Medical Science Publication No. 4, Volume 1
DISCUSSION ON CONSULTANTS AND ORGANIZATIONOF SURGICAL SERVICE*
MAJOR CURTIS P. ARTZ,MC
Various types of organization have been used on surgical services inforward units. Auxiliary surgical teams were utilized in World War II.The organization and working schedule should be made for greatest efficiency.Usually it is wise to divide the surgeons into two groups in order thateach group may be responsible for a 12-hour period-one team for daytimesurgery, the other for night surgery. The teams may shift from week toweek in order that one group may be on duty during the day for one week,then during the night the following week. It is of greatest importancethat each team have as a team captain a more experienced surgeon who isresponsible for all patients admitted during his team's period of duty.
The chief of surgery should supervise and be responsible for all patientsadmitted, regardless of the team that is on call. Since he cannot supervisethe preoperative, operative and postoperative phases of every patient'scare, he should have as deputies two skilled surgeons who have had appreciableexperience in the management of battle casualties. These captains of thesurgical teams may then designate the operator for each particular caseand assist the less experienced men with preoperative preparation, operationand postoperative care. Unless this type of plan is followed, surgeonswith inadequate experience may be forced to handle severe cases that shouldbe cared for only by more mature surgeons. Triage in the preoperative sectionis an important function of the captain of the surgical team. The chiefof surgery and the team captains should visit the evacuation hospital occasionallyto ascertain the results of the initial surgery.
When a new surgeon first arrives at a forward surgical unit, he mustbe carefully indoctrinated in the surgery of the severely wounded. Theorganization of a forward surgical service should be somewhat similar tothe organization of a department of surgery in civilian medical schools.The chief of surgery serves as the professor and his two assistants areresponsible for their two separate services. The surgeons who head theservices have less experienced men on their
*Presented 20 April1954, to the Course on Recent Advances in Medicine and Surgery, Army MedicalService Graduate School, Walter Reed Army Medical Center, Washington, D.C.
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staff for whom they are responsible. Only with an organization of thistype can the training and experience of the surgeons be utilized in themost efficient manner. It is most unfair to the severely wounded soldierto permit a less experienced surgeon to care for him when the judgmentof a more experienced surgeon is available.
During times when casualty loads are heavy, it is imperative that surgeonsbe given adequate time for rest. Usually a 12-hour schedule is optimum.On the other hand, if 8 hours are available for much needed rest, it hasbeen found possible for a surgeon to be on duty during a 16-hour period.Adherence to a rigid schedule is most important, with definite periodsof rest during times of increased activity.
Because of the type of injury and the limited number of surgeons, manyoperative procedures are performed without an assisting surgeon. Surgeonssoon become accustomed to operating with one or two capable technicians.They must select the patients on whom they require another surgeon as firstassistant. This is usually necessary in most abdominal wounds and chestwounds. Minor débridements may be done with the aid of one scrubtechnician. However, when a large amount of muscle is damaged and thereis profuse bleeding, it is important that a capable assistant be availablein order that the operation can be conducted with maximum hemostasis inthe shortest possible time. All too frequently, inadequate assistance leadsto unwarranted blood loss.
When multiple areas are involved, it is wise to use two surgical teamson the same patient. One team may perform an upper extremity amputationas another team débrides or amputates a lower extremity. The utilizationof two teams decreases the time under anesthesia and proves most beneficialto the patient.
Since initial surgery in the severely wounded is so important, it wouldseem wise that the chief of surgery in a forward hospital be a more experiencedRegular Army surgeon trained in the principles of resuscitation and combatsurgery. So frequently the more mature, higher-ranking surgeons of theArmy Medical Corps are assigned to rear hospitals. Because most of thesurgeons in a forward hospital are obtained from civilian life and do nothave extensive experience in the surgery of trauma, it would seem to bea good policy to have as a leader one of the more mature Army surgeonswith previous combat experience. Only by utilizing surgeons with widerknowledge of initial care of the severely wounded man can we expect todecrease the morbitity and mortality of the injured mail. Improved medicalcare will come with increased emphasis on teaching the principles of forwardsurgery that are now known. The greatest need in the forward hospitalsis dissemination of existing knowledge about resuscitation and combat surgery.One of the real responsibilities of the Regular
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Army surgeon is the care of the soldier wounded in combat. All surgeonsin the Regular Army should be thoroughly trained in the management of theproblems of trauma. Their subspecialty should be forward surgery. Physiciansin civilian life do not have the opportunity to obtain knowledge and experiencein the management of severely wounded patients. The problems associatedwith severe war injuries are peculiar to the Army Medical Corps and itssurgeons should maintain a particular interest in this type of management.Young career surgeons in the Regular Army should always be given an opportunityto gain experience in forward surgical hospitals.
Utilization of Consultants
From time to time it is important that experienced, mature leaders inthe field of surgery visit forward surgical installations as consultants.Their valuable advice is most stimulating to younger men who are managingbattle casualties. The teaching done by these experts is invaluable. Toofrequently, however, the consultant visits the rear hospital, the evacuationhospital and several forward hospitals in a short period of time. Thispermits him to spend only 1 or 2 days at each installation. His knowledgecould be better utilized if he actually performed some surgery and, byfirst-hand experience, became extremely familiar with the problems of theparticular institution he visited. A consultant should probably visit onlythree hospitals; and he might spend 2 weeks at each installation. Duringhis visit he should care for some of the patients, assist surgeons, makeregular ward rounds and share his knowledge with less experienced surgeons.The system used by many medical schools of having so-called "visitingprofessors" for a period of 10 days or 2 weeks is a good one. Sucha program could be utilized with great efficiency in a theater of combat."Visiting professors" in anesthesiology and surgery would leadto a closer bond between military and civilian surgery. As our nation becomesmore frequently involved in conflict, it appears that our professors ofsurgery must stress the principles and concepts of forward surgical care.
