Surgical Lessons Learned on the Battlefield

"I would remind you again how large and various was the experience of the battlefield, and how fertile the blood of warriors in rearing good surgeons." [1] "The dividing lines between trauma in the civilian and military populations are becoming, unfortunately, increasingly blurred." [2] SOME HISTORICAL ASPECTS OF THE ORIGINS OF MILITARY MEDICINE AND SURGERY (Figure 1) The origins of military medicine in the United States date to the first days of the Revolutionary War. [3] In that campaign, a physician-patriot named Dr. Prescott, of Lexington, Mass, was involved in the activation of the minutemen, fought in the Concord engagement beside these first soldiers, and subsequently transported and cared for those wounded in his home. During the revolution, the Continental Congress approved a medical department, but this was dissolved at the end of the war. At the time of hostilities with Britain in 1812, there was a provision for hospital surgeons but no medical department or surgeon general. Although this was eventually addressed, it was not until after the war with Mexico in 1846 that a study was performed that resulted in the introduction of ambulances for the transport of the wounded from the battlefield. When the American Civil War began, military resources were limited and unprepared for the magnitude of the task required of them. Many different factors contributed to the nonexistent state of readiness present in the medical deparment. [3-5] There was only a small standing army supported by limited medical resources. The policy of hands-off Federalism practiced at the time resulted in limited commitment of funds to support the medical department, compounded by a surgeon general who publicly denounced the costly practices in the medical care of the day. The standards for medical training in the United States resulted in physicians trained in a variety of different methods with little consistency or competence. Yet all called themselves physicians. The militia system depended on to field the large volunteer army necessary for the conflict was unsuited to the recruitment, training, and equipping of the forces who responded to the call. Death from illness far exceeded death from wounding, with the common soldier and officers sharing equally in the risk of dying from diseases such as typhoid, dysentery, pneumonia, and tuberculosis. [5,6] Death from wounding was also a significant risk. More soldiers died from wounds in this conflict than in any of the subsequent major wars fought by the United States in total. [4] Several factors, including an ill-prepared military, an inadequate medical department, and the horrendous death rates from illness and wounding, frequently overshadowed the good accomplished by the medical department as it improved during the war years.Figure 1: Wllllam F. Fallon, MD, FACS, President, Eastern Association for the Surgery of TraumaThe origins of military surgery have been felt to date to 1899. [7] Practices before that time involved conservative, observational treatment for penetrating abdominal wounds. Soldiers were kept at rest to limit the extent of peritonitis from wounded hollow viscera and to allow these wounds to seal. It was recognized in the mid 19th century that eviscerated intestine with injury could be closed with sutures, but there was not a general consensus on the use of abdominal exploration for penetrating abdominal wounds. This changed in World War I. [8] Mortality rates from abdominal injury decreased to 50%, and the prompt use of abdominal exploration for injury became the standard for military surgeons. Further refinements of this operative policy for abdominal injury occurred through experience in subsequent wars. Military surgery does not represent a significant departure from the accepted surgical standards that we practice today. For the military surgeon and the medical department, the challenge is to maintain these principles even under difficult or adverse conditions. There are certainly operational differences between surgery in military and civilian settings, however. These relate primarily to the process of wounding and the types of treatment and evacuation necessary for the care of casualties who must also be removed from the potential for further injury in the ongoing battle. Chief among these is the pattern and type of wound sustained. [9-12] Military weapons are typically high-velocity and are associated with extensive tissue destruction and contamination requiring specific treatment protocols. There is also a pattern of wounding by multiple fragmentation seldom encountered in the civilian setting. The sequential pattern of postinjury wound care and postoperative care necessitated by the echelons of care in which different surgeons and surgical teams may care for the wounded soldier at various points in the recuperation from injury is not practiced in the civilian sector. Finally, although all civilian hospitals practice for mass-casualty events in their facilities, and some occasionally experience them, it is typical of the military surgical hospital to regularly receive large numbers of casualties in short periods of time. This requires a