Battle Casualties in Korea, Studies of the Surgical Research Team, Volume I
The Value of a Field Research Project*
Captain John M. Howard, MC, USAR
Colonel Richard P. Mason, MC, USA
The field army has an opportunity for research that cannot be duplicated by any other organization. Just as the staff of a tuberculosis hospital studies tuberculosis, or a cancer hospital studies cancer, the Army Medical Service must study trauma. No other institution has an opportunity or responsibility in the field of trauma comparable to that of the Army Medical Service. To fail to recognize and to develop this opportunity is first to neglect the wounded soldier and second to retard the development of the Army Medical Service.
Field surgery is not civilian surgery under canvas. It is a specialty in itself. Unless its problems are studied and documented, the lessons of previous wars must be relearned in each war. Meanwhile, lives and limbs are needlessly lost. Field research offers the means of studying the field problems and documenting the surgical experiences so that they need not be relearned each time at the expense of our combat casualties.
Field research offers the opportunity for finding better means of caring for the combat soldier. That such an attempt should be made is, of course, obvious. The question, therefore, is: Should the attempt be an organized project by a specialized full-time team? This question must be evaluated in terms of its contributions and potential contributions versus its cost in manpower and money. A review of the record of the work of the past 20months demonstrates a conclusive, affirmative answer.
A single specific example proves the value of an organized project and far more than justifies the outlay of manpower and money.
Shortly after the arrival of the Surgical Research Team in Korea in December 1951, it became apparent that one of the major problems confronting the surgeons was the management of casualties with arterial wounds. Standard practice in previous wars had been to ligate the vessels as anastomosis had not proved feasible. Meanwhile, progress had been made in the general field of vascular surgery in the United States which warranted a revaluation of this practice. The
*Previously published in United States Armed Forces Medical Journal 6: 237, 1955.
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problem was discussed with the Surgical Consultant of Eighth Army who stated that repair of arterial wounds in the Korean conflict had been repeatedly attempted by various surgeons and had not proved feasible. In his experience the only casualty with injury to the popliteal artery who had not lost his leg was an occasional casualty in whom the arterial injury was incomplete, was not recognized and therefore was not explored.
The repair of arterial wounds was then undertaken as a project by the Surgical Research Team. The results demonstrated the feasibility.1,2 The amputation rate following popliteal anastomosis fell from 72per cent (World War II)3 to approximately 20 per cent. Surgeons from each hospital were taught the technic and provided with better instruments. As a result, the amputation rate fell throughout the theater. Soon the trained surgeons had rotated from Korea and the amputation rate again increased. Again, surgeons from each hospital were instructed by members of the Surgical Research Team.
As a result of this single project, hundreds of limbs have been saved and will continue to be saved. The man-days of useful activity will far exceed the man-days spent by any and all research teams. The cost to the American taxpayer of supporting a veteran with an amputated extremity has been estimated at approximately $100,000.4 A hundred such casualties would cost $10,000,000. The investment in the entire research team, in manpower and in dollars, is thus but an insignificant fraction of the immediate dividends from this single project.
Other studies have delineated the problems of management of the casualty with post-traumatic anuria and definite progress has been made in lowering the mortality from this complication in the combat theater. The entire blood program, for the first time, has been thoroughly surveyed at the point of utilization in the combat theater and the effects of transfusion on the clotting mechanism have been reviewed. The introduction of the plasma expanders into the combat theater has been supervised and their effectiveness in the seriously injured battle casualty established, thus permitting a potential decrease in the high incidence of plasma hepatitis. The characteristics of the wound and the sequence of bacteriological and histological changes have been described. The problems of resuscitation and massive transfusions have been analyzed and recommendations made for better treatment at this time.
These projects have proved practical and of unquestioned value. The value of field research to the Army Medical Service has therefore been proved. The responsibility no longer rests primarily on the field research unit to prove its value. Instead, the responsibility now
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rests primarily on the leaders of the Army Medical Service to acknowledge and to develop the potentialities of field investigation.
The Mission of Field Research
The primary mission of field research is to find better means of providing medical support to the field troops. From the practical standpoint, this consists of defining the problems and then solving them. The identification of the problems may require clinical, laboratory and statistical studies. Questions such as "Does the stress of combat sometimes lead to adrenalin sufficiency?" require considerable basic work and the result maybe merely to demonstrate that no problem in adrenal cortical function is detectable. There is no short cut to the identification of such problems. Similarly, if patients after massive transfusions demonstrate a mild bleeding tendency, the basic problem has not been identified until the clotting mechanism has been studied and the specific defect pinpointed. Thus basic research may be necessary in identifying and solving some of the problems. Basic research as a primary objective should seldom be undertaken in the field because of the inherent difficulties and cost involved. Such work can be better performed in the Zone of Interior. The greatest contributions from combat surgical research will come from those studies directed toward therapy. The second aspect of the mission is to report the findings immediately back to the combat theater and thereby permit the medical officers to keep abreast of developments. The third aspect of the mission is to report to the Research and Development Board those problems which require additional work in the clinics and laboratories in the Zone of Interior. Thus the problems of field research will start in the front lines and extend through the entire chain of evacuation. The influence which such work will have on civilian thinking and practice is an additional benefit but of secondary importance in the planning of the work. To repeat, the mission of field research is primarily to support, directly and indirectly, the field soldier.
Methods of Operation
The research program should be coordinated through the Coordinating Committee on Medical Sciences, Office of the Assistant Secretary of Defense (Research and Development) to insure that all three of the Armed Services are equally informed of the research that is to be conducted, to ascertain whether triservice participation is indicated, to avoid unnecessary duplication, to lend fiscal support and to make available to the other Services reports of progress and ultimate results.
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The areas of research conducted should be those directed by broad policy of the Department of Defense.
The administration and technical support should follow directives of the sponsoring Service responsible for the research team, and should be coordinated through the Theater Commander.
The Chief, Medical Research and Development Division, Office of The Surgeon General, Department of the Army, or similar divisions of the Navy and Air Force, should provide over-all direction of effort and coordination, should select personnel, and should gain the cooperation of military and civilian establishments in the United States for development of teams and methods. He should also assist in liaison between the work in the field and the work in military and civilian institutions in the Zone of Interior. His direction must be very broad for the specific direction and administration of the teams must remain in the field. The Army Medical Service Graduate School provided such an institution in which methods could be developed and personnel trained.
The Surgical Research Unit in the field should be attached to a Medical General Laboratory for technical and logistical support. Since the mission of the theater laboratory is to support the field work, it should participate, as opportunity provides, in the technical projects of the research teams. A successful example of such an administrative arrangement is the attachment of the Far East Medical Research Unit to the 406th Medical General Laboratory in Tokyo. The Surgical Research Team was one part of the Far East Medical Research Unit. The Director of the Theater Medical Research Unit, or his Deputy, should travel between various research units within the theater area, advising and assisting the members professionally and administratively. He should keep the Army Surgeon informed of work planned, work in progress, and work completed.
The liaison also provides an opportunity for the research units to utilize the perspective of the consultant staff of the Army and Theater Surgeons in planning research projects originating at the combat level. All reports from the field research units should be made to the Director of the Theater Medical Research Unit and through him to the Theater and Army Surgeon and to the Director of Surgical Research in the Zone of Interior.
The Surgical Research Units should be attached, when feasible, to existing medical facilities in the field for rations, billeting, movement of the unit, and clinical opportunities. In practice, at the local units, the research teams have worked as one department within the hospital.
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The surgical research program, as designed in Korea, had an officer in the combat Infantry Division to study resuscitation and evacuation, a unit at a forward hospital to study the combat casualty during further resuscitation and primary surgery, and a third unit at an evacuation hospital to study those casualties who developed postoperative complications. In addition, certain casualties could be selectively evacuated to Tokyo Army Hospital and to Walter Reed Army Hospital for follow-up evaluation. This system requires limited extension. Added emphasis must be placed on the work in the Infantry Division for it is at this level that most lives are lost. Furthermore, there should be a research unit in the Communications Zone working in cooperation with the units in the combat area. This unit could be attached to a general hospital for rations, quarters and clinical facilities but should be assigned to the Medical Research Unit of the Theater Medical General Laboratory. Thus over-all direction and technical support is retained by the Director of the Theater Medical Research Unit. In the Far East such a unit could be located at Tokyo Army Hospital and based on the Far East Medical Research Unit and 406th Medical General Laboratory for direction and support. This plan would permit a casualty to be observed from the time of wounding to the time of leaving the theater. The unit in the Communications Zone would provide a means of obtaining systematic follow-up in all clinical studies. Casualties could then be selectively evacuated to designated institutions in the Zone of Interior for continued observation.
To insure orientation of the program along the lines of finding and solving the practical problems while protecting at all times the welfare of each casualty, the Surgical Research Units should be under the immediate direction of a well-trained, conservative surgeon. He should direct the Surgical Research Program at the field level and be directly responsible to the Director of the Theater Medical Research Unit. If research is simultaneously in progress in other fields of medicine (epidemiology, psychiatry), every effort must be made to overcome the limitations of travel and communication so as to maintain liaison with the work in progress by these groups.
The Field Director in the Zone of Interior should spend several months a year in the field. Consultants from civilian or other military installations should be available when special problems are encountered. They can be most effective when available shortly after the beginning of a project. They are, in this way, in a position to assist in the development of the project as related to technical approaches and to emphasis.
Communication and travel are two of the most difficult obstacles
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in a combat theater. The routine monthly visits of the Director, Theater Research Unit, to each field unit would do much to overcome the handicaps of communication. Means of transportation should be assigned to the Theater Research Unit for distribution to the various specialized groups. Travel orders should be issued which permit frequent travel between the units in the Combat Zone and between the Combat and Communications Zone.
Except for accepted medical presentations, no publicity should be given the work except by the Theater Surgeon.
Organization of a Surgical Research Unit
The Surgical Research Unit should be prepared to study primarily the battle casualty. This consists of studying the injury, man`s response to the injury, the tools and methods available for his treatment, and when possible, the wounding agents. With such a purpose, the team should consist primarily of the following officers:
a. Division Level
1. Surgeon
b. Surgical Hospital (Mobile Army) Level
1. Surgeons-two or more
2. Chemist
3. Hematologist
4. Anesthesiologist
5. Physiologist (cardiovascular and autonomic nervous system)
6. Pathologist
7. Bacteriologist
8. Administrator (and supply officer), MSC
c. Evacuation Hospital Level (including Renal Failure Center)
1. Internists-two
2. Surgeon
3. Chemist
4. Pathologist
5. Bacteriologist
d. Communications Zone Hospital (including further work in metabolism, renal failure and surgery)
1. Specialized surgeons with laboratory support as required.
The findings of these men should ultimately be utilized in establishing policy. They should therefore be assigned to the Theater Medical Research Unit for a regular tour of duty with a minimum overseas tour of 1 year. In order to keep work integrated and creative, the members in the Combat Zone should return to the Com-
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munications Zone Unit as necessary for a period of approximately 1 month. This should be used primarily for development of methods, writing and relaxation. Thus efficiency of the unit could be maintained without interruption of the over-all program.
Other officers could be assigned for shorter periods of time for special projects so long as their projects did not affect the policy. Officers in the Communications Zone Unit should go to the Combat Zone whenever advisable.
Technicians should include men trained in patient care, chemistry, hematology, bacteriology, typing and photography. Each unit should have an officer or enlisted man with a knowledge of medical supply procedures.
The Initial Phase
The program of field research should have the support of the Assistant Secretary of Defense (Health and Medical), as well as the Assistant Secretary of Defense (Research and Development), and every other officer in the Armed Forces. This support should be formalized in a statement for distribution. Any project which has proved its ability to save limbs, lives and millions of dollars is worthy of this support.
Initially, a unit should be organized in the Zone of Interior, preferably in time of peace, and its general field of work should be outlined in as much detail as possible. Prior to beginning work the officer responsible for the unit, the officer responsible for its support in Washington, and an investigator with previous field experience should tour the theater and select a site for operation. In selecting a site for research, attention should be given first to the assurance of cooperation from the hospital commander and second to the stability of the area. A slow, steady flow of casualties offers the ideal opportunity for observation. An active front, with frequent movement of the hospital is much less desirable. The officer responsible for the unit, a chemist and an administrative-supply officer should begin work in the field approximately 2 months before the arrival of the rest of the team. The second group can bring whatever equipment is not available in the theater.
Operative Phase
The stability of the front lines will determine to a large extent the type of research which can be performed. If the lines are stable, as was the condition during the last 20 months in Korea, an adequately equipped laboratory can be maintained at a forward hospital. If the hospitals are moving frequently, the work must be limited more to the
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operative field, to resuscitation, evacuation, effect of drugs, and the collection of specimens for shipment to other laboratories.
Much more could be accomplished in the operative field if adequate follow-up could be achieved, as was done in neurosurgery and vascular surgery by the selective evacuation to hospitals in the Communications Zone and the Zone of Interior. Thus the forward surgery could be rapidly altered as indicated by subsequent results. Such a program is essential to the improvement of all phases of traumatic surgery. The program would rapidly pay its way by increasing the effectiveness of early therapy. The research units outlined above would permit such a selective follow-up.
Constant summary of the work in progress is essential for two reasons. First, it is essential for continued perspective and direction of effort, and secondarily, it is essential that as a project is completed, the information be provided to the theater. In this way recommendations designed to improve the care of the wounded soldier are instituted immediately in the Combat Zone. This provides the theater the advantage of the most advanced experience and gives the research team adequate observation of the general applicability of their recommendations.
Conclusions
1. Field research is a valuable adjunct to the Army Medical Service.
2. The mission of field research is primarily to find better means of supporting the combat troops.
3. A surgical research unit should consist of a team at each level in the evacuation chain.
The authors gratefully acknowledge the influence of the work from World War II in developing this program. Of particular assistance were the experiences of Colonel William S. Stone, MC, and of the members of the Board for the Study of the Severely Wounded.
References
1. Jahnke, E. J., and Howard, J. M.: Primary Repair of Arterial Wounds. Archives of Surgery 66: 646-649, 1953.
2. Jahnke, E. J., and Seeley, S. F.: Acute Vascular Injuries in the Korean War. Annals of Surgery 138: 158-177, 1953.
3. Beebe, G. W., and De Bakey, M. E.: Battle Casualties: Incidence, Mortality and Logistic Considerations. Charles C. Thomas, Springfield, Illinois, 1952.
4. Stewart, R. E.: Prosthetics and Sensory Aid Service. Department of Medicine and Surgery, Veterans Administration, Washington, D. C. Personal Communication from Research and Development Division of The Surgeon General`s Office, Dept. of Army.
