Medical Science Publication No. 4, Volume 1
CARE OF THE BATTLE CASUALTY IN ADVANCE
OF THE AID STATION*
RUSSELL SCOTT, JR.,M. D.
A review of the statistics dealing with the battle casualty in pastwars has thrown increasing attention upon the extreme importance of themedical care given the wounded soldier during the first few hours afterwounding. The mortality rate of the battle casualty after admission toa fixed hospital has fallen from 17 percent in World War I to 5 percentin World War II to 1.7 percent in the Korean War. In spite of these encouragingstatistics, one out of every four wounded soldiers dies. The ratio of Killedin Action to Wounded in Action has changed very little since the FirstWorld War. The mortality rate at division and particularly battalion levelhas not paralleled the fall in the hospital mortality. For this reason,improvement of all facilities that speed the casualty to resuscitationand that bring resuscitation as far forward to the casualty as possibleshould be continued. In particular, intensive effort should be directedto the casualty in the most forward area.
To realize these aims it is of the utmost importance to appreciate whatthe optimal care of a battle casualty can and should consistof, under what conditions optimal care has been demonstrated to be possible,and what policies in training and supply must be adopted to insure thebest care under any set of circumstances. It is necessary also to appreciatethat variations in weather, terrain, tactical situation, efficiency ofsupply, etc., sometimes render optimal care difficult, but not impossible.We must therefore strive to modify our care as circumstances permit inorder to give the best care possible at all times. As simple as this mightappear, there is usually a significant delay in improving our care as circumstancesallow. In order to have optimal care it is necessary for us to have a clearidea of what the optimal care of a battle casualty should be.
Before we go into the specific first aid procedures, let us formulatethe broad aims and objectives of the early phase of resuscitation.
The broad aims and objectives of resuscitation are first to save life,then save limb and, at the same time, do the most good for the greatest
*Presented 19 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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number of casualties. To achieve these objectives we must understandthe pathology of trauma so that from this knowledge we may emphasize themeasures of resuscitation that are of real importance in savinglife and limb.
Briefly, four major phenomena threaten life following wounding.
1. First, and most important, blood is lost and continues tobe lost, not only to the exterior but into the damaged tissue at the woundor fracture. With blood loss there is progressive decrease in blood volume,fall in cardiac output, fall in blood pressure, decrease in renal bloodflow and decrease in oxygenation of tissue.
2. Tissue is damaged. With tissue damage specific organs andsystems are damaged, the media for bacterial growth are produced, and thelatest laboratory work indicates that toxic products may be released fromthe damaged tissue and have a general systemic effect which in itself maycause death.
3. The defense against bacteria is broken, wounds become contaminatedand bacterial evasion of the tissues and of the blood stream may occur.
4. Mechanical defects may develop, such as blockage of the airway,hemothorax, pneumothorax, cardiac tamponade or increase in intracranialpressure.
It must be understood that all of these four processes are progressive,synergistic, and will continue until measures are institutedto slow them down (first aid) and finally correct them (definitive surgery).As long as these processes are in motion, the casualty continues to deteriorate.In general, the intensity of early therapy and the time lag before theprocesses are finally brought to a halt determines the outcome of eachcasualty.
Aims of Resuscitation. It is important to appreciate that "resuscitation"includes the whole process of slowing down and stopping the pathologicalprocesses set in motion by wounding; first by simple local means, secondlyby plasma or blood replacement therapy, and finally by operative interventionat the surgical hospital. In its complete sense, first aid in the fieldand surgery at the surgical hospital should be considered integral partsof resuscitation.
The specific aims, then, of resuscitation include:
1. Prevention of continued blood loss.
2. Prevention of additional tissue damage.
3. Prevention of additional bacterial contamination and suppression ofbacterial growth.
4. Replacement of blood volume deficit.
5. Prevention or correction of mechanical defects in the cardiorespiratoryand central nervous system physiology.
6. Relief of pain.
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7. The removal of damaged tissue and repair of specific organs.
