History

Medical Science Publication No. 4, Volume II

TRAINING OF MEDICAL OFFICERS*

COLONEL JOHN M. SALYER,MC

There are many involved factors and conditions, some considered favorableand others unfavorable, operating presently as well as during World WarII and the Korean War, that affect and influence the overall accomplishmentof the Armed Forces Medical Missions. During and immediately followingthe conduct of overseas combat endeavors, all Arms and Services of theNational Military Establishment have their full quota of problems fallingunder the categories of personnel procurement, training and job accomplishment.The Medical Services have had and will continue to experience for sometime in the unpredictable future an overabundance of difficulties relativeto medical officer procurement and training in preparation for specificoverseas and Zone of Interior duty coverages.

In view of such almost insurmountable obstacles in the past, it is ratheramazing that the medical and surgical accomplishments during the KoreanWar were so highly laudable and at times approached the miraculous. However,in only about 85 percent of traumatic cases, aside from most medical problems,were the early and overall final results as ideal as we in the medicalprofession could desire or anticipate. This generalization is offered withdue recognition that the fatality rate of wounded men reaching medicalinstallations during the Korean War was only 56 percent of that statisticallyestablished during World War II; this percentage is based upon the factthat 4.5 percent of such casualties failed to survive during the last warand this mortality percentage was decreased to 2.5 percent during recentmilitary operations in the Far East. It is our desire that this percentageof survivors among our troops and those of our Allies, i. e., 97.5 percent,will be increased during any future "peripheral war" not conductedon an atomic level, as well as in any group of unfortunates that sufferthe severe injuries that all too frequently result from the bizarre, mysterious,violent and destructive forces of nature.

During the past decade Churchill [1, 2] and others have madeit clear in their writing and lectures on the subject of traumatism that

*Presented 26 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Medical Center, Washington, D. C.

such civil injuries are not unlike typically destructive and highlycontaminated battle wounds and as such should be similarly managed. Theseinitial comments and some of the subsequent remarks do not appear to bemore than remotely related to my subject dealing with problems relativeto the training of young medical officers, but seem somewhat appropriatein a dissertation on this broad and somewhat controversial subject. Theseviews and comments are entirely those of the author and as such are influencedby surgical concepts and the surgical problems encountered during and immediatelyfollowing the last 14 months of the Korean War. Some viewpoints would seemapplicable and/or related to other professional specialty problems andcircumstances encountered during any overseas military campaign. Some ofthe unfavorable factors that have been rather obvious in the past and mayaffect the efficient operation and conduct of the Medical Services areas follows:

(1) The size of the Regular Army Medical Corps has not been sufficientlylarge to provide medical care throughout a combat operation such as wehave just experienced in the Far East. Roughly two-thirds of the numberof medical officers required have of necessity been provided by the implementationof the doctor draft law-professionally speaking, this is a workable butnot an ideal solution. It is rather obvious that a physician called intothe Service against his will may not have the necessary enthusiasm to doa superb job that a career medical officer should conceivably have.

No actual complaint is offered with reference to the care of the sickand wounded; as a general rule, doctors of medicine do a fine professionaljob and will work around the clock when fellow men are in urgent need oftheir professional assistance; fortunately this professional characteristicis just as true in the Service as it is evident in civil life. However,of great importance is the requirement for a larger Regular Medical Corpsimbued with a career desire and the necessary distribution of highly trainedspecialists assigned in staff and professional positions, as well as administratorswho in their own right should be categorized specialists. We have a sizablenumber of such medical officers but too many are presently departing for"greener pastures." Such a tendency, the Services, as well asthe entire medical profession and our nation, can ill afford. These problemsshould receive the highest priority of consideration in our Federal legislativebranches-Congress alone has the authority to make the necessary adjustmentsto keep the various Medical Services sufficiently attractive to keep themsupplied with a highly trained and competent professional cadre of careerpersonnel. Such a situation, if ever attained, would be for the best interestof all components of the medical profession.

(2) The doctor draft system as presently in operation, i. e., periodically,does not supply the Services with the proper ratio of professional specialists.It is understandable, for example, that in one group of inducted physiciansthere may be far too many obstetricians and few, if any, anesthesiologists,otolaryngologists, etc. In this period of specialization it is most likelythat there will always be a shortage of MOS 3100's or general duty medicalofficers-indeed they are, during a war, never available in sufficient numbers.The vast majority of these doctors who are the most adaptable for servicewith forward combat units will of necessity continue to be supplied fromgroups of recent medical graduates who have had little, if any, trainingbeyond internship. Numerically and professionally speaking, a great needfor such officers to meet specific military situations in the future isa distinct possibility.

