of the junior consultants serving on the Continent was held in Paris in June 1945.

These meetings, like all the others, were in effect training sessions. Clinical, administrative, and associated problems were discussed and clarified, and the exchange of experiences proved extremely profitable.