Again, the level or echelon at which each of the above measures maybe carried out will depend upon many variables: the weather, tactical situation,terrain, efficiency of supply, and the ability and attitude of the medicalpersonnel involved.
It should be obvious from this discussion that neither "first aid"on the battlefield nor surgery at the surgical hospital can be separatedfrom resuscitation. The whole process of resuscitation should be consideredto be an integrated program, beginning with first aid in the field andending with surgery at the surgical hospital. We all know that militarysurgery is not just civilian surgery carried out in a tent; likewise, wemust appreciate that combat first aid is not Boy Scout first aid carriedout on the field of battle. If we are to lower the present battle mortalityof 25 percent, every effort must be made to make the initial phase of resuscitationprompt, intensive, exact and thorough. One oversight or break in technicmay well cost a life because of the long time lag involved in evacuation.
It would be impossible with the time and space allotted even to outlinea complete course in first aid. The following section deals with the firstaid measures believed to be the most important.
Optimal resuscitation begins with the aidmen in the field who attemptto slow down or stop the basic pathological processes that have been setin motion by wounding. This is done by initiating the aims of resuscitation.
1. Prevention of Continued Blood Loss
a. Pressure Dressings and Pressure Points. The vast majorityof bleeding wounds can be controlled by the application of a pressure dressing.In addition to the pressure dressing, the patient may be instructed toadd additional pressure. In most instances bleeding can be controlled bysuch measures.
b. Tourniquets. When a pressure dressing has proven to be unsatisfactoryfor the control of hemorrhage, a tourniquet should be resorted to. I usethe word "resorted" advisedly, for the necessity of a tourniquetshould occur only infrequently. It is of the utmost importance that allaidmen be well grounded in the use of the tourniquet. Often the tourniquetwill not be applied correctly so that hemorrhage is not completely controlled,or the tourniquet may slip and bleeding recur so that a casualty will bleedto death while on the way to the aid station.
During cold weather an extremity with a tourniquet applied is unusuallysusceptible to freezing and gangrene formation. During the freezing monthsthe aidmen and surgeon should be unusually careful
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not to apply a tourniquet unless it is absolutely necessary and shoulddo so only when repeated efforts to control hemorrhage have failed.
Once a tourniquet has been applied, any member of the medical team removingthat tourniquet should exercise extremely good judgment, as bleeding mayrecur after the patient has passed through that period of observation.The removal of a tourniquet in cases where followup observation is impossible,such as during the period of evacuation, is extremely hazardous and shouldbe avoided. The untimely removal of a tourniquet with recurrent hemorrhage,even when recognized and immediately stopped, has been shown to be serious.On occasion this error has thrown a casualty back into shock from whichhe could not be revived. However, when safe, the removal of a tourniquetreduces the chances of the casualty's losing an extremity. In casualtieswith extensive tissue damage where the need for amputation is obvious,the tourniquet can and should be left in place to avoid any chance of additionalhemorrhage. This decision, however, should be made only by a medical officer.
c. Immobilization. Splinting of a fracture is of real assistancein preventing further vascular damage near the fracture site, and therebypreventing additional blood loss, both to the exterior and into the damagedmuscle. Immobilization of any portion of the body which has been woundedis a sound principle to observe in order to decrease the chances of recurrenthemorrhage. Should an arm or leg be wounded, it is advisable to instructthe patient not to use that extremity until a location has been reachedwhere complete resuscitation is possible should bleeding recur.
2. Prevention of Additional Tissue Damage
a. Splinting of Fractures. The proper application of a splintis the single most important factor in preventing additional tissue damage.Inadequate splinting, rough evacuation, or inadequate instructions to thepatient as to how to manage himself during the period of evacuation, mayresult in additional tissue damage at the fracture site. The importanceof prompt and adequate splinting cannot be overstressed. We should continuethe motto of "when in doubt, splint them where they lie."
b. Immobilization of Any Wounded Part. Regardless of location,with or without fracture, it is also important to impede further tissuedamage. If a missile should be lodged in a leg and a casualty is allowedto walk, the metallic fragment may well produce additional tissue damageor hemorrhage. Every wounded casualty should be instructed not to movethe injured part for fear of producing additional tissue damage. If thecasualty is disoriented, measures should
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be taken to restrict movement of the wounded part. Should a leg haveextensive muscle damage, a splint will do no harm.