different approach to the wounded than what is routinely practiced in the civilian setting. As Dr. Rich alluded to in his Hume Memorial Lecture in 1993, [2] there has been some blurring of the differences between wounding in combat and the pattern of injury seen in the civilian sector. Multi-fire, higher-velocity weaponry is finding its way into the hands of individuals in the civilian sector who use them for all sorts of purposes and with predictable results when the target is another human being. Terrorist groups engaged in campaigns to accomplish specific agendas have resorted to bomb attacks that can result in multiple casualties sustaining wounds from fragments of the device. Civilian refugees from civil strife yield victims wounded by high-velocity weapons of military make, often among the very young and defenseless. The likelihood that civilian surgeons will encounter wounds similar to those seen by our military counterparts is increasing. Fortunately, the modern civilian surgeon caring for critically injured patients has benefited greatly from the century of advances in combat casualty care seen in the medical departments of the United States military. There are several that I wish to discuss with you today. These include principles for the debridement of wounds, resuscitation from shock, the treatment of thoracic injury, and the management of colorectal injury. Although these areas do not represent a complete list of advances in the care of the injured learned from the battlefield, they are, I believe, the basic treatment methods necessary for every surgeon to know who cares for injured patients today. WOUND CARE Wound care strategies are as old as recorded accounts of combat. All are linked by the recognized need to stop bleeding, treat the wound itself, remove impaled, embedded objects or projectiles, and promote healing. In the 19th century, wound care, as described in a surgical text published in London in 1859, [13] entailed the arrest of hemorrhage, the extraction of foreign bodies with the use of probes, and the treatment of the wound itself to limit the inflammation associated with the wound. This often involved incision along the course of the wound. The wound classification system of the 1800s divided wounds into four categories: incised, lacerated, contused, and poisonous. Gunshot wounds were considered contused, lacerated wounds that occurred as a consequence of "the nature of the projectile, the force with which it is [the projectile] driven, and the direction in which it strikes." [13] Because wound healing almost always proceeded by suppuration, incision along the course of the projectile's trajectory may have been an attempt to provide external drainage for the process. An alternative hypothesis has to do with the nature of wounds and how they heal. It was known that clean, incised wounds healed by primary intention more frequently than wounds contaminated with contused, necrotic tissue and foreign bodies. An excisional approach to these wounds perhaps was an attempt to convert a contaminated wound into a clean one for healing purposes. These two approaches are the foundation of the concept of debridement, which was first popularized in this century during World War I. The exact origin of the term is hard to determine. Various authors credit surgeons from Larrey [7,14] to Hunter [12] to the French military surgeons. [8,12] The word "debridement" literally means to unbridle, [15] "to dilate by incision the path of the ball." [13] These incisions should be "free incisions, in the direction and the axis of the limb, to lessen inflammatory tension, prevent extension of sloughing and favor the escape of matter." [13] This interpretation of debridement was typical of the French, who practiced three specific maneuvers in wound care: debridement, epluchage, and parage. [12] Debridement is consequently, most likely in reference to the initial stages of wound exploration and fasciotomy, opening and looking at the depths of the wound, which also served to relieve intracompartmental pressure, evacuate hematoma, obtain hemostasis, and assure drainage. American surgeons took an approach to debridement that was based on an aggressive philosophy. George Crile, writing about wounds seen in the First World War, noted that more than 95% were infected. [8] He proposed and practiced "excision revision" to restore wound resistance to infection and promote wound healing. This was referred to as debridement by the Americans and actually encompassed all the separate phases of wound care practiced by French surgeons and others in staged fashion. [12] In the Second World War, research by the British documented a wound culture-positive rate of 51%, and debridement was less extensive as a result. [12] All concepts of debridement take into consideration the wounding potential of projectiles. It is well known that the mass and velocity of the projectile set the theoretical limit of potential disruption of tissue that can occur with wounding. The construction and shape of the projectile limit the potential that can be reached. Debridement is a particularly important treatment for the "compound" full metal jacket projectiles used in every conflict