As stated above, it is quite understandable that the supply of thisgroup will continue to be short and that doctors rather far advanced inspecialized training may have to be utilized as general medical officerson a rotation basis from time to time; this mode of professional coveragehad to be adopted periodically during the Korean War. This system, obviously,is not conducive to the best in esprit and morale. Only seldom do we seea medical officer, whether he be a regular or a reserve, who is completelywilling to relinquish his specialty temporarily as well as some of hisknowledge and skill and serve with troops whether they be on a trainingor combat mission; however, it has been a distinct surprise to many thatsurgeons, urologists, obstetricians, only to mention a few specialists,have done such outstanding jobs at division level and forward to hospitalinstallations during the Korean conflict.

Regarding Training Prior to Overseas Assignment

It is proper and logical that medical officers should have a short militarymedical indoctrination course such as is now offered at the Medical FieldService School. We will all admit that a medical officer should know howto properly don and wear his military uniform and how to properly executethe military salute which, of course, is always executed in the positionof attention and never with a cigarette or pipe in the mouth; such propermilitary conduct creates better respect and relations with military associates-bothenlisted and officer personnel-and will never detract from the prestigeof the Medical Corps. Some understanding of military discipline, commandprinciples, medical supply methods and field sanitation is necessary. Itmay be noteworthy to relate that some knowledge of the conduct of propermilitary discipline and authority will prevent suffering and may save lives-referenceis made to a military force located in a cold

climate where cold injuries may be either negligible or numerous. Inthe same vein, death rates will be high and unwarranted discomfort greatamong prisoners of war if some should ever be so unfortunate as to be takeninto captivity by a ruthless enemy and have no remaining semblance of militarydiscipline promulgated by officers and noncommissioned officers among thegroups of captured personnel.

Physical Training

There is little need for any prolonged period of physical training formedical officers prior to overseas or Zone of Interior assignments; thispoint is made in the interest of professional personnel utilization economy.To date no means or methods are employed to maintain perfect physical fitnessof officers while en route to distant overseas stations-thus most medicalofficers arrive without any subjective or objective evidence of prior indulgencein physical culture routines. I desire to leave this thought with someof you who may at some future date have military assignments and dutiesthat may in some way either directly or indirectly control some phase ofofficer training and/or assignments. This simple concept regarding theutilization of physicians, who indeed are scarce in the true sense of theword, seems mandatory and their early and appropriate assignment to professionalduty without unnecessary delay is of the essence. This fact will be muchmore evident if other peripheral wars develop, not to mention the professionalpersonnel shortages that will be critical if World War III should occur.

Noteworthy Surgical Problems Related to Professional Training

Only an occasional young medical officer, at the time of overseas assignment,is even remotely well informed as to the proper early care of war wounds.This generalization applies to surgeons who, so to speak, have had excellent"stateside" surgical training in our fine military hospitalsas well as in the largest and best university hospitals. Many of our outstandingsurgeons, both civil and military, are cognizant of this grave teachingdeficiency in our graduate training program and they, along with varioussurgical societies and organizations, are making plans to improve thisdeficiency in our postgraduate surgical training programs.

Surgeons who had had average to excellent surgical training by civilianstandards, but with only meager knowledge as to adequate care of war wounds,over and apart from the surgical concepts and principles alluded to bythe Theater and Army Surgical Consultants during indoctrination lecturesafter reporting for assignments, were in most instances able to serve ashort preceptorship with surgeons

who had been similarly taught or had learned the unfortunate way-i.e., that inadequate surgical care such as inept débridement of woundsor the improper application of a plaster cast can cost the patient hislimb or perhaps his life. A surgeon assigned to an Army Surgical Hospitalwould often progress from a very inadequate wound surgeon to one that couldperform excellent surgical work independently within a period of 3 to 4weeks. Such was more often the rule when the surgeons had had excellentprior surgical training and were receptive to realistic appraisal of theearly and late results of their surgical work by themselves, their fellowmedical officers and by surgical consultants who were in almost daily contactwith hospitals that were most active in the care of the battle wounded.

Early Indoctrination as to Surgical Concepts and Policies

Reporting surgeons were given detailed information as to the policieson the early and late care of battle wounds and the natural and/or untowardsequelae thereof were stressed in informal lectures by the Theater andArmy Surgical Consultants as well as by periodic professional informationin staff publications from major headquarters. Chiefs of Services in thevarious hospitals, as well as division and corps surgeons, also contributedto this professional policy indoctrination program. Dissemination of suchknowledge related to patient care was especially directed to those officersbeing assigned to forward medical units in divisions as well as to surgicalhospitals, "so-called mobile," and to evacuation hospitals. Firstaid measures, triage, selective evacuation and distribution of the woundedand the initial surgical care following or concurrent with resuscitationmeasures in priority I and priority II patients were stressed repeatedlyin great detail. Only some of the more important instructional points relativeto the overall treatment of battle wounds will be discussed briefly.

Early Wound Care

The principles and concepts regarding wound débridementand the non-suture method of handling such wounds, as a generalpolicy with limited exceptions as mentioned below, were stressed in considerabledetail. This all-important surgical measure, which theoretically impliesthe complete excision of devitalized tissue and foreign matter as completelyas clinical surgical judgment will allow, was stressed repeatedly to allmedical officers who were to be given assignments in medical installationsproviding early wound care. The important aspects of wound management werestressed to all surgeons at the time they arrived in Japan, again in Korea,and often in the operating rooms along with technical demonstrations. Itwas most encouraging

to see surgeons who had had creditable former surgical training becomeadept wound surgeons within a very few weeks; however, an occasional surgeonseemed never to grasp the full significance and appreciation of the necessityof an adequate débridement and such officers were ultimately transferredto medical installations where initial wound surgery was seldom done. Perhapsit is noteworthy to relate that recommendations were made to the effectthat the following types of wounds, and only these, were to be consideredeligible for primary closure at the time of initial adequate débridement:

1. Wounds of the face, neck and mucous membranes lining naso-oro-pharyngealspaces.

2. Simple lacerations of the scalp.

3. Craniocerebral wounds.

4. Conversion of sucking wounds of the chest by suture of intercostalfascia and muscle bundles.

5. Partial closure of abdominal wounds to prevent evisceration and

6. Closure of synovial membrane or joint capsules.

7. For the past 2 years primary closure of hand wounds was definitelynot recommended-viable avulsed skin was to be left intact and loosely tackedat the former site to partially cover important anatomical structures suchas tendon sheaths and tendons. Primary closure of wounds of the hand underwar or mass civilian disaster conditions should always be discouraged.

Those medical officers who were most likely to be assigned to medicalunits forward to the surgical hospitals in Korea were informed, on theirarrival in Japan, that their primary duties during active combat wouldbe to provide first aid, resuscitation measures such as the establishmentof adequate respiratory exchange, shock therapy before and during evacuation,the alleviation of pain and apprehension, the institution of antibiotictherapy and the administration of the routine tetanus toxoid booster injections;the necessity for timely, early evacuation and distribution to appropriatesurgical or evacuation hospitals was stressed.

A definite point about which there is always some controversy shouldbe mentioned. It is in regard to the most logical echelon level at whichinitial wound surgery should be performed. It is the contention of theauthor that initial surgery of any significant magnitude should never beattempted forward of the mobile surgical hospitals. There are many cogentreasons for this recommendation, some of which are as follows:

1. Competent anesthetists and highly trained surgeons are seldom assignedto units forward to first-priority hospitals-only seldom can

the most minor of war wounds be débrided under conditions otherthan well controlled general anesthesia.

2. As a rule, adequate x-ray facilities are not available for properlocalization of radiopaque foreign bodies.

3. Sterile supplies and equipment in sufficient amounts, as well asspecialized equipment for proper preoperative care and postoperative complications,are usually not adequate.

4. Improvised operating rooms are poorly lighted and difficult to maintainin a dust-free state.

5. Nurses who are so necessary in the conduct of the operating room,operative procedures and in the care of the seriously wounded patientsare not available.

6. If medical officers are involved in the surgical care of patients,they are not available to conduct their specific delineated duties at theforward echelon-this fact is especially obvious when casualties are numerous.

Other points, many of which were of paramount importance, were stressedin discussions with medical officers regarding the care of wounded men.Time limitations permit little more than the listing of some of these conceptsas related to patient care:

Records. Adequate field medical and clinical records should bemaintained-concise significant entries should be a must requirement. Allechelons providing professional care should be "clinical record conscious."A revised clinical record form is urgently needed; a notebook type withspaced item headings and of good serviceable and durable paper would providea much more satisfactory record which could be maintained intact with somesemblance of stability and order.

Narcotics. The overmedication with narcotics, especially in woundedmen who are in impending or frank hemorrhagic or wound shock, is a problemthat must always be guarded against. The value of small dosages intravenouslysupplemented on occasions with barbiturates has been advocated by Beecher(3, 4), Dripps (5), and other noted authorities in the fieldof anesthesia.

Surgical Delay. The surgical lag should be kept in mind. Ideally,the seriously wounded should be receiving initial surgical care within6 hours after injury. If surgery is required as an integral phase of theresuscitation process, then it should be instituted much earlier.

Plasma Volume Expanders. The limited value of substances suchas dextran was usually pointed out in the indoctrination discussions, andthe fact that there is no substitute for whole blood in the replacementtherapy for patients suffering from severe wound and/or hemorrhagic shockshould be common knowledge. The red blood cell

rules supreme in the transport of oxygen to all tissues of the body-nosubstitute for the erythrocyte has yet been discovered.

Intra-arterial Versus Intravenous Transfusions. Until the endof the Korean War intra-arterial transfusions were advocated and frequentlyemployed in the treatment of severely wounded men and no doubt this methodsaved many lives-perhaps only because of the rapidity by which blood wasgiven by both routes simultaneously. It is doubtful if intra-arterial bloodadministration provides immediate assistance in the oxygenation of cerebraland cardiac tissue since the whole blood given is not oxygenated. Latein the war it was recommended that radial arteries should never be employedfor intra-arterial transfusions as the danger of ischemic loss of a hand,fingers, or perhaps an arm is a distinct possibility. The posterior tibial,the femoral or an artery proximal to a mangled extremity were recommendedif the intra-arterial route for whole blood transfusion was considerednecessary.

Amputations. Sites of election are never considered when doingwar or mass casualty surgery-the circular procedure commonly referred toas the guillotine method is performed at the lowest possible level to beconsidered as an adequate débridement.

Plaster Casts. Never did we have enough trained orthopediststo assign to all forward hospitals; however, general surgeons, by and large,provided excellent initial surgical care for patients with open fractures-namely,adequate débridement. The splitting of plaster casts and all underlyingcircular bandages down to skin level was a MUST after plaster cast application.This policy saved many limbs as well as occasional lives.

Arterial Injuries. The fine results in the care of such injurieshas been reported elsewhere at this meeting. Perhaps this aspect of specificwound care brought forth greater periodic teaching efforts than for anyother type of injury. Visitations and rather lengthy periods of duty byLieutenant Colonel Carl W. Hughes and Major Edward J. Jahnke from the WalterReed Army Medical Center were made available for the express purpose ofproviding expert surgical care for such traumatic problems. Many surgeonswere given detailed instructions as to technical details on laboratoryanimals as well as in the operating rooms of the busy surgical hospitals.

Thoracic Injuries. Conservative measures as a general rule inthe early care of such problems were constantly stressed. This policy paidoff as evidenced by the overall fine results obtained.

Liver Wounds. All medical officers were constantly encouragedto control hemorrhage by appropriate suture methods and the very importantemployment of ample and dependently placed rubber drains-such drains areremoved gradually at a late date. Management with-

out adequate dependent drainage or the early removal of drains invitesdisaster in the form of severe early and late complications.

Bowel Injuries. It goes without saying that injured segmentsof colon are exteriorized, if at all possible, through a stab wound apartfrom the laparotomy incision. If anatomically impossible to exteriorize,repair of the defect and a defunctioning proximal or a diverting colostomyare performed-preferably a double-barreled colostomy. This policy was aMUST as it was in World War II. Much suffering and disability from extremecomplications and/or fatalities are the rule when such a policy is notstrictly followed. Small bowel injuries are closed or resected and bowelcontinuity re-established-exteriorization of the small intestine is seldomwarranted.

I have mentioned only some of the prevailing principles and conceptsin war or civil disaster wound care that should be clearly establishedin the minds of members of the medical profession whose lot it is to provideinitial surgical care for those unfortunate individuals who are injuredby the many destructive forces that could descend upon large segments ofour population. I am sure we will continue to have better results in woundcare as new and better biologic, therapeutic and technical methods andconcepts are unfolded.

Surgical Consultants Program

In the Far East we have been very fortunate and highly pleased withthe policy of having frequent consultant visitations by outstanding civilianauthorities as well as from equally capable consultants from the MedicalServices of the Armed Forces. This consultant program has been as successfuland as popular in the other major Services' specialty branches as it hasbeen in the fields of surgery and its related subspecialties.

Consultants, by and large, have been extremely well selected. They make,on the average, 30-day tours about the Theater and present formal and informallectures and teaching clinical ward rounds with the respective specialtyconsultants assigned to the Theater and to the Field Army. These consultantshave contributed a great deal toward the fine professional results thathave been obtained during the Korean War and each of them has remarkedthat he too has gained much from his contacts with Service personnel andthe professional problems with which the Military must deal during a verycomplicated and extremely destructive war such as has been experiencedin Korea. An added professional stimulus and a decided boost in the moraleof our medical officers has almost always resulted during and after theircontacts with consultants such as visited and worked with us during theKorean War. The expenditure for such a fine consultant program

should be of little concern to providing authorities when "professionaldividends" are so regular and of such profound value.

Theater Medical Societies and Periodic Professional Meetings

Professional societies organized in the interest of professional trainingand interspecialty exchange of scientific knowledge have been created andconduct periodic meetings regularly with very satisfactory attendance byprofessional personnel from all local and somewhat distant United Nationsunits as well as from our own Army, Navy, Air Force and Marine organizations.Doctors and other professional personnel with worthwhile and timely subjectmatter for presentation are invited to participate on such prearrangedand well publicized programs. The itineraries of visiting consultants arealways so planned that such consultants may appear as guest speakers atthe regularly scheduled meetings of the more popular societies such asthe I Corps' 38th Parallel Medical Society of Korea, the Korea CommunicationsZone Medical and Dental Society which meets monthly on three consecutivedays, namely, at Pusan, Taegu and Taejon, and the Southern Honshu MedicalSociety which usually conducted monthly meetings in Osaka, Japan. Periodicspecialty group meetings are scheduled from time to time with personnelfrom all Medical Services of the Armed Forces as well as native physiciansfrom the particular locale in which the meetings are conducted. It is noteworthythat Japanese and Korean doctors have been duly invited and are attendingin increasing numbers-some have participated very creditably on the programs.

Professional Journals and Memoranda

The Far East Medical Bulletin, a monthly publication, in whichbrief professional articles of distinct value as to timely subjects andprofessional trends in policies are published, was read by most medicalofficers in the Far East. Professional personnel are invited and encouragedto contribute material for consideration by the Editorial Board for publicationin this bulletin and in the past such response has been very generous.

A Symposium on Military Medicine in the Far East Command, a supplementaryissue to the Surgeon's Circular Letter, was published in September 1951-thisconcise publication containing material of a technical and professionalnature has been distributed throughout most nations of the world. It isstill the "professional bible" for our medical officers in theFar East. A few revisions have been made and these are published and distributedas often as necessary.

Professional Library Facilities

A well-stocked lending professional library is located in Tokyo, Japan.Textbooks and journals are mailed to any professional person in the FarEast and may be retained for a period of 4 weeks. Such library servicehas permitted many medical officers to prepare successfully for participationin specialty board examinations. It is noteworthy that on a single occasionas many as 21 candidates from the Armed Forces Medical Units in the FarEast have taken the first part of the American Board of Surgery Examination.If excellent library facilities had not been available, these eligiblemedical officers would seldom have had the courage to participate. Allmedical installations having five or more medical officers assigned wereprovided with an acceptable basic textbook library and are furnished themost popular professional journals.

Summary and Conclusion

Again I should like to stress some of the better circumstances and viewpointsunder the general heading of professional conduct and training that madeit possible for the Theater and Army Surgeons to provide medical servicesthat were so generally successful during the Korean conflict:

Doctors of medicine as a general rule, and regardless of their respectivespecialty, are very adaptable and have an ardent desire to perform a creditablejob, especially if their duty assignments are related in a general wayto the overall medical effort and linked directly or indirectly with theprevention of disease or the care of the sick and injured. We can be thankfulindeed that medical officers no longer are required to serve as Registrars,Post Exchange Officers, Mess Officers, etc. The wise and timely eliminationof such periodic duty assignments which resulted in the increase in thesize of the Medical Service Corps prior to and during World War II andlater with the inauguration of the very popular and successful graduateprofessional training program, has done much to preserve the integrityof the Medical Corps and perhaps prevented a "Corps suicide."

References

1. Churchill, E. D.: Panic in Disaster. Annals of Surgery(Editorial), December 1953.

2. Churchill, E. D.: Management of Wounds (Initial andReparative Surgery). Symposium on Treatment of Trauma in the Armed Forces,Army Medical Service Graduate School, Walter Reed Army Medical Center,March 1952.

3. Beecher, H. K.: The Relief of Pain. Symposium on Treatmentof Trauma in the Armed Forces, Army Medical Service Graduate School, WalterReed Army Medical Center, March 1952.

4. Beecher, H. K.: The Early Care of the Seriously WoundedMan. Journal of the American Medical Association, January 1954.

5. Dripps, R. D.: The Anesthetic Management of the SeriouslyWounded. Symposium on Treatment of Trauma in the Armed Forces, Army MedicalService Graduate School, Walter Reed Army Medical Center, March 1952.