Battle Casualties in Korea: Studies of the Surgical Research Team Volume III
Future Research in Support of the Battle Casualty
Captain John M. Howard, MC, USAR
The responsibility to problems of the combat casualty is not limited to the military surgeon, nor is it limited in time to the period of combat. It is a continuing, national responsibility with ever- increasing overtones to the civilian as well as to the military population.
The problems observed in the care of the battle casualty center around two considerations: the local destructiveness of the wounding agents, and the effect of the wound on the entire body. Thus there are two major effects of the trauma: the local tissue injury, and the subsequent involvement of the circulatory system. These might be considered two sites of primary injury and they are the two which may produce a continuing, deleterious influence. The third site of injurious action, which may be primary and continuous, is that of the nervous system. The possible role of this injury in producing a deleterious effect is less obvious and needs further study.
Research in support of the battle casualty must therefore proceed in several directions in order to include the problems of tissue destruction, hemorrhage, resuscitative agents, treatment, and the sequelae of injury.
As suggested above, research must proceed not only at the national level but, should the occasion arise, in the combat theater.
Research at the National Level
The Local Wound
This, the focal point of the entire insult, has not been adequately studied. Continued investigation of wounding agents and of wound ballistics is required.
Knowledge is needed as to the extravasation of fluid, blood, albumin, globulin, and plasma expander into the wounded tissue. The extent and duration of the extravasation are unknown.
The changes in the circulation in the wounded extremity should be studied as to the degree and duration of these changes. This study might provide a sound background for the continued study of the absorption of endogenous toxins and of the electrolyte shifts occurring in traumatized tissue.
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The delineation of viable from nonviable tissue at the time of primary débridement is a very practical problem of tissue conservation which requires additional study.
Wound infections seldom appeared to be a major, life-endangering problem under military conditions in Korea. However, the ever-present possibility of mass casualties, inadequate surgical therapy, as well as the inevitable loss of tissue and function, and the increase in hospital days secondary to noncritical wound infections require that studies of wound infections be continued.
Since the achievement of a healed wound is a primary objective in the case of the injured, wound healing and the factors affecting it in the battle casualty deserve continued study. It was the clinical experience in Korea that wound complications were among the major causes of death in casualties with posttraumatic renal insufficiency. The underlying defects, therapeutic or biologic, require elucidation.
The Circulation
The study of factors controlling the circulation should be expanded at all echelons. This cannot be overemphasized. At the practical level, the problems lie in the support of the circulation after hemorrhage has been controlled and transfusion instituted. Study should emphasize not only the factors controlling the circulation, but also the effect on the circulation of analgesic and anesthetic agents.
The observations already made in Korea are threefold. (1) Massive transfusions were required to maintain the blood pressure and prevent death after very severe injuries. (2) Vascular collapse was more frequent following cranial and abdominal trauma., but it. also occurred following wounds limited to the extremities. (3) Post-traumatic renal insufficiency was a major complication among battle casualties.
Abdominal Wounds
Although the mortality from abdominal injury has steadily decreased, it remained at 12 percent in the experiences reported from Korea. Studies, both at the basic and the clinical level, should be made in an effort. to reduce this mortality. Particular attention should be paid to the control of intra-abdominal hemorrhage, peritonitis. and of wounds of the liver, colon, kidney, urethra, duodenum and inferior vena cava.
Injuries of the Brain and Spinal Cord
Although the figures from Korea are not available, the mortality of casualties with injuries of the central nervous system reaching the hospital probably ranged from 15 to 25 percent. If patients with injuries of the brain reached the hospital alive, it would seem that
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means could be found to prevent the progression of the injury short of fatality.
Burns and Irradiation
These were not major problems in Korea and are included only because of the obvious increase in destructiveness of military weapons.
Plasma Expanders and Red Blood-Cell Preservation
Continued study should be made to increase the effectiveness of plasma volume expanders. Although the expanders used in Korea (dextran and modified fluid gelatin) were reasonably satisfactory under the conditions of a 3.5-hour period of evacuation, they might not prove effective should the time lag increase. An expander is needed which will stay in the blood stream longer than would those studied in Korea. An even more satisfactory preparation might be achieved by the success of the present studies of the long-term preservation of red blood cells.
The Fate of the Red Blood Cell After Massive Transfusions
Clinical experience in Korea dictated the need for massive transfusions in support of the casualty with extensive injuries. In spite of intensive studies, the fate of the red blood cell was never adequately ascertained.
Anesthesia
Whereas the use of anesthesia is an aid in the correction of the injury to the wound and the injury to the circulatory system by débridement and transfusion, it furthers possible injury to the nervous system. Time and again the casualty with a normal blood pressure was found to become severely, even fatally, hypotensive as anesthesia was induced. Additional efforts should be directed toward understanding and minimizing this trauma by carrying out basic studies in anesthesia. These should include studies of the patient in the "unsteady state," i. e., the injured patient whose circulatory system is partially compensated but which collapses after movement, changes in posture, or anesthesia.
Post-traumatic Renal Insufficiency
Although infrequent, post-traumatic renal insufficiency is a major complication among severely injured battle casualties. Continued study should be directed toward understanding the cause of this syndrome as well as toward increasing the effectiveness of therapy. For the severe stages of post-traumatic renal insufficiency, the case fatality rate remains at least. 50 percent.
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Refractoriness to Transfusion
As a fatal complication, this condition develops very infrequently; however, it was the clinical impression in Korea that many of the casualties developed a limited degree of refractoriness as indicated by the need for large transfusions. Although continuation of studies of basic mechanisms is essential, lethal refractoriness was not a frequent complication. It may well be that it is more of a problem in the older patient than in the young battle casualty.
Hepatitis
The author had little personal experience with this complication of transfusion in Korea, but investigators have indicated its importance both in the management of the combat casualty and in civilian patients.
The Systemic Response to Injury
Studies in Korea indicated that the entire body took part in the response to trauma. Among the practical problems encountered which had not been adequately explored were the problems of paralytic ileus and the possible need for support of the autonomic nervous system following severe injury. Although paralytic ileus is observed routinely following abdominal injury, both in military and civilian practice, all too often it is accepted without interest. Like renal vasoconstriction, paralytic ileus may serve as a protective mechanism following injury; but in this day of transfusion and closure of perforated viscera, both responses may add to the morbidity after the initial defects have been adequately corrected. Under conditions of mass casualties, delayed medical attention and inadequate supplies may lead to neglect. Under such circumstances, oral administration of fluids may prove the only feasible means of treating even the seriously wounded. Gastrointestinal absorption of fluids and electrolytes following injury has not been adequately explored.
The autonomic nervous system has not been adequately studied. Its response as to mechanism, degree, duration, and possible deficiencies is an unknown factor in the defense following injury. The role of vasoconstrictors in resuscitation cannot be evaluated adequately until this basic response is elucidated.
The degree, duration and the effect of the adrenal cortical response has been fairly well outlined within the limits of present day methodology. No deficiency in this response was recognized in the battle casualty. Future work should pursue the development of new methods of study with emphasis on fluid and electrolyte shifts within the body. The significance of the decrease in plasma
sodium concentration and its therapeutic implications following injury deserves intensive study.
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Organ Transplantation
Perhaps the greatest contribution in military medicine might be made in the field of organ transplantation. Work in this sphere should have unlimited support.
Research in the Combat Theater
Should the occasion ever arise again when American troops are engaged in combat, or should the occasion present itself for research work in any combat theater, the opportunity for field research should be immediately grasped. This work should be planned at the present time and organized in such a way that effective work could be instituted at an early date.
Studies in the Division Area
Since approximately 20 percent of all soldiers wounded by enemy action die before reaching the forward surgical hospital, this should prove the most fruitful site for clinical investigation. Work here should entail not only prevention of injury, but emergency therapy. Much might be accomplished in the field of resuscitation and evacuation by utilizing seasoned clinical investigators at the most forward medical installations as well as at other points throughout the forward chain of evacuation. It is realized that studies in this area would have to be carried out by men who are at the same time physicians and surgeons.
Clinical Surgery and Organized Follow-up
Experiences in neurosurgery and in vascular surgery in Korea demonstrated how much could be accomplished by concentrating on specific clinical problems in the forward area and then selectively evacuating the casualties to specified hospitals in the Communications Zone or in the Zone of Interior. Such work should be planned for every sphere of traumatic surgery. By correlating the experiences in the forward area and in the secondary hospitals, new technics could be developed and immediate follow-up might permit evaluation of a given clinical program or permit the surgeons to revise their program at an early date as experience dictated. The importance of such a program cannot be overemphasized.
The Management and Study of Abdominal Trauma
As described earlier, the mortality from abdominal trauma remains high. In the forward surgical hospital, clinical as well as basic studies should go hand in hand in an effort to describe the cause of fatality while, at the same time, every effort is being made to lower the current fatality rate.
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The Study and Management of Patients with Injuries to the Central Nervous System
As with abdominal trauma, this condition is listed separately for added emphasis.
The Management and Study of Casualties with Post-traumatic Renal Insufficiency
Because of the relative frequency of this complication of trauma in the combat theater and because of its high fatality rate, the continued study of renal insufficiency should be established in the combat theater.
Débridement and Wound Infections
Because almost every casualty admitted to the forward hospital has an open wound and some degree of wound infection or contamination, either clinical or subclinical, an unlimited supply of patients is available for the study of the proper management of wounds.
Anesthetic Management
The battle casualty differs from many civilian patients in that, prior to anesthesia, he has lost blood and developed some response of the autonomic nervous system. Since this response appears to be partially blocked by anesthesia, anesthesia is a greater hazard than in many of the nontraumatic casualties. Imaginative leadership in this sphere might well lead to the saving of additional lives and the accumulation of data of fundamental interest.
Study of the Blood and Plasma Expander Program
As in the study of wounds, a study of transfusion should be continued not only because of the inherent problems in such a program, but also because of the tremendous clinical experience which is available for study and analysis.
Burns and Irradiation
Study of these wounds should be carried out if indicated.
Summary
To reiterate, the responsibility to problems of the combat casualty is not limited to the military surgeon, nor is it limited in time to the period of combat. It is a continuing, national responsibility with ever-increasing overtones to the civilian as well as to the military population.
