History

Medical Science Publication No. 4, Volume II

THE TRAINING OF TECHNICIANS FOR MEDICAL CARE
WITHIN THE INFANTRY DIVISION*

RUSSELL SCOTT, JR.,M. D.

The extreme importance of the detailed care that a battle casualty shouldreceive in the first few hours after wounding has been discussed. It waspointed out that while the hospital mortality of the wounded soldier hascontinued to fall, there has been no change in the overall battle mortalitysince World War I. Still about 25 percent of those wounded die. The importanceof prompt, intensive, meticulous care and attention to detail in the initialcare of the battle casualty cannot be overemphasized.

First, let us outline briefly the concepts which should be a part ofour policy, training and indoctrination if we are to succeed in loweringthe present battle mortality and give the combat casualty optimal care.I feel there are five general headings.

The first concept is concerned with the initial phase of trainingand indoctrination given to the aidmen.

a. This indoctrination should include the teaching that the aidmanhas a prestige that approaches or equals that of the chaplain, that thereis a respect due to him and that his duty requires of him a loyalty to"cause" which few medical officers are ever in a position toachieve. This ideal should be part of his training.

b. Second is the indoctrination of the "team concept"of resuscitation. Most of the improvements and improvisions which increasethe excellence of early care will be made possible through an understandingby the battalion surgeon and his aidmen of the ultimate goal of resuscitationand by an understanding of the role they play in achieving the goal. Fora team to succeed, and resuscitation is a team job, each member must havea clear understanding of the final objectives. The aidman must be madeto feel that what he does or does not do will influence to a large extentthe outcome of each casualty.

c. Finally, after the trainee has real understanding of his obligationsto the wounded, an understanding of the broad scope of resuscitation, andthe vital role he plays in resuscitation, he must be taught the specificmedical knowledge that he will be required to use

*Presented 26 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.

in the field. This of course includes control of hemorrhage, splinting,intravenous therapy, etc.

The second concept to be included in our policy is continuedtraining after the initial period of indoctrination and teaching. Refreshercourses and on-the-job training must continue at theater headquarters,while a unit is in reserve, or even in actual combat. We must further developthe concept that training is a continuing job.

The third portion of our policy, designed to increase the excellenceof medical care, is to obtain the complete control of the enlisted medicalpersonnel by the Medical Service both for training and subsequent assignment.At the present time the Medical Service is responsible for training, butthen loses many of its best men through improper assignment by other departmentswithin the Army. This defect must be corrected.

The fourth concept to be adopted is that all members of the MedicalService and all members of tactical units recognize and appreciate thegreat challenge placed on the aidman and battalion surgeon and be willingto support these individuals. No other members of the Medical Service arecalled upon to render unsupervised care to such a critically injured groupof patients as are the battalion surgeons and aidmen. We, in the MedicalService, should recognize the need for the best trained men in the mostforward area where the greatest test of ability is made and make everyeffort to see that only the most capable personnel are assigned to thesevital positions.

The fifth concept is concerned with the fact that compromisesin training and care will have to be made at various times. We must, however,be ever alert to recognize these expediencies as compromises and eliminatethese compromises as the tactical situation, terrain, supply conditions,availability of personnel, etc., permit. The recognition and eliminationof compromise is of course dependent upon a sound understanding of thegoal of the Medical Service.

Let us now take up these five points in more detail.

Training

The training required to prepare an aidman should, as stated, includea sound philosophic approach to his responsibility as well as specifictechnical knowledge. The aidman must understand the broad objectives ofresuscitation and know that his role is as vital as the role played bythe battalion surgeon or the surgeon at the Surgical Hospital. He mustnot adopt the idea that once he has performed a few self-imposed dutieshis obligations to the patient and the team have ended. There was a distincttendency for aidmen to fall into this

habit and this was particularly true with splints and bandages. Oftenan aidman would see a fracture, apply an ineffectual splint and feel hehad fulfilled his obligations. The same was true of bandaging. If the aidmanwas corrected for his error, the standard reply was "but I did whatthe book said" or some similar remark. He had done what the book said,that was, apply a splint in cases of fracture, but he did not have thefinal bit of training that makes an excellent aidman. The same is trueof morphine therapy. Few efforts were made to evaluate the degree of painor relieve pain by reassurance or immobilization of the wounded part. Theaidman literally came to the wounded casualty with morphine syrette drawn.

These may seem like small errors but small errors, committed early,will be magnified later in the course of events and can cost lives.

We must not let our aidmen become stereotyped in their care of the battlecasualty. We must develop the concept early in their training that thecare of a battle casualty is individual and requires thought and consideration.

He must understand that at the completion of the basic training coursehis real period of learning has just begun and to become proficient hemust remain alert, objective, and susceptible to suggestions from his battalionsurgeon in combat or during refresher courses while in reserve. The developmentof such a philosophy among our aidmen is advantageous.

The job responsibility of the aidmen can be outlined by simply restatingthe aims of resuscitation. The aidmen should be prepared to:

1. Prevent blood loss by-

a. Tourniquet.
b. Pressure points or pressure dressings.
c. Immobilization.

2. Prevent additional tissue damage by-

a. Splinting of fractures.
b. Immobilization of the wounded part.
c. Proper instructions to the patient.

3. Prevent additional bacterial contamination and bacterial growthby-

a. Proper dressings.
b. Antibiotic therapy.

4. Replace blood volume deficits by intravenous therapy.

5. Prevent and correct defects in cardio-respiratory physiology by-

a. Closing sucking chest wounds.
b. Proper instructions to the patient concerning position of headand body during evacuation.

6. Relieve pain and fear by-

a. Immobilization and instructions.
b. Reassurance.
c. Morphine.

7. Arrange for proper transportation and protection from the elementsby-

a. Evaluating the type and severity of injury.
b. Knowing the modes of evacuation available.
c. Proper instruction to the patient and litter bearers.

In analyzing the job responsibility, certain duties are of greater importancethan others and should receive the greatest portion of attention in a trainingprogram.

Control of Hemorrhage

The control of hemorrhage is probably the most important single jobof the aidman. Specific points concerning the application of pressure dressingand tourniquets and the arresting of hemorrhage through the use of pressurepoints are familiar to most aidmen. However, most aidmen fail to appreciatethe importance of attention to details and follow-up observations. Oncea tourniquet or dressing is applied, the aidmen fail to appreciate thatthe tourniquet may slip or that with a rise in blood pressure bleedingmay recur. These principles of follow-up care must be emphasized.

The fact that the simple movement of an injured extremity may dislodgea clot and produce additional hemorrhage should be impressed on the aidmen.Each aidman should be familiar with the fact that even a small hemorrhage,while a tourniquet is being readjusted, may result in death in the criticallyinjured casualty.

The aidman should understand that if he does not produce complete hemostasisof visible hemorrhage by one method, he should try another and anotheruntil hemorrhage has ceased.

In the control of hemorrhage the aidman should not only be taught whatto do initially but should know how to look for and correct inadequatehemostasis initiated by other aidmen.

In the realm of hemostasis the aidman must be taught to be prompt, thorough,and ever mindful that what he does or does not do may cost a life.

The importance and technic of locating fractures shouldbe impressed. All too often fractures are missed and serious hemorrhageor additional tissue damage results from movement during evacuation. Theprinciple of "when in doubt, splint them where they lie" shouldbe stressed.

The technic of splinting is usually understood by most aidmen.They fail, however, to appreciate the importance of adequate splint-

ing and therefore fail to carry out adequate splinting whileunder the stress of combat. The thought process of the undertrained aidmanseems to be that once a splint is applied, regardless of how ineffectiveit may be, his duties have been fulfilled. He should appreciate that insome cases a poor splint may be worse than no splint at all. The aidmanshould be impressed with the importance of rechecking his splints or anyother aidman's splints as often as the opportunity presents itself. Atevery echelon the sight of a splinted extremity should make the aidmanask himself: "Is the splint immobilizing the extremity and has theblood supply been unharmed?"

Relief of Pain

The role of immobilization in the relief of pain should be stressed.Although this fact is readily accepted by the aidman, he seldom uses ithimself and this information is rarely passed on to the patient or litterbearers.

Reassurance is an extremely helpful method of relieving pain. The aidmanshould be indoctrinated to appreciate how much fear and anxiety a casualtysuffers and how this anxiety will magnify in the patient's own mind theseverity of his pain. The aidman should understand that to be able to giveadequate reassurance, the patient must have confidence in him and thatconfidence is founded on his ability.

If immobilization and reassurance fail, the aidman must then have theability to evaluate the patient to see if contraindications to morphinetherapy exist. The indications and contraindications for morphine therapywere discussed in the section on first aid. During one survey of battalionmedical care in Korea, it was determined by interview that battalion surgeonsfelt that only 60 percent of their aidmen used good judgment in givingmorphine to men who needed it and in refraining from administering it tocasualties with contraindications to morphine therapy. The answer thatonly 60 percent of the aidmen are qualified to give morphine does not necessarilymean that the remaining 40 percent cannot list the indications or contraindications,but the latter figure represents those who do not exercise good judgmentin giving morphine under field conditions. This is the group of aidmenwho approach the casualty with morphine syrette drawn. It was generallyfelt that the figure of 40 percent was being reduced by persistent teachingfrom the battalion surgeon during combat and while in reserve after themen had had combat experience.

Replacement of Blood Volume Deficit

Interviews with aidmen actually serving in combat emphasized the inadequatebackground that most aidmen had concerning wound shock and replacementtherapy. As part of the survey mentioned above,

40 aidmen who were serving in combat were interviewed. A representativeconversation would go as follows:

"How many months have you been an aidman in combat?"
"Five months."
"Do you consider yourself qualified and able to start plasma on yourown?"
In almost every case the answer was "yes."
"Have you ever started plasma or albumin in Korea or in the ZI?"
"No" was the routine answer.
"Why have you not started it?"
"I have seen no casualties that needed it."
"What types of serious wounds have you treated in advance of the aidstation?"
"Men with one or both legs blown off, abdominal wounds, chest wounds,but none of these men needed plasma."
"What type of men do you feel need plasma?"
"Those in shock."

These aidmen had the impression that shock was a condition diagnosedonly by a medical officer with a sphygmomanometer and that it could nothave been determined by them in the field by the nature of the wound, norcould the condition of the patient be determined by simple diagnostic signs.Occasionally an aidman would state that he could have helped some particularcasualty with plasma but would offer as an excuse that he did not carryplasma or that the time lost in starting plasma would do more harm thanthe plasma would do good. This, I believe, is not true.

Seventeen aidmen were questioned at length about their experiences.On initial questioning only 1 of the 17 believed that he had seen a patientin advance of the aid station in whom replacement therapy was indicated.With closer questioning, 9 of the 17 men described one or more seriousinjuries (traumatic amputation, chest or abdominal wounds) which they hadtreated in advance of the aid station. After recalling these patients,the nine aidmen were still under the impression that plasma was not indicatedin casualties with these types of wounds. Further questioning revealedthat of these nine aidmen, six had treated casualties who died before theyreached the aid station; three patients with traumatic amputations, twopatients with multiple fragment wounds of the abdomen, and one with aninjury not described. In only one of these six fatalities did the aidmanin charge believe that plasma was indicated. It was obvious from theseinterviews that only the best trained aidmen recognized even severe woundshock and felt confident to treat it.

The aidman should be taught that shock, in one form or another, canexist without hypotension and that wounds of a certain type and

magnitude sooner or later will be accompanied by shock and that casualtieswith these types of wounds will be benefited by early intravenous therapyeven though clinical shock may not be present at that time. Traumatic amputationsand large evulsing wounds fall in this group. Intravenous therapy in thisgroup of patients with incipient shock would be nothing but helpful. Inour training programs the aidman should be taught specifically which typeof wounds, when encountered in the absence of "clinical shock,"would be benefited by intravenous therapy. This training program couldbe carried out by academic lectures and by the demonstration of the specifictypes of wounds with colored pictures.

In addition to recognizing the types of wounds that will eventuallyproduce shock and that would be benefited by early intravenous therapybefore "clinical shock" developed, the aidman of course mustbe able to recognize clinical shock. Few aidmen, as pointed out above,were able to do this.

This weak point in their training could be overcome in three ways:

1. By an intensive training program on the signs and symptoms of clinicalshock.

2. By establishing an Army policy for each battalion surgeon to notifyeach aidman when he had made an error in not giving a casualty intravenoustherapy. (This policy was carried out by some of the battalion surgeonsin Korea with encouraging results.) This suggestion is of extreme importancebecause in any training program it is impossible to train each aidman aswell as we would desire. It is essential to follow through with supervisionand training in combat.

3. By establishing an Army policy to have, when feasible, all aidmenreplacements remain at the battalion or regimental aid station for a periodof "on-the-spot" indoctrination into the clinical signs of shockand practical experience in intravenous therapy. If a large group of replacementscame at one time and were needed forward, it would be possible to recallthem in groups of two or three for instruction.

It was the belief of some observers in Korea that at least one aidmanon each patrol, on each outpost position and with each assault unit shouldhave thorough training in the technic of intravenous therapy. This wouldmean that approximately two of the five aidmen assigned to a given "linecompany" should be so trained. It would be preferable of course ifthey were all well trained in intravenous therapy, but the training of40 percent (two out of five) of the aidmen in intravenous therapy may pushour training facilities to the limit. It has been suggested that such anaidman could carry a special MOS and rank and that the Table of Organizationof a medical company call for a given number of men with this MOS.

How could such a man be trained? In addition to the basic indoctrinationon intravenous therapy and shock given to all aidmen, such a man shouldhave practical experience in doing venipunctures. The trainee would beginfirst on rubber tubing in his classroom, second on soldiers in receptioncenters, serology laboratories or blood banks, and finally on patientsin Army hospitals needing intravenous infusions. The trainee should receivepractice in doing venipunctures with the tourniquet on and off the armso that he is accustomed to dealing with collapsed veins so often foundin a patient in severe shock.

Undoubtedly such a training program would cause extra work and stressto the regular members of the installations used for training, but theresults obtained would pay worthwhile dividends.

Tremendous numbers of venipunctures are performed each day in countlessnumbers of Army installations throughout the world. There is no reasonwhy this broad classroom cannot be employed for our own benefit.

Following the initial training of our enlisted personnel, how can theMedical Service keep this level of proficiency high? One point that shouldbe appreciated is the need for the best trained man in the most forwardposition where the greatest test of ability is made. There is a real tendencyat all levels to hold back the best trained men and send forward the greenestmen; such a policy is in error.

Additional training of course is essential, and several methods areavailable. One valuable training aid is to hold enlisted personnel at theechelon to the rear of the echelon where they will eventually be assigned.This is valuable for several reasons.

1. It gives the aidman a period of refresher training before enteringcombat.

2. It gives him a sound understanding of what is to be done for thecasualty at the echelon to the rear and shows him how he can better preparea casualty for evacuation and treatment at the rear.

3. It will show him the common mistakes made by the aidmen in the forwardarea and how these mistakes can cost lives.

4. It indoctrinates him into the "team" concept.

5. Finally and most important of all, it shows the aidman that thereis nothing magical about the aid station and that he can actually initiateall the phases of resuscitation except débridement.

If at the time an aidman is assigned to a battalion, he is needed criticallyin the forward area, he may be pulled back at a later date for this periodof indoctrination.

Another valuable period of training is the time during which the unitis in reserve. This is valuable for newly assigned personnel because theyreceive on-the-spot indoctrination by the surgeon they will work

with. It is valuable for the aidman who has served in combat becausemuch of the instruction that he now receives will take on new meaning,and in some cases, will be understood for the first time.

Another important training aid is to notify an aidman by a confidential(personal) note or phone call each time he makes a mistake or shows poorclinical judgment. If done in the right manner, this does not cause illfeeling and will aid materially in raising the efficiency of the medicalteam.

The belief that the Medical Service should secure the complete controlof its enlisted personnel is probably of equal importance to any of theother five concepts. Because of limited time and space, only a brief statementwill be made enumerating some of the discrepancies that can and do takeplace in the assignment of enlisted personnel.

Within the replacement depots the MOS of line personnel is sometimeschanged to that of a medical aidman to fill a given quota. At one periodduring the Korean War (February 1952) a survey revealed that of 40 aidmenserving in combat only 9 had had the required course of training, 23 hadhad 4 weeks of first aid, 8 had had 1 week or less of medical training,and 3 had entered combat without training. This, I believe, is not a reflectionon the Medical Service but on the method of assignment. The Regimental,Division and Army Surgeon had to do the best they could with the personnelthat finally filtered through to them.

By interview other discrepancies became obvious. Enlisted men who hadhad experience in dispensaries as litter jeep drivers or similar non-clinicalexperience were readily given the MOS of an aidman without additional training.Such practices were carried out in replacement depots and not by the MedicalService.

We all appreciate that at times personnel needs do change and inadequatelytrained personnel must be utilized. After the period of improvision, changesshould be made. An effort should then be made to reorganize and get theright man in the right job. It is my opinion that the problem could bebetter handled by the Medical Service than by any other Corps within theArmy.

For completeness, let us state briefly what clinical responsibilityis expected of the enlisted personnel at echelons to the rear of the aidstation. The collecting station indulges in more holding, however, andsome few aidmen will be responsible for the observation of these patients.These additional duties can be adequately learned by on-the-job instructionsfrom the surgeon.

The clearing station will have holding wards, and active nursing careis needed. At this level minor surgery is carried out and enlisted personnelwill be expected to set up for and assist in this surgery. While theseadded duties can be learned by the aidmen through on-the-

job training, the presence of operating room technicians would be preferable.It is the opinion of many, however, that when personnel shortages existwithin the division, the clearing station should receive the least trainedpersonnel as their work will be supervised, and the best trained aidmenshould be sent to the infantry company where their superior skill willbe put to the greatest use.

At the Mobile Army Surgical Hospital the full range of surgical proceduresand technics are carried out, all of course under the closest of supervision.

At this level the technician is expected to catheterize and pass nasogastrictubes, be familiar with oral-gastric, nasopharyngeal and chest suctionequipment. He should be familiar with oxygen equipment. He should be ableto set up for and assist at major surgery. Finally, he must be able todo nursing care on the postoperative ward. Again, all of these duties areunder close supervision and much on-the-job training is possible. Withthe supervision and on-the-job instructions that the technicians in Koreareceived, it was rare that they did not reach a high degree of proficiency.

Conclusion

In this discussion and in the talk on the early care of the battle casualty,we outlined the extreme importance of the role played by the aidman indetermining the ultimate outcome and mortality rate of the battle casualty.

From the statistics presented it appears obvious that the next significantreduction of the present battle mortality must be made by the personnelin the most forward area. The paramount importance of the proper selection,training and assignment of these individuals must be kept foremost in ourplanning. We must continue to recognize the absolute necessity for havingonly the most capable personnel in the forward area where the greatesttest of ability is made and where our next great contribution to the battlecasualty must be made.