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The rotor blade wash from MedEvac helos is a fair wind of salvation in battle. The wounded troops’ survival, though, will come down to the experience of their surgeons—like this young Navy lieutenant operating in Vietnam (inset, right)—in treating combat injuries.
Peacetime displays of a well-trained and -equipped military proudly show uniformed personnel marching in precision beneath colorful banners to rousing martial music and sleek, gray warships fitted with impos- lng weapon systems, sailing off majestically toward the horizon. Such scenes help demonstrate U. S. defense integrity and determination, but they may also belie the °ften brutal reality of military confrontation. In his book, 1999—Victory Without War (Simon and Schuster, 1988), former President Richard M. Nixon writes that 120 mil- hon people have been killed in 130 wars in this century— teore than all those killed in war before 1900. At the Somme in World War I, for example, the high hopes of teany ultimately culminated in 60,000 casualties on the first day of battle alone, without any tangible military result. In recent years, the casualties sustained in the Iraqi uttack on the USS Stark (FFG-31) were harsh evidence of S. military vulnerability, even in an era of sophisticated electronic warfare defenses.
The bulkhead sign outside of sickbay on board an obscure Navy frigate perhaps hits the bottom line of casualty care: “Navy Medicine—Our Day Begins When Yours Is Almost Over.” There is certainly nothing more valuable teat a combat force can do than to care for its sick, injured, and wounded.
In military medical training exercises, the mass movement of litters bearing simulated casualties and the sight of tee MedEvac (medical evacuation) helicopter are impres- s*ve and dramatic. The sheer spectacle of the flights—the Presumption that lives hang in the balance, the noise, the flying dust and debris upon arrivals and departures— Provide unforgettable images for onlookers. Ultimately, however, beyond the high drama surrounding the vehicles °f conveyance is the requirement that some responsible party will administer definitive treatment to patients. In combat, this treatment must often be delivered under ad- vcrse and austere conditions. In peacetime, there is cer- teinly an implied expectation that, if called upon, those directly responsible for the life and physical integrity of tee wounded will be well oriented to the unique requirements of combat injuries. But in holding on to this expec- tetion, we may be taking too much for granted.
The Responsible Parties and the Establishment—Three §roups of personnel will render medical care in combat: active duty staff, drawn from military health care facilities Previously functioning in a peacetime setting; reservists, most of whom practice in a peacetime civilian setting; and untoward numbers of conscripted physicians, accompanied by other health-care personnel obtained through Selective Service. Preparing a military medical establishment to shift its rules of professional performance to a combat mode is not easy. Lessons learned from past military engagements and an appreciation of the relationships between modern offensive weapon design and wounding are critical for the survival and conservation of military manpower during combat. Unfortunately, training programs, such as “Advanced Trauma Life Support” and “Advanced Cardiac Life Support,” have been modeled upon the types of acute medical situations seen only in the civilian practice setting and not designed to prepare military medical personnel for war. Although the pseudonym, “combat casualty care” is used and students are dressed in camouflage clothing, the orientation of the overall program neglects the lessons of previous military conflicts. Furthermore, this civilian-oriented policy presupposes the Vietnam War model of unfettered air superiority with rapid helicopter evacuation of the critically injured to high-tech, relatively fixed medical facilities (for example, fleet hospitals), within reasonable flying distance of forward battle areas.
Analysis of the types of injuries actually sustained during combat, however, demonstrates that few patients would receive the best care possible at the medical treatment facility level from the procedures emphasized in civilian accident courses.
Traditionally, military surgeons have received their indoctrination to wartime surgery by “on-the-job training” within the combat zone. It is unrealistic to assume, however, that surgeons spontaneously convert into expert managers of combat injuries by merely donning uniforms. When a young surgeon meets such injuries for the first time, he or she is likely to treat them by employing conventional (exacting and highly technical) methods of civilian surgery, with the potential for a disastrous result for the patient.
Under field conditions, even an experienced civilian surgeon may make costly mistakes in managing traumatic wounds. Surgeons must obviously be reoriented to the special techniques for rendering the rapid but “adequate” type of care required by massive military wounds and massive trauma in a highly contaminated and infection- prone combat environment. Army surgeon Captain H. Richard Hornberger of the 8055th Mobile Army Surgical Hospital (MASH) in Korea, speaking as Richard Hooker, pseudonymous author of M*A*S*H, provided meaningful perspective on one phase of this reality—the early surgical reception of combat casualties:
. Meatball surgery is a specialty in itself. We are not concerned with the ultimate reconstruction of the patient. We are concerned only with getting the kid out of here alive, enough for someone else to reconstruct him. Up to a point we are concerned with fingers, hands, arms and legs, but sometimes we deliberately sacrifice a leg in order to save a life, if the other wounds are more important. In fact, now and then we may lose a leg because, if we spent an extra hour trying to save it, another guy in the pre-op ward would die from being operated on too late. . . . Our general attitude around here is that we want to play par surgery. Par is a live patient.”
To complicate the surgeon’s task, many types of diseases incurred in the combat environment are not commonly seen in peacetime practices. For example, while working inside the belly of a wounded Korean soldier in the 1950s, a U. S. Army surgeon reportedly felt something crawling into the top of his glove. “I got out of there fast,” he admitted. In time, operating room personnel learned that the intestines of many Koreans were full of worms, and that when the intestines were penetrated by a bullet, the abdominal cavity would soon become full of worms as well. When the abdomen was opened, the worms would crawl out. Worms would even crawl into tubes draining the stomach and block them. U. S. surgeons in Vietnam subsequently reported such experiences as well.
The principles of managing wartime trauma have been well defined by the experiences and writings of military surgeons from the past. Unfortunately, following a war, knowledge of the special techniques of medical management required in caring for these militarily unique injuries and illnesses becomes, in essence, a “lost art.” Surgeons in World War II and in subsequent conflicts were anxious to record for their successors the lessons that they had painfully wrung from bitter experience in the treatment of battle casualties. As these doctors consulted the literature from World War I, however, they often discovered that they themselves had merely retraced the steps trodden by their predecessors. Such realities are borne out by examination of the wide spectrum of militarily specific injuries that can be incurred during Navy combat or Marine air- ground operations. These include blast injury, penetrating tissue wounds, flame and incendiary agent burns, white phosphorus injuries, combat environmental contaminant exposure, and unconventional weapon injury. Studying
Combat surgeons oriented toward civilian practices and unschooled in the lessons learned of past wars will have difficulty treating military-specific wounds and infections caused by blast, incendiary agents, and new types of weaponry.
these phenomena in peacetime will help prepare surgeons for what they will face in time of war.
Militarily Specific Injuries—Blast Injury: On 21 October 1967, Egyptian missile boats attacked and sank the Israeli destroyer Eilat opposite Port Said, Egypt. While the surviving crewmembers struggled in the water, the Egyptians fired another missile that missed the destroyer and exploded in the water nearby. As described in an arti-
U. S. NAVY/INSET: U. S. SIGNAL CORPS
Experiences with another form of blast injury are e9Ually illuminating. During the campaign in Norway dur- jug World War II, for example, seven men on board a Royal Navy warship were positioned near a magazine natch when the ship blew up. These men managed to reach shore, but one of them felt so ill that he was unable to stand and had to be carried by his comrades to shelter in a school, where the party turned in for the night. The sick tnan was horrified to wake the next morning and see the °ther six men lying dead. Undoubtedly, these men had all suffered from “blast lung.” It is noteworthy, though, (hat they were able to save themselves and even to help their shipmate to safety before collapsing. This was not
unusual.
c*e in the U. S. surgical literature in 1970, rescuers removed 32 of the injured Eilat sailors from the water five to six hours after the explosion, and those rescued reached a hospital eight to eleven hours after the time of injury. Allhough one survivor had fractures of both forelegs, and Jour had sustained minor skin injuries on board ship, none nad any other external signs of bruising or injury. Among the 32 survivors, 24 subsequently demonstrated the pain- ml signs of acute intra-abdominal injury. Surgery revealed that 23 of them had internal abdominal tears with ruptured m hemorrhaging intestinal walls. Four patients died fol- towing surgery. In addition, 19 of those operated on had Slgnificant lung injury. The eight patients who did not require surgery for abdominal injury subsequently devel- °Ped signs of significant lung injury as well.
Those experienced with militarily unique injuries would mstinctively recognize that the subsequent underwater explosion near the Eilat had inflicted “immersion blast mjuries” to most of the sailors who had survived the direct ml. The injury is, perhaps, rare in peacetime, but it has a ong documented history in military medical literature. In mid-1916, Royal Navy medical officers reported several Cases of immersion blast injury from exploding mines and ^ePth charges. In World War II, Allied and German medi- Ca' personnel gained much more experience and insight into the seriousness of water blast injury. Repeated dive °mbing and torpedo attacks on ships quite often left the majority of a ship’s company in the water after a direct hit.
those occasions where a depth charge, mine, or torPedo exploded near swimming survivors, grave danger of i°ss of life from water blast existed—and frequently occurred.
During World War I, men were occasionally picked up head in the field in the “attitude of life,” without any external injury. This was inexplicable to military medical officers. Blast was something known to either blow a man to pieces or throw him violently, causing injury upon impact. Medical literature of the period acknowledged that although ear drum injuries could be expected without other external injury, blast injuries of the abdomen and chest only occurred in association with surface wounds.
A researcher working in Rouen, France, in 1917, however, investigated the effects of explosions on rabbits and observed that massive hemorrhages could occur in the lungs without signs of external injury. Subsequent experiments on animals showed that most were killed if exposed to explosions at short distances. For animals submerged in water, the area within which the fatal effect occurred was almost ten times greater in water than that in air. However, although some experimental animals died immediately after exposure to explosion, others were able to run about for some time before dying.
Medical observations of similar cases from the field, as well as the experimental data noted previously, were known and commented upon in medical journals at the time. Nevertheless, as soon as the war ended, so did interest in the subject. No cases were reported for many years afterward, until the Spanish Civil War.
The implications of these observations and experiments which remained dormant between many military conflicts are important. Blast-exposed humans who survive the immediate blast, although very shocked, may show no obvious signs of injury for several hours. They will presumably receive first-aid treatment for their shock, but not for their as yet undetected blast injuries. Physical examination at an early stage, in fact, may reveal little. After some time has passed, the patient may complain of pain in the chest and a difficulty in breathing and develop a short, rather grunting cough that causes great distress. Abdominal discomfort caused by immersion blast injury may be similarly delayed. An alert, trained military surgeon, however, would suspect the possibility of “blast lung” or immersion blast injury under the circumstances, and make provisions for protecting the patient from receiving the wrong type of anesthesia or excessive amounts of intravenous fluids, both of which might seriously endanger chances for survival.
Meanwhile, new technology is being developed for the air-land war that will increase the potential for blast injuries among forces. Fuel-air explosives (FAEs) are one type of effective blast weapon, basically a variation of the napalm bomb (containing thickened gasoline). Upon ground impact, an FAE breaks open and disperses a mist of flammable liquid, which is then detonated by a small delayed action explosive. Igniting the cloud of flammable mist may be likened to igniting a spark within a confined dust-filled civilian grain elevator. The pressure of the blast is sufficient to wreck vehicles, ships, and equipment and fatally injure personnel. These devices, used in cluster bomb units, have been successful in clearing mines because of their area effect. In Vietnam, large FAEs were used to clear helicopter landing sites in the jungle. Recent reports have suggested the use of such agents in Afghanistan for antipersonnel purposes. Obviously, detailed, professional education concerning blast weapons and treating blast-related wounds and injuries in warfare is a critical facet of medical readiness today.
Wounds and Infections: During the U. S. Civil War, the uncontrolled infection of war wounds led to amputations and often death. As noted by historian Mary C. Gillett:
“Hospital gangrene, probably caused by Streptococcus Pyogenes, had such a rapid and horrible effect on wounds that it inspired both dread and strong efforts to find a cure. The skin around gangrenous wounds sloughed off, revealing flesh that slowly turned ‘reddish, greenish, purplish or black,’ while the gray edges of the opening grew wider at the rate of half an inch an hour. Arteries and even bones were rapidly exposed and the stench of rotten meat filled the air. As his skin turned gray, the patient’s breath became sickly sweet, his body alternated between chills and sweats, and his pulse grew even faster, even feebler. So great was the fear of the spread of this infection that in several areas medical officers established special facilities to isolate its victims.”1
During World War I, at least 100,000 German soldiers died from wounds associated with various gas-producing bacteria. Research decades later showed that when bullets were fired into the thighs of anesthetized goats, avoiding major bone and blood vessel damage, the wounds healed uneventfully whether they were inflicted by various pistol and revolver bullets or by the much higher-velocity military rifle bullets. However, when a high-explosive charge was directly applied to the goat’s thigh, more extensive soft tissue damage as well as severe blood vessel damage occurred. If the only treatment then rendered was the stopping of bleeding, death always ensued. The bacteria responsible for gas gangrene—the condition known as the scourge of the combat wound—were found to grow freely in such wounds.
Gas gangrene is a far more common and life-threatening complication of war wounds than of civilian-type injuries. Factors that facilitate its development in wartime include extensive injury to the muscle and its blood supply and contamination. Military explosives and high-velocity missile attacks will inflict more extensive damage to tissues than civilian assaults with “Saturday night specials,” or vehicular, industrial, and home accidents. The soldier’s wound is also, generally, more extensively contaminated with dirt, debris, and clothing particles forcibly introduced by the wounding agent. Moreover, wounds are often incurred on terrain where human and animal waste products have been added to the soil. In describing conditions during the Korean War, historian Albert E. Cowdrey noted:
“Even U. N. soldiers arrived in hospitals with ‘most wounds . . . grossly contaminated with field dirt,’ leaves of rice plants, and crumbs of human excrement plainly visible in some of them. Wounded North Korean prisoners of war showed the same problems in exaggerated form, their injuries ‘frequently infested with hordes of maggots.’ ”2
Nearly two centuries ago, Napoleon’s surgeon, Domi- nique-Jean Larrey, working from a horse-drawn ambulance, found that combat wounds fester when closed immediately, and that they must be left open to heal properly. During the Falklands Conflict, the success with which each side treated its wounded clearly reflected levels of combat experience and past lessons learned. The Argentines, for instance, had not fought a war in 130 years, and their physicians were accustomed to peacetime medical practice. British medical personnel, on the other hand, had been exposed to many combat-type wounds in
Northern Ireland. Inexperienced Argentine physicians clamped many wounds shut, relying on antibiotics to combat infection. Captured Argentine casualties, whose wounds were closed before all contaminated tissue had been removed, often suffered from gas gangrene or tetanus (lockjaw) by the time they reached British medical facilities. Horrified British physicians spent considerable time reopening and cleaning mishandled wounds.
The dangers of such practices were debated in surgical journals during World War I, and then forgotten. They were rediscovered in subsequent wars and examined as if they were new topics debated for the first time. Military surgical history is replete with examples of such lessons painfully learned in previous wars, which had lain fallow between conflicts and had to be relearned at great human expense in subsequent engagements.
In the absence of civilian expertise on the subject, 27 civilian cases of gas gangrene were recorded between 1964 and 1974 in Miami, Florida, including ten cases among the survivors of a single airplane crash near the city. This contrasts with the fact that U. S. forces, during eight years of combat in Vietnam, accumulated only 22 cases of gas gangrene. Unlike the wounds managed by U. S. medical forces in Vietnam and British teams in the Falklands, which were left open and closed only when 4 appeared safe to do so, the wounds in Miami—similar to those treated by the Argentine physicians at the Falklands— were closed improperly during initial treatment.
In light of these past realities within the craft of combat surgery, it is uncertain whether our future combat wounded, managed by active duty, reserve, and conscripted military physicians who come from the same peacetime practice milieu as the physicians in Miami, will be adequately treated. Therefore, it is imperative that those responsible for providing the care of combat wounded receive updated clinical guidance, in keeping with current progress in the discipline of surgery, for proper combat casualty care to be ensured.
Flame and Incendiary Agent Bums: The Greeks devised methods for flame throwing in 429 B.C., when destructive flammable mixtures of pitch and sulfur were used in the Siege of Plataea. “Greek fire,” composed of pitch, sulfur, and naphtha, together with a method of projecting it through brass tubes or in red-hot balls of stone or iron, was developed in earnest about 670 A.D. in the arsenals of Constantinople.
Modern flame agents, the most famous of which is napalm, are special blends of petroleum products, usually in thickened form. They ignite easily and can be projected onto a target. Although the major uses of flame today are in flame throwers and fire bombs, they are also used in some field expedient weapons, such as mines and flame illuminators. Flame is used mostly for detection and localization of intruders (as in flame “mines”), and for flushing out people hidden in foliage or enclosures.
Incendiary agents, on the other hand, are compositions of chemical substances used in the planned destruction of buildings, property, and material by fire. Burning with an intense localized heat, they are difficult to extinguish and are capable of setting fire to materials that normally do not
'gnite or burn easily. Incendiary grenades are intended primarily to destroy equipment. Incendiary bullets and armor- P'ercing incendiary ordnance are used against such targets as aircraft and armored vehicles. Small incendiary bombs generally are dropped in clusters and disperse in falling in 0rder to start a number of separate fires that will merge m‘o a major conflagration. Large incendiary bombs are used against such targets as air bases and factories.
The medical implications of these forms of weapons and offensive systems are frequently misunderstood, 'here is still a surprising amount of confusion among medical personnel concerning the proper steps in the early medical management of injuries resulting from flame and mcendiary munitions. Some of the misunderstanding s'ems from inadequate knowledge of the basic properties such munitions and their variable effects on tissues, ‘kor example, further study needs to be done to determine 'he extent to which various thickeners used in flame muni- h°ns [for example, napalm] actually affect the severity of 'he burns as compared to those from unthickened gaso- me.) Other misunderstandings are also the result of poor 'ransmission of existing information on research findings and technical advances in munitions design, as well as in treatment advances.
Flame agents, for example, certainly produce bums.
Naval personnel train to operate in the midst of a chemical warfare environment. If overcome, they will need doctors and surgeons who themselves have trained realistically to treat such severe injuries.
The extent of damage, however, is also influenced by additional factors, such as the specific munition used and its method of employment. In dry environments, flame weapons can ignite clothing, brush, and susceptible structures, producing additional bums by secondary effect. Other factors, such as the completeness of combustion, the types of combustible materials involved, and the degree of ventilation in the target area, help determine the percentage of lung injury from factors, such as oxygen deprivation, carbon monoxide, and inhalation of toxic fumes.
Health care workers, obviously, must be schooled in the fundamentals of such weapons and the various treatment options available for managing the effects of flame and incendiary devices.
White Phosphorus Injuries: Although white phosphorus (WP) is often classified as an incendiary, it is commonly employed as a screening smoke or as an igniter of other munitions. At a sufficiently high temperature, WP reacts with air and water vapor to produce a dense cloud of phos-
phorus pentoxide—a very effective screen. Incendiary and antipersonnel effects of WP also have military application, since burning particles of WP can start fires in many combustible materials and can cause burns.
WP injuries most commonly occur following explosions of various munitions, where the embedded phosphorus particles within wounds produce chemical bums. When WP is uncovered while a wound is being treated surgically, the environmental temperature may be sufficiently high to ignite it, resulting in spectacular smoking particles within the wound. Particles of WP, therefore, can cause serious burns as well. There are few other bums that are frequently combined with explosive fragmentation wounds of the soft tissues. Obviously, the extent of a patient’s required hospitalization for the complete healing of such complex wounds is significantly longer.
More detailed study of the actual clinical significance of embedded WP, as far as effects upon the local wound, as well as the whole body are concerned, would assist in the planning of surgical procedures. Exposed WP has to be identified and removed because it may bum. Plasticized white phosphorus (white phosphorus particles mixed with viscous synthetic rubber in certain antipersonnel devices) as well as other types of phosphorus materials, may differ in their effects upon tissues, and the body as a whole. Combat surgeons, therefore, will require further instruction before they can treat these wounds adequately.
Environmental Obscurants and Contaminants: Beyond the expected new and unique methods for inflicting injury upon an adversary, the physiological effects from the conditions of the combat environment itself may have serious medical sequelae. The inhalation of agents used as environmental obscurants (akin to smoke screens), such as anthracene, picric acid, or aerosols of fine brass particles, may have unforeseen debilitating effects upon the lungs of every combatant in the field. Perhaps even the purported flaming nitric acid aerosols from Eastern Bloc rocket propellants could ignite the very filters that are used in standard devices to protect personnel from conventional gas warfare, and further complicate the medical problems of the modern battlefield.
Many of these phenomena may have very serious and incapacitating medical results. Their management is certainly ambiguous, and cannot be directly extrapolated from civilian life. The potential for gross incompatibilities between commonly accepted medical treatments and the special nature of these injurious phenomena need to be continuously examined. Lives may be lost should an unprepared medical organization take a “trial and error” approach to treatment.
Unconventional Weapons: The potential spread of weapons of mass destruction—whether chemical, biological, or nuclear—is a matter of increasing international concern. Technology transfers make proliferation more feasible, and even Third World regional powers may well perceive political or military value in unconventional weapons.
Concern relative to the spreading use of chemical and biological weapons has been heightened by evidence of their use by the Soviet Union in Afghanistan, their em
ployment during the confrontation between the Peoples Republic of China and Vietnam in 1979, and their use by Egypt—albeit with counterproductive results—in Yemen in the early 1960s. Fragmentary evidence of chemical/ biological use by Vietnam in Laos and Kampuchea has also surfaced. Iraq’s success in thwarting overwhelming Iranian offensives with chemical weapons sent a clear message to the Third World: There may be important military advantages of chemical/biological warfare use in certain conflicts (that is, against forces massing for assault that are not equipped for chemical/biological warfare defense or to retaliate in kind). There is certainly little reason to believe that the cultural or religious revulsion or inhibitions against chemical/biological warfare use that exist in the West are similarly perceived in Asia or the other Third World nations.
Medical personnel must obviously be familiar with the effects of toxins, chemicals, biological agents, and radiation upon previously healthy troops. Equally important, however, is the need to know how medical treatments for common combat injuries must be modified when they have been acquired in such contaminated environments- The added burden of adverse environmental exposure may not only affect the ability of patients to survive anesthesia and surgery, but also may have a major impact on their healing and recuperative capacities.
Although patient care practice within the military setting is firmly rooted in the fundamental principles of medical and surgical practice, specialized knowledge is obviously required for adapting these principles to combat casualty care. Tactical realities, austere conditions, and the unique properties of wounding agents add a heavily complicated dimension to such treatment. With this in mind, “meatball surgery” and all of the other historically validated combat-unique aspects of medical care should remain as permanent courses in the Navy’s training menu, and not be allowed to be again forgotten.
'Mary C. Gillett, The Army Medicine Department, 1818-1865, The Army Historical Series (Washington. DC: Center of Military History, U. S. Army, 1987).
p. 280.
"Albert E. Cowdrey, The Medics' War: The U. S. Army in the Korean War (Washington, DC. Center of Military History, U. S. Army, 1987), p. 87.
Captain Smith is professor of surgery (urology) at the Medical College ot Georgia, Augusta, Georgia, where he is also a medical school liaison officer for the Navy Recruiting Command. He received his medical degree from the University of Maryland School of Medicine, Baltimore, and was an intern and resident in surgery at the New York Hospital- Cornell Medical Center. After a residency in urology at the Columbia- Presbyterian Medical Center in New York City, he was a fellow in urological cancer surgery at Memorial-Sloan Kettering Cancer Center in New York. Captain Smith entered the Navy in 1965 and served as a surgeon on board the USS Randolph (CVS-15), followed by service with the U. S. Naval Hospital, Memphis, Tennessee. He served as commanding officer of Naval Reserve Medical Contingency Response Unit 507 in Charleston, South Carolina, and as senior medical officer on the staff of Naval Reserve Readiness Command Region Seven in Charleston. He currently is assigned to the Uniformed Services University of the Health Sciences in Bethesda, Maryland, in the departments of Surgery and Military Medicine. He is a previous Proceedings author.