since the turn of the century. [16] It recognizes and accommodates the ballistic behavior of these projectiles and is particularly suited to addressing the secondary cavitation that has been recognized since the introduction of these bullets. [12,16] It is very appropriate for the care of wounds in which fragmentation has occurred. Debridement as practiced today includes using a minimal skin incision. [7,12] Wounds may be extended to allow exposure. If this is done, it should be along the long axis of the extremity. The fascia should be incised liberally as well, to achieve exposure of the depth of the wound. Injured muscle should be excised to bleeding tissue, normal color, consistency, and contractility. Bone incised should be conservative, with only nonviable fragments removed from the wound. Tendons, nerves, and blood vessels should be debrided sparingly. Blood vessel repair should be performed if indicated after excision of the gross injury at the end of the vessel. Arteries and veins are treated in the same way. All wounds are left open for delayed primary closure or skin graft at a later date. SHOCK Like wound care and debridement, shock was a phenomenon recognized in the 19th century. It was, however, less well characterized than wounding. A surgical text published in London in 1859 had a total of 1,000 pages. Three were devoted to the subject of shock. [13] Despite the relative paucity of description, many of the observations are quite accurate and pertinent to how we view shock and injury today. Shock was considered to be an immediate and constitutional effect of injury. This was noted to lead to disturbance of the functions of the circulatory, respiratory, and nervous systems. The magnitude of the manifestation correlated with the severity of the injury and the duration of the condition was proportional to the extent of the injury. The condition was noted to last for a variable period of time. The duration depended on the severity of the injury and the extent of the "nervous susceptibility" [13] of the individual. It was recognized that this susceptibility might lead to death from shock in some individuals. Most recovered, however. Reaction set in and the disturbed balance was gradually restored. This reaction, however, could progress beyond normal limits and lead to febrility as well as remote local consequences. Read in the context of our present understanding of shock after injury, this sounds as if the author is describing the systemic inflammatory response seen with some forms of severe injury today. Another prescient observation was that this reaction beyond certain limits was recognized to be the source of many structural diseases. This observation was based on autopsy data obtained when the patient with shock died months after injury. Alterations in structure with extensive, local mischief, usually of an inflammatory character, was noted on autopsy. This appears to be one of the first references to multiple organ failure as a consequence of the injury and shock state. There is no mention, however, or recognition of the correlation of shock with blood loss. Death from blood loss on the battlefield is the result of a complex interaction involving the type of wound sustained, the time interval from wounding to definitive care, and the treatment employed. In the 19th century, improvements in the evacuation of the wounded from the battlefield occurred with the innovations of Larrey in the Napoleonic Wars and with the organizational improvements introduced by Letterman in the American Civil War. [3,15] In the wars of this century, improvements in evacuation were associated with decreasing mortality rates. In World War I, it was observed that mortality was only 10% in those who reached care within 1 hour versus a 75% mortality rate for those who reached care more than 8 hours after wounding. [3] It appears that this is the origin of the observation of the "golden hour" after injury. In terms of the treatment available, blood transfusions were used to treat the low venous pressure seen among patients with shock. Surgeons recognized the necessity to balance restoration of blood pressure with surgical control of the wound and hemostasis. In the Second World War, after a shaky start, the wounded soldier benefited from improvements in evacuation, resuscitation, and the use of blood products. Reports of organ failure, particularly renal failure, began to be observed among some who were treated for massive shock. In Korea and in Vietnam, there was a steady improvement in the evacuation to definitive care that lessened death on the battlefield from wounding. The military employed the helicopter, first introduced in World War II, to rapidly transport wounded soldiers, often directly from the battle or with blood primarily was by the aggressive use of There was experience with organ The exposure of our soldiers to wounding has not decreased as the century to a This has seen the with wounded soldiers as a result. A from the experience of the in published in the of casualties that were those who at the hospital to receive three All of these were the result of occurred from and one from blood loss not by a The is difficult to use in When not it is As as the was with George the the at it would be a as to it would be a loss or a [8] as our experience with wounding, blood and control are to the experience with these is our present understanding of shock. that a complex set of is by shock and injury The of on the battlefield and in the civilian trauma include tissue injury and AND of thoracic injury has from the treatment methods described in the 19th century. Military learned have been in this in the 19th century for wounds to the was [13] The mortality was If a patient management for treatment of the wound would often be This treatment would the wound, of foreign bodies if and bleeding the patient to venous This last was to the bleeding that occurred within the after wounding. century physicians recognized the of penetrating wounds to the the of foreign and that surgery might be required for ongoing The common of the time was that bleeding within the would to the of bleeding from the injured for blood or and might be The treatment of thoracic wounds in World War I with many of the basic principles of 19th century [8] there was of the for was not in the that of the injured occurred. Surgeons practiced closure for wounds and removed foreign bodies. however, was delayed for hours to that the patient was likely to the wounding When surgery was practiced for thoracic injury in the First World War, it was very aggressive and In to their surgical counterparts in the American surgeons with the used pressure and a for the exposure. The injury was with and of the The incision was closed wounds were all and no were This was associated with a in mortality to in these In World War II, there was a recognition of the of associated with after wounding, and aggressive for was was often until the was was into the and the was to and the This was also good for to more normal was for those in this was were in patients with for wounds, or significant structure injury, and some forms of foreign bodies. mortality with treatment of wounds was as The conflict in Korea was a challenge for the medical and often or with casualties pressure on treatment and evacuation of patients who often required resuscitation was a The medical support was unprepared for the of this The management of was a treatment very suited to these conditions. In one of patients from the War, were by In there was a experience with the for drainage of The introduction of more to for the encountered with In Vietnam, drainage for injury and was at the often within of wounding or directly from the of wounding. and with good resuscitation protocols. the of in this was indicated for patients with although the for its use today is the for the treatment of AND In World War I, wounds of the and wounds of the occurred with and Mortality for these wounds was not however, and Although mortality was it progress the experience A policy of immediate for penetrating abdominal injury was for these Crile, in his on described the of immediate [8] These concepts that are very to the trauma surgeons of A from to was for exposure. The concept of the use of an with abdominal closure to control contamination and for patients who were at the time of surgery was of the if injured was injury was The risk associated with a colorectal injury involving the was at the end of the experience of the First World War, however, was the of primary repair or for the treatment of colorectal injury. In some experience to favor primary were not as and with became the required on from the for the management of colorectal injury, a pattern of treatment in World War and in the The use of for these became a of The had to be to the This was particularly important for colorectal injury. with this treatment mortality from these to In World War II, it to and in it decreased even more to A of this often was the policy of not any wounds. This the risk of infection and the wound as a potential source of infection that might treatment during the evacuation process. [7] In Vietnam, was to the treatment for injury. In a of the use of with patients for it was not and documented different there was minimal and no there was significant and mortality care for injury had into four of the and repair of the injury if of the treatment of and injury learned from the battlefield the concept of prompt abdominal soldiers care at different after wounding as well as different of care at various surgeons at different in the evacuation must to any in abdominal wounds open to the fascia was one used to the treatment of the wounded to the of A of injury and with the use of was another important to promote care through the evacuation process. The of closure when no necessary was also in the military. also used the of delayed closure of the abdominal wound to primarily wound such as this one are always in this and on the from experience with military medicine as a in the surgery at from through Many will have far more experience and than I in the care of the injured I certainly would not for surgical learned from the battlefield, particularly from those who have actually surgical practice in those practice has been by the of combat casualty care in the areas I have and I that I a surgeon for you all very