New Zealand Medical Services in Middle East and Italy
A full report on this subject was submitted by Colonel Ardagh, ADMS 2 NZ Division, and a shorter report by Lieutenant-Colonel King, OC 4 Field Ambulance. Colonel Ardagh stressed three main factors in the successful working of a divisional medical service and in the efficient treatment of battle casualties:
Early collection and evacuation from place of injury to the nearest station providing surgery.
Provision of resuscitation at ADS and/or MDS.
Provision of efficient surgery as nearly as possible within the optimum period of six to twelve hours.
His report ran:
Early evacuation cannot be ensured without an adequate supply of ambulance cars on the line of evacuation, RAP to ADS to MDS. It can fairly be said that, unless casualties can be collected quickly, given initial treatment including shock therapy, and evacuated early to the nearest station providing surgery, the benefits of modern surgery and skilled surgical teams will be largely negatived; the result will be, in proportion to the delay past the optimum period, increased loss of life, limb or function, with relatively much lengthened periods of recovery and convalescence in general. It is well known that wounds in modern warfare are accompanied by considerable shock, apart from haemorrhage, and that if wounded are left lying out in the field or around RAPs for any length of time, with the attendant nervous strain from the proximity of shell or bomb explosions, this shock is considerably aggravated, just as loss of body heat and dehydration are accentuated by the delay in receiving resuscitation. The supply of ambulance cars necessary to deal with busy periods and thus avoid this delay can be effected by increasing the establishment to 20 cars for Field Ambulance as is the case in Light Field Ambulances, or by attaching extra cars whenever a Division is going into an active role.
2 NZ Div. has right through this campaign had sufficient cars attached by DDMS Army or Corps to make this quick evacuation possible, permitting at least one car with each RAP and nine cars at each ADS.
Resuscitation which includes administration of fluids, warmth, comfort and especially relief of pain, with, in more severe cases intravenous use of blood and/or plasma must be available at an ADS, unless an MDS underground could be close enough to dispense with the necessity for an ADS. In the period July to August this was most essential at certain periods where travel was rough, as many patients transfused at the ADS would not otherwise have survived the rough journey to the MDS.
At the MDS, with surgical teams attached, resuscitation is necessary on a large scale, not only to prepare serious cases for operation, but to fit them for the journey, often long and rough, to the CCS or, in rarer cases to fit them for air ambulance evacuation to Base Hospital.page 372
It is the definite and considered opinion of all surgeons and experienced Field Ambulance officers that ‘whole blood’ even if held in the refrigerator for 14 days is much superior to ‘plasma’, inasmuch as not only does it produce a quicker response, but maintains the improvement much longer. With this end in view and also in order to conserve supplies of blood, the administration of plasma may be used in conjunction with whole blood.
The attachment of a Transfusion Unit to the MDS is a big advantage as it supplies a skilled team to attend solely to intravenous therapy, thus relieving the MDS staff and surgical teams in busy periods of much work, and it ensures an adequate supply of blood kept at the correct temperature in the special refrigerator. The alternative is an easily available ‘Blood Bank’ provided by Corps. A shuttle service of blood between MDS and ADS was provided in August and in the recent battle and undoubtedly saved a considerable number of lives by early administration at the ADS.1
It will be accepted by all that at least lifesaving surgery should be done at the most forward operating centre for even the delay of an hour or two will deprive the patient of prospects of recovery and this is especially so in the penetrating abdominal wounds. In these cases provision should be made to nurse them in hospital beds and so hold them for the necessary period varying from 2 to 10 days. In static conditions, or in an advance this is always possible, for if the MDS has to move, sufficient personnel to continue nursing these patients in situ can be provided, and throughout most of the campaign as many as 20 patients at a time were held in the MDS, nursed in beds with an additional saving of life thereby. If a retirement should be ordered, or a sudden retreat enforced, it would obviously be necessary for the MDS to evacuate these patients, or to carry them with the Field Ambulance in ambulance cars. The alternative of leaving them with the enemy would not be voluntarily considered as it is certain that the enemy would in any case move them and would be unlikely in doing so to give them as good treatment as our own units.
Where the tactical situation makes it possible, or where the route of evacuation is long and rough as in the period June to September, more than merely life-saving surgery can and should be done at the MDS, except on rare occasions such as the period 23 Oct. to 4 Nov. when the CCS was distant from the MDS only two hours on a smooth main road. Once the optimum period is passed even a short delay of a few hours in providing surgery, and even in less serious wounds, lessens the prospects of quick recovery and control or prevention of wound infection, and increases the risk and degree of loss of function, as well as necessitating for such patients much longer periods of hospitalisation and convalescence.
So far in the desert campaign from June last it has always been possible and beneficial to the wounded to provide resuscitation, surgery and nursing at the open MDS without in any way impeding the ability of the Field Ambulance to close, move or open when and as required.
Lieutenant-Colonel King stressed the necessity of having attached to our active MDS two surgical teams, one of which should be a light section of a CCS with facilities for post-operative nursing. He considered the surgical team should contain three medical officers to allow a measure of relief. Strong support was given to the attachment of an FTU to the MDS and the highest praise expressed for page 373 the work done by Captain Muir and his staff. He stated that on 4 September no fewer than seventy-nine vehicles were used for the evacuation of casualties in 2 NZ Division's area and from the MDS to the CCS, all but ten of them being ambulances, and they were fully employed.
The lessons learnt are clearly enunciated in these reports, and could be summarised as:
The importance of a considerable increase in the provision of ambulance cars in the forward areas.
The great value of early blood transfusion with the attachment of an FTU to the operating MDS.
The need for the attachment of at least two surgical teams and a nursing section from a CCS to the MDS to ensure skilled surgery and post-operative nursing.
Early air evacuation is dangerous for abdominal cases and chest cases with any respiratory distress. It is eminently suitable for all other cases.
Wireless inter-communication between medical units is desirable in mobile warfare.
The value of sterilised dressings forwarded from the base.
1 CO 6 Field Ambulance in January 1943 said: ‘“Blood Forward” is the greatest single advance of the last year.’