War Surgery and Medicine
The post-operative nursing of the abