Medical Science Publication No. 4, Volume 1
DISCUSSION OF PAPERS ON PREOPERATIVE TREATMENTOF BATTLE CASUALTIES*
LIEUTENANT COLONEL CARLW. HUGHES, MC
About all that I can add to what Colonel Lindsey has had to say aboutevacuation is further praise for the helicopter pilots. Actually, somenights when it was so dark that the bats wouldn't fly, one would hear aBell helicopter coming in the distance. When they flew on such nights weknew that they were bringing in very severely injured patients. The helicoptersoften had to land by use of jeep, truck, and ambulance lights.
I want to emphasize further the thought brought out by Colonel Lindseyregarding the use of surgeons in the forward aid stations and clearingstations. I had occasion to see a number of trained surgeons come in tothe theater each expecting to be given a hospital assignment where he couldutilize his training by doing operative surgery. It seemed extremely unfairto the surgeon to send him up forward to work in an aid station or clearingcompany. Early, I felt it was a waste of a trained surgeon. Now, I am convincedthat the use of a trained surgeon in the forward station was far more beneficialto the patient than many of us realized.
I have little to say on triage except that I would like to clearly emphasizemy feeling for the need of a trained, experienced person in each hospitalto supervise triage, to follow through surgery, and be available for consultationpostoperatively. Such a man need not necessarily perform surgery but hispresence would be extremely important.
Dr. Howard mentioned the priority of a bowel and popliteal artery injurysaying, of course, that the bowel injury takes priority for surgery. Ireadily agree with Dr. Howard, but I only want to make the point that whenone does have such injuries it is quite often possible to utilize two surgicalteams and do both operations at once.
Major Artz made it clear, and I readily agree, that we cannot separatesurgery from resuscitation since surgery is a part of resuscitation. Iwould, however, question the necessity of passing a plastic catheter throughthe femoral vein into the vena cava in order to give
*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.
115
intravenous fluids. I realize that such a catheter in the femoral veinmust be placed in for a short distance in order to keep it from being accidentallypulled out. If placed into the vena cava I wonder about the possibilitiesof thrombosis and embolism. Normally, I feel that one should be able todo a percutaneous puncture of the femoral vein or the femoral artery andavoid most cut-down procedures. We were fairly successful in using thefemoral vein and femoral artery for transfusions and failed to get intoany difficulties, except that when the needle or the patient moved abouttoo much, there was apt to be a hematoma at the needle puncture site.
As far as intra-arterial transfusion is concerned, I would like to mentionthat very good use can be made of the exposed artery which is often seendangling from the extremity of injured patients, particularly those withtraumatic amputations. The artery, being constructed as it is of strongertissue than the muscle, is often dangling and visible and can be readilyrecognized and utilized by inserting a Webster cannula or a size 13 or15 needle directly into the artery to replace the blood by way of the arteryfrom which it was lost. We used this method a number of times as well asintra-arterial transfusion into the femoral artery. We did feel that usingthe exposed artery was an excellent method of transfusing. I feel thatmost of us in the theater tended to underestimate the need for blood inmany patients even though some received 40 to 50 pints of blood. Many ofthem still had need for blood when taken to surgery.
Major Artz mentioned the use of the urinary output as an indicationof the condition of the patient. We also used this method of evaluationbut found it was more indicative of the condition of the patient with abdominalinjury than those with extremity wounds.
We made it a habit to give intravenous glucose whether blood was goingto be required or not. If blood was started and glucose could be startedconcurrently, the patients received both and if necessary blood was alsogiven in more than one port. I raise the question as to how valuable intravenousglucose was to these patients who had been in shock, whether or not itplayed any part in decreasing the number of patients developing renal shutdown.
Mention has not been made here of the use of norepinephrine. I thinkmost of us realize that it does not have much, if any, place in resuscitation.However, we have used it in some cases preoperatively and found in someinstances that it did improve the blood pressure. Some feel that when apatient is in profound shock that the vasoconstrictor mechanism has undergoneits maximum vasoconstriction and the use of norepinephrine is then ineffective.We did find norepinephrine of value postoperatively. I am speaking of thepostoperative period as a part of resuscitation. We have used norepine-
116
phrine during that period until the patient became refractive to itand died in spite of additional blood and plasma expanders.
We found some patients who, during preoperative resuscitation, apparentlyreached their point of maximum benefit and passed that point of maximumbenefit before we realized it and became worse instead of better. Thisseemed to be especially true of patients with abdominal injuries with bowelwounds who were no doubt developing peritonitis or had well advanced peritonitisat that time.