3. Prevention of Additional Contamination and Bacterial Growth
a. An adequate dressing should be placed on the wound as soonas possible. By adequate is meant a dressing that is large enough and thickenough to protect the wound in its entire extent. Often more than one ofthe conventional dressings will be needed.
b. Antibiotic therapy in the field is also desirable under certaincircumstances. In outpost positions, during assaults, or in any tacticalsituation where the casualty cannot reach the aid station until 4 or 5hours or longer after wounding, antibiotic therapy by the aidman in thefield is most desirable. This practice can be carried out with minimaleffort by the use of penicillin syrettes. Antibiotic therapy at this earlytime is not only important in suppressing bacterial growth at the siteof wounding, but also may be of particular value to casualties with abdominalwounds where the peritoneal cavity has become contaminated with fecal matter.Recent work indicates that in such cases bacteria may enter the blood streamand be deleterious to the patient's condition. Dressings, once applied,should not be removed so that wounds are exposed by the "look-seeprocedure" to satisfy the curiosity of the aidman or battalion surgeon.In the absence of continued bleeding or severe pain, removing the dressingto look at the wound accomplishes nothing and increases the chances offurther contamination or hemorrhage. The unofficial policy or habit oflooking at the wound at each level should be abandoned.
c. Burns should be covered with dry sterile dressingsat the earliest possible time. In many instances, because of the extentof injury, this cannot be accomplished before the casualty reaches theaid station. All personnel should be warned not to use Vaselinedressings at this early time. Adequate cleansing of the wound in advanceof the surgical hospital is impossible, and the application of Vaselinedressings in the field usually contributed to bacterial contamination.A Vaseline dressing, however, is preferable to no dressing at all, andshould be used rather than leaving the burn completely exposed during evacuation.The application of a dry sterile dressing in the field does not obligatethe casualty to continued treatment by the closed method. At the surgicalhospital the first aid dressing applied in the field may be removed andthe patient treated by the open method if the surgeon in charge so desires.
4. Replacement of Blood Volume Deficit
The replacement of a deficit in blood volume is second only to the controlof hemorrhage in saving life. With the new plasma ex-
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panders, found to be efficient in combating shock, the aidman has arelatively harmless aud inexpensive agent with which to resuscitate morecompletely the battle casualty at an earlier time. Prior to the adventof the plasma expanders, when pooled plasma was used, many surgeons feltthe risk of hepatitis was probably too great to allow many aidmen to usetheir own discretion in administering plasma therapy on their own. Withthe new expanders the danger of hepatitis has been eliminated.
During the winter months it was found difficult and sometimes impossibleto reconstitute the dried plasma. The loss of this expensive agent throughbreakage of the glass containers sometimes accounted for half of the plasmaallotted to a given battalion. In addition, the glass containers were bulkyfor use on patrol, and the process of reconstituting the dried plasma requiredvaluable time. Plasma expanders are now available in a light plastic containerwhich can be easily carried by the aidmen. Plasma expanders so preparedare light, non-breakable, and can be kept warm under the clothing of anaidman prior to administration. Their contents can be given under pressureby manipulation of the bag or by placing the casualty on the bag to createpressure.
Also important is the more vigorous replacement of the blood volumedeficit in the field of battle prior to evacuation. This is important forthree reasons:
a. First, the patient will be brought out of shock earlier andwhat deleterious effects shock has on the casualty will not operate aslong.
b. Second, the condition of the seriously wounded patient isimproved for his journey to the rear, he is in a less critical condition,and his chances of surviving the litter carry are better. All of the casualtieswith multiple penetrating wounds of the extremities, peripheral vascularwounds and traumatic amputations in whom hemostasis has been establishedwill be greatly benefited by vigorous replacement therapy shortly beforeand during the period of evacuation to the aid station.
