Medical Science Publication No. 4, Volume 1
EMERGENCY TREATMENT AND RESUSCITATION
AT THE BATTALION LEVEL*
MAJOR MEREDITH MALLORY,JR., MC
1. Introduction
In discussing emergency treatment and resuscitation practiced at battalionlevel, a breakdown of casualties into three general groups is helpful indefining our problem. These are: Group I-those killed outright or severelywounded past any help, Group II-severely wounded requiring continuous medicalsupport and supervision, and Group III-those requiring minimal attentionuntil they undergo definitive surgery. Group I is fairly sharply definedand is important medically only in that hopeless cases during heavy casualtyloads must not be allowed to distract medical attention from the more fortunatewho can be helped by it. The example given later illustrates how this mighthappen. The medical effort expended on Group II is justified primarilyby the moral obligation to prevent loss of life. The salvage value of thesecasualties is limited for direct military purposes, but of considerableimportance to the gross national output; especially when we contemplatethe heavy financial obligation assumed by the Government in the event ofmortality.
Group III represents the source of greatest return for medical manhourexpended. It is in this category that the human machine is repaired andthe man returned to the duty for which he has been so expensively prepared.Although this is obvious to all and is implicit in the motto of the MedicalService, we sometimes partially lose sight of its immediate and directconsequence. This is that our medical capacity must satisfy the requirementsof Group III category before any other with the exception of basic lifesavingmeasures necessary in Group II. This distinction must constantly remainin front of us if we are to tackle tomorrow's medical problem with theeconomy mandatory for all on the logistical team.
Groups II and III will tend to merge; indeed it is the primary aim ofour forward care to preserve those in Group II until surgery is available(or else, by proper measures, such as tourniquet and splints,
*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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bring them out of Group II severity to the Group III level. Once a casualtyis determined to be in the Group III class he then is promptly passed onto rear medical installations with but minimum treatment in the aid station.
The numerical proportions involved in these groups vary from war towar and battle to battle; however, an order-of-magnitude for the Koreanwar can be given. Roughly, out of 100 casualties, 25 will fall into GroupI, 8 to 10 in Group II, and the remainder in Group III, with a number ofthe latter being borderline Group II. It is Group II, about 10 percentof all casualties, which composes almost the entire demand for forwardmedical care. Moreover, a brief look at casualty statistics by branch ofservice shows that the infantry is the major contributor, which means thatforward medical care is essentially a matter of infantry support.
We will now go to a brief description of the circumstances in whichforward medical care operates and the technics employed.
2. Physical Factors of Battle
Misunderstandings arise as to what should or should not be done in theinfantry battalion aid station because of lack of consideration for thetactics involved. Table 1 portrays a concept of the variables which affectorganized battle and its logistical support. Each combination of thesevariables forms a different circumstance occasioning great variation inthe quality and quantity of medical care permitted in the aid station.It should be noted that the farther forward in battle the greater the impactof these variables on medical or other operations. To illustrate, the Koreanwar was fought under all three types of maneuver, in mountainous terrain,in generally temperate to cold weather, without analyzing each possiblecombination. It follows from the above that what should be done in theaid station cannot be stated inflexibly but will consist of doing a maximumnumber of desirable procedures according to limitations of a given situation.
Table 1.-Variables Affecting Logistical Supportof Combat
Maneuver | Medium | Climate |
Forward operations | Jungle | Very cold. |
Retrograde operation | Desert | Cold. |
Static operations | Mountain | Temperate |
| Plains | Hot. (Dry. Wet) Hot. (Dry. Wet) |
| Airborne | |
| River crossing | ---------- |
| Amphibious | ---------- |
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Types of procedures recommended for aid station practice appear in thefollowing discussion.
3. Technics
a. Shock. Shock, actual or potential, in the aid station meansonly one thing, the administration of fluids. Blood is the solution ofchoice with the solutions of albumin-size molecules next. It is, I believe,universally accepted that plasma infected with hepatitis virus is definitelycontraindicated when the synthetics are available. The administration offluids is based on rapid clinical evaluation alone as neither time norequipment will permit more detailed observation. For purpose of resuscitationclinical judgment is sufficiently accurate. The combat injured are usuallydehydrated so that glucose and/or saline can almost always be given advantageouslyto those requiring intravenous therapy. Venesection and cannulation shouldbe a matter of routine practice for all patients for whom continuousfluids in large amount will be required. The value of these proceduresin easing the handling of such patients in the rear surgical installationsis difficult to exaggerate. Any intravenous therapy, once started,should not be intentionally discontinued until the patient reaches hospitalcare. Medical officers, fresh to combat, are usually unaware of the drasticrequirement for blood and fluids occurring in severe trauma. Perhaps thisis due to the relative rarity of trauma in combat degree in civil lifeand the fact that experience in handling it is simply not available.
b. Splints, Bandages, and Tourniquets. These technics, properlyapplied, do most to elevate a patient's category from Group II to GroupIII.
(1) Splints. The factor of traction has been overemphasized inhandling battle or ordnance-caused fractures, since, as severity increases,generally the traction requirement decreases. Rigid immobilization andprotection of the injured limb is the primary consideration. Our presentsplints and technics are not entirely satisfactory in this respect. Forinstance, I have seen a considerable amount of unnecessary and harmfulmanipulation due to our inflexible, dedicated, and withal, rarely expert,use of the Thomas splint. The Navy plywood splint was very popular withbattalion surgeons in my experience and a splint of this type as a supplementto the Thomas splint seems to be required.
(2) Bandages. Although bandaging is important, our approach tothis technic has been and remains unrealistic. Bandages do three things:(a) provide hemostasis, (b) prevent dis-
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turbance of the wound by foreign objects, and (c) prevent bacterialcontamination. Of these, only hemostasis is important in battle. A bandagethat secures hemostasis provides incidentally sufficient protection fromforeign material and bacteria. In respect to bacteria, all battle woundsare grossly contaminated and remain so until débridement. Too mucheffort is wasted in procurement of and training in a complicated arrayof bandages and bandaging technics.
(3) Tourniquets. Application of adequate and timely tourniquetsin battle is a vital essential at battalion level. Patients, whose woundsshould place them in Group III often become Group II, and all too frequentlyGroup I members through lack of an effective tourniquet. Present methodsare time-consuming, inaccurate as to pressure exerted and often requireexcessive manipulation of the injured part (especially when applied bya single person). Self-application is virtually impossible. In the caseof lower extremity wounds, which give rise to the most severe hemorrhagecontrollable by tourniquet, it has been my observation that too few doctors,much less their lay assistants, have a concept of the constricting pressurerequired about the thigh to abolish the flow of blood. Since the amountof blood lost after injury is probably related to time in an exponentialfashion, most of it occurring the first few minutes, the tourniquet tobe effective must be applied before the patient reaches the aid station.This requires that it be done in or very near the battle area. This furtherdemands that the method be very simple and rapid and applicable by anyone-characteristicsnot possessed by the present means. Although we can improve applicationof tourniquets by increasing the training of the soldier, medical or other,this has two very undesirable features:
(a) It is only a partial solution of the deficiencies noted above.
(b) It will encroach on other more essential combat training. We need,critically, a better tourniquet device.
c. Points in Handling Specific Wound Types.
(1) Chest. Penetrating wounds of the chest (sucking) must besealed airtight by the first medical officer to treat the patient. Anymeans, even to application of bare adhesive strips over the wound, arepermissible as long as a good seal is obtained. Rubber sheeting over thewound sealed with Vaseline is another method. Simple gauze bandaging ismost often not effective. A few deep sutures through the wounds to approximatewound edges may be necessary and can be done in the aid station. Althoughbut infrequently necessary, the medi-
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cal officer in any forward medical installation should be prepared toperform chest aspiration using a large needle, three-way stop-cock andlarge syringe. An evacuated intravenous bottle may also be used to producesuction (evacuated by boiling a small amount of water in it and sealingwhile filled with steam). These patients, often short of breath becauseof the reduced respiratory volume, need encouragement probably more thanany other casualty. Their symptoms frequently exceed the immediate criticalityof their condition.
(2) Abdomen. Those with penetrating abdominal wounds requiremaximum rapidity in evacuation to definitive surgical attention. They shouldbe retained in forward installations only long enough to support adequatelythe circulation for transport to the rear. Mortality on these patientsvaries directly with time-lag between wounding and surgery and is virtually100 percent at 24 hours.
(3) Central Nervous System Injuries. Patients with these injuriesrequire immediate evacuation to neurosurgical care. Spinal cord injuries,in general, require the most immediate surgery of any injury, if salvageof cord function is to be a possibility. The recommendations as to positionof patients with spine injuries have always appeared equivocal and contradictory.For injuries caused by ordnance probably the best solution is to minimizemovement and evacuate the patients in the position they arrive in the aidstation, prone or supine.
(4) Extremity Injuries. Hemostasis should be secured by bandageand/or tourniquet. Fractures should be adequately splinted. In combinedextremity and trunk injury it is imperative that hemostasis and splintingof the extremity wound be done properly so that the additive effect ofthe multiple trauma will be combatted and prevented from delaying earlysurgery. Extremity injuries, by themselves, should never occasion mortalityexcept in the most unusual circumstance if adequate tourniquet proceduresare available.
d. Sedation. Patients with fractures and uncomplicatedsoft tissue injury may have morphine until adequate bandaging and splintingare applied. It is contraindicated in chest, head and belly wounds forobvious physiologic and diagnostic reasons. The single dose should notexceed 0.25 grain (one-half syrette) and each dose must be accuratelyand clearly noted on the Emergency Medical Tag. Pain is very infrequentlya significant factor in injuries seen at forward levels. In extreme coldthe administration of morphine should be even further curtailed.
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e. Antibiotics. The requirement for early administrationof antibiotics is recognized by all and needs no further discussion here.
f. Triage. Selection of patients for type of evacuation(helicopter or ambulance) is essential, especially when movement and transportationare limited. The following wound types are listed in order of priorityfor rapidity of evacuation to surgical care.
Priorities for Evacuation
(1) Spinal cord.
(2) Uncontrollable severe hemorrhage (after blood and fluids have beenstarted).
(3) Abdomen.
(4) Chest.
(5) Head.
(6) Extremity.
Time of wounding is also an important consideration in triage. A freshfracture occurring just outside the aid station door does not have thenecessity for immediate treatment that a 24-hour-old moderately severesoft tissue wound of the thigh does.
4. Management
In applying the technics above, in battle circumstances, to the threecasualty groups specified, it is clear that efficiency will not be obtainedwithout premeditation and organization. I would like, now, to mention mattersof arrangement, equipment, procedures and training.
a. Arrangements. The aid station must be arranged to handlea large volume of wounded and not just to handle sick call or occasionalpatients. This arrangement should be as elaborate as is possible to devisein a given situation. It should provide for orderly flow and segregationof casualties in the station. Each person should know precisely his placeand job in the casualty stream. Litter supports to place the litter attable height must be procured and the medical equipment laid out nearbyto be readily available. A system must be devised with the battalion S-1and S-4 to handle the stragglers, hangers-on and materiel that swiftlyaccumulate about the aid station in heavy fighting. Neglect of this itemof arrangement can cut the effectiveness of an aid station by many times.
b. Equipment. The equipment presently organic to the aid stationcontained in Dispensary Medical Set, Field; Medical Field Set, Combat;and Medical Field Set, Supplemental Supply; is, in general, appropriate.Instruments to accomplish vein cut-downs, tracheotomies and chest aspirationshould be immediately available. These can be made up in formal sets packagedsterilized or can be merely a collection of instruments requisitioned asneeded in addition to that in the field sets. Refrigerators and electricalgenerators are very
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desirable but are logistical problems. Iceboxes may have to be improvisedfor the storage of blood. In general, the more frequently the aid stationmoves, the less equipment it will carry. The best solution is to have aminimum of organic equipment and augment it whenever additional equipmentis indicated. It is the province of the Division and Army Surgeon to seethat all necessary and appropriate technics and materiel are employed inthe battalion aid station.
c. Procedure. The basic principle of procedure is that the medicalofficer must not involve himself in anything that he can train someoneelse to handle. He must occupy himself with the severely injured patients,leaving the moderately injured to his assistants. As indicated above, heshould be prepared to institute any emergency measure to save life, suchmeasures to include thoracentesis, tracheotomy, venesection, and placementof deep sutures to secure hemostasis. In one case we moved an anestheticmachine from clearing station to battalion aid to intubate a head patientin respiratory arrest, the battalion surgeon and others administering artificialrespiration for 1 to 2 hours while waiting for its arrival. The patientwas intubated and moved 30 miles by ambulance to a MASH with anesthetistattending and survived the journey, although he eventually succumbed fromhis hopeless wound. It is difficult to be too radical in an aid station.Errors arose frequently from "too little" and never from "toomuch." We do not teach the handling of acute severe trauma well inour medical institutions, judging from results observed in Korea. Happilya short period of on-the-job training usually sufficed. Improved and moreuniform treatment would result, however, if this problem were attackedearlier in our medical education.
d. Training. It goes without saying that training must be constantand unremitting from a short course for the doctor in division before hegoes forward to become a battalion surgeon to the training he himself administersto his subordinates to enable himself to be free of the multitude of detailsof bandaging, splinting and sorting of the uncomplicated patients. Thepersonnel replacement stream for medical officers should be liberal enoughto allow for a short period of formal and on-the-job training in division.This time can be secured by cutting Zone of Interior training where muchis taught that has limited value. Personnel assigned to division will havetheir life's total combat experience in the succeeding few months thatthey serve with that division. They need only be trained for this narrowrestricted experience and a large part of it can be given in the divisionwhere specific points relative to local problems of medical support canbest be emphasized.
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5. Personnel
a. 0fficer. Two officers are required in each infantry aid station,either two MC's as with the Marines, or one MC and one MSC as in the Armyunits. In my opinion, the MC-MSC (or possibly Warrant) combination is best,provided this is utilized to make available battlefield commissions forqualified enlisted personnel from the aid platoons.
b. Enlisted. The enlisted medics (MOS 3666) generally availablein Korea were of excellent caliber. In fact, one wonders if we do not investtoo much capability in unskilled tasks such as litter bearing. The oneemolument here, of course, is that litter bearers are then available toact as aidmen. However, by accepting lower-quality personnel it might befeasible from the standpoint of manpower economy to augment our presentlitter bearer units. Though the proportion of aidmen required may be opento argument it is certain that these people must be trainable to act withinitiative and effectiveness by themselves in administering first aid.They must be able to bandage, splint, apply tourniquets and give fluidsintravenously without supervision and assist in all the many other medicalresponsibilities of the aid station. Their present training is satisfactoryexcept for a tendency to include too many technical nonessentials. Continuedon-the-job training by interested medical officers should further technicaleducation and can create some extraordinarily effective medical assistantsout of many of these soldiers.
6. Conclusion
Our present theory and practice of medicine in the aid station is wellconceived and effective in general application. We might seek improvementin detail as follows:
a. Devote specific attention to securing a better method of applyingtourniquets.
b. Give specific instruction in medical school in battlefieldand disaster emergency therapy and resuscitation.
c. Re-evaluate certain of our bandaging and splinting doctrines.
d. Reapportion training time of the medical officer so that amaximum occurs in the combat zone where his medical practice will be located.
e. Examine the feasibility of utilizing lower-quality personnelfor the menial, non-technical jobs in medical soldiering in combat.