The casualty with internal bleeding is another problem. Vigorous replacementtherapy and delay to any extent should be reserved for an echelon whereimmediate surgical intervention is possible should abdominal bleeding continueor recur as the blood pressure rises to normal; in most instances thiswill be the surgical hospital. In the hands of a skilled, well oriented,mature aidman, certain types of casualties would be definitely benefited,however, by more vigorous resuscitation in the forward area before evacuationis begun. By vigorous resuscitation is meant the administration of 500to 1,000 ml. of a plasma expander over a 10-minute period. A "delay"of more than 10 minutes by the aidman is, probably not justified. I avoidthe
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use of the word holding. Any delay in evacuation, however, should bereserved for those patients in whom complete hemostasis has beenestablished. If any degree of hemorrhage continues, it would beunwise to expect an aidman to have the clinical judgment required to makea decision as to whether a patient's evacuation should be delayed for morevigorous resuscitation. If there is any question about continued hemorrhage,intravenous therapy should be started and a speedy evacuation to the aidstation begun.
Whole blood therapy, which was shown to be practical in the aid stationsunder certain circumstances, is probably not practical in advance of theaid station, at least in the hands of the aidman. As a rule, it is usuallyimpractical to give more than 1,000 cc. of an intravenous solution to apatient before he reaches the aid station and plasma expanders can be usedwithout reservation in this amount.
c. Finally, it is important to recognize that certain types ofwounds will eventually be accompanied by clinical shock unless intravenoustherapy is instituted early. Such injuries as traumatic amputations andlarge evulsing wounds will eventually require intravenous therapy. Earlyintravenous therapy in such patients may well prevent clinical shock. Thisis the third reason that casualties will be benefited by intravenous therapybefore and throughout the period of evacuation to the aid station.
5. The Prevention or Correction of Defects in Cardio-respiratoryPhysiology
At the time the battle casualty is initially examined, an effort shouldbe made to determine whether the patient has signs of respiratory difficulty.If the patient has a sucking chest wound, this should be immediately closedwith a Vaseline dressing. Many battalion surgeons instructed their aidmento have the casualty exhale completely an instant before the Vaseline dressingis applied. This will force the major portion of free air out of the thoraciccavity thereby reducing the "dead space" caused by the free airwithin the thorax and will result in a larger vital capacity followingclosure of the chest wound.
The patient should be examined about the face and neck for wounds. Ifthere is partial occlusion of the airway, this may be relieved by manipulatinga shattered larynx or positioning the head in a particular manner. Instructionsto the patient concerning how to hold his head or how to lie on the littermay be lifesaving during the period of evacuation. With bleeding aboutthe nose and mouth, the patient should be instructed to lie in a mannerthat will allow the blood to drain to the exterior and not pass into thethroat and cause aspiration and suffocation. The treatment of a hemothoraxor cardiac
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tamponade is beyond the ability of the aidman and should be reservedfor a medical officer.
6. Relief of Pain
a. Immobilization of the wound is one of the greatest factorsin relieving or preventing pain. This may be accomplished by splintingin the case of suspected or known fractures and by instructions to thepatient as to how he should prevent movement of a wounded part during evacuation.
b. Reassurance and explanation to the patient is often beneficial.Many casualties expect pain, or in the excitement of battle, a fear ofdeath or deformity actually magnifies in their own minds the amount ofpain they are experiencing. A simple explanation that their wounds do notthreaten life or limb and that a small amount of pain can and should betolerated will quite often give gratifying relief to the casualty.
c. Morphine Therapy. Several known facts should be taken intoconsideration by the aidmen before administering morphine. These factsare:
(1) A very small percentage of battle casualties actually have painsevere enough to warrant morphine therapy. This is particularly trueof casualties in shock. Patients in shock may be restless, hyperactive,and appear disoriented. The untrained will interpret this as a responseto pain when the reaction is actually on the basis of cerebral anoxia.As stated, a large portion of the patients who claim to have pain are merelyanxious and can be relieved of this anxiety by adequate psychotherapy foundedon mature judgment of a sincere and well trained aidman or surgeon.
(2) Morphine may be deleterious in certain types of casualties.
(a) Casualties with head wounds should not receive morphine becausemorphine can alter the neurologic response of the casualty and make physicalexamination and evaluation before operation difficult.
(b) Patients with chest wounds and impaired respiratory physiologymay have slowing of respiration and additional difficulty with adequateoxygenation of their blood.
(c) Patients in shock with poor peripheral blood flow may accumulatemorphine in the peripheral tissues and receive an overdose once shock hasbeen combated and adequate tissue profusion is restored.
(3) It has been clearly shown that a dose of one-sixth to one-fourthgrain is as effective in relieving pain as a one-half grain dose and hasless side effects.
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(4) Morphine may cause nausea and vomiting, which can be deleteriousto the patient.
(5) Morphine may increase the hazard of anesthesia.
In view of these facts, a real consideration should be made before morphineis given and any aidman administering morphine should have a thorough understandingof the indications and hazards as well as contraindications to morphinetherapy. Many capable medical officers and civilian consultants feel stronglythat the Medical Service should recall the one-half grain morphine syrettesand replace them with one-fourth grain syrettes.
7. Transportation and Protection from the Elements
It is important for all personnel dealing with the battle casualty toappreciate that exposure to the elements is deleterious to the casualty.It is important that adequate numbers of blankets (four to five) be availablewhen a casualty is to be transported outside of a heated vehicle duringthe winter months. This can be made possible by instructing all membersof a litter team to carry one blanket in addition to their normal loadwhile on patrol or during an assault.
It is also important for all members of the medical team to appreciatethat movement of the casualty is often deleterious, particularly whilea patient is in shock. We should abandon the motto that "the shortestlitter time is the best litter time" and put in its place "thesmoothest litter carrier is the best litter carrier." This is particularlytrue after bleeding is controlled and intravenous therapy has been startedwhen the need for speed is not urgent. It was observed at the Mobile ArmySurgical Hospital that the movement of casualties from the preoperativeward to the x-ray table, not 50 feet away, can cause some patients to goback into severe shock. In two cases this resulted in death. The conceptof preparing a patient for evacuation and then carrying out a smooth litterevacuation must be well understood by all members of the Medical Service.
The evacuation of casualties with head injuries is an individual problem.The ease of movement is more important following head injury than in anyother injury. It was the feeling of some neurosurgeons attached to theMobile Army Surgical Hospitals that a patient with an open head wound,received during the hours of darkness when helicopter evacuation was impossible,had a better chance to survive if he were held at the aid station untildawn to be evacuated by helicopter, rather than have a traumatic evacuation,via ambulance. Once evacuation is started, the patient with a head injuryshould be positioned on his stomach to prevent aspiration should he vomit.
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A smooth period of evacuation is not only important for the "generalcondition" of the patient in shock or with a head injury but, as stated,prevents additional tissue damage in extremities that have fractures. Indealing with problems of evacuation, it is the duty of the battalion surgeonto be ever alert for means of improving the speed and ease of evacuationfrom the fields of battle or in taking resuscitation to the casualty. Thismay be done in a number of ways.
a. By securing additional litter teams from labor pools of indigenouspersonnel.
b. By requesting additional vehicles, such as tanks and armoredcars, to be used to pick up casualties under enemy fire.
c. By requesting that the battalion commander have litter trailsor tramways coustructed where indicated.
The construction of a "forward aid station" on the main lineof resistance has enabled a medical officer, without unnecessary risk,to advance and set up an aid station on the main line of resistance inbunker positions. The bunkers are constructed to accommodate six to eightlitters of patients and are usually within easy access of any portion ofthe battalion sector. In addition to this forward aid station, some battalionsdeveloped the concept of a "mobile aid station." The mobile aidstation group usually consisted of the battalion surgeon or assistant battalionsurgeon and two to three aidmen from the aid station. It was their functionto move forward of the main line of resistance and meet incoming patrolswith casualties or to move laterally to concentrations of casualties whodid not have easy access to the forward aid station. In one sector a3/4-ton truck was converted into a heated, lightproofcompartment and could be dispatched to any area night or day for the receptionand treatment of wounded under adverse weather conditions. This was ofgreat value on winter nights when a message was received that a numberof wounded would arrive at a specific location distant from and inaccessibleto the forward aid station.
Within the aid station more aggressive resuscitation by the medicalofficer should he carried out. To mention but a few examples: An intravenouscutdown may be instituted to insure that intravenous therapy will not beinterrupted in a critically injured casualty; thoracentesis can be carriedout to relieve a mediastinal shift; closure of sucking chest wounds, tracheotomyand intensive blood replacement therapy may be carried out at this level.These procedures will be discussed under the section on resuscitation withinthe aid station and details will not be given at this time.
A brief consideration of the supplies and equipment required to carryout effectively the aims of resuscitation is in order. Only the
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equipment of the aidman and aid station pertinent to the care of thebattle casualty will be considered.
An aidman should have available the following equipment:
1. Aid bag.
2. Tourniquets-either rubber or strap, probably two to three in number.
3. Carlyle pressure dressings with supplemental ace bandage, roller gauzeand adhesive tape.
4. Arm sling.
5. Morphine syrettes (gr. 1/4).
6. Penicillin syrettes.
7. Scissors.
8. Plasma expanders in plastic containers.
Such items as bandaids, merthiolate, hydrogen peroxide, cough syrup,APC's and swabs were found useful but not essential.
Within the aid station certain items are essential for adequate careat this level:
1. Adequate light-flashlights or Coleman lanterns.
2. Tourniquets, hemostats, Carlyle dressings and ace bandages for the controlof hemorrhage.
3. Thomas lantern and wood splints with roller bandage for proper immobilization.
4. Scalpel, hemostats, suture material for performing a venous cutdownor closing a sucking chest wound.
5. Tracheotomy set.
6. Several 100 ml. syringes with No. 15 and No. 18 gauge needles to performthoracentesis.
7. Procaine in sterile ampules for immediate injection.
8. Morphine in syrettes.
9. Penicillin in syrettes.
10. Tetanus toxoid.
11. Plasma expanders in plastic containers for administration under pressureif needed.
12. Sphygmomanometer and stethoscope.
13. Oral airway for unconscious patients.
The physical setup of the aid station will vary greatly depending uponthe tactical situation, time available to construct the aid station, casualtyflow and weather conditions.
In general, one should select a site for constructing an aid stationwhich will give the surgeon adequate room to move as freely as possiblefrom patient to patient. When the casualty load is heavy, it is advantageousto have the aid station divided into areas: a receiving area for sorting,a shock area, a splinting area and an area for patients waiting evacution.
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Another important consideration of the aid station is protection fromthe elements. This is essential for the wounded casualty. When the tacticalsituation is fluid, a house or tent will suffice; when the line becomesstable, a tent which has been "dug in" or a large bunker is satisfactory.As stated, on occasion a closed, heated, 3/4-tontruck may be used as a mobile aid station.
Conclusion
In conclusion, we may say that any significant reduction in battle mortalitywill be made by saving lives now lost within the battalion.
Most of the improvements and improvisions which increase the excellenceof early care will be made possible through an understanding by the battalionsurgeon and his aidmen of the ultimate goal of resuscitation and the rolethey play in achieving this goal. For a team to succeed, each member musthave a clear understanding of the final objective.
Our training must stress the broad scope of resuscitation so that eachmember, both officer and enlisted, will realize that his actions play avital role in the outcome of each casualty.
It is of the utmost importance that all members of the Medical Serviceand all members of the tactical units recognize and appreciate the greatchallenge placed on the aidmen and the battalion surgeon and be willingto support these individuals. No other members of the Medical Service arecalled upon to render unsupervised medical care to such a critically injuredgroup of patients as are the battalion surgeons and aidmen. We must allrecognize the need for the best trained men in the most forward area wherethe greatest test of ability is made and orient our policy and trainingto achieve this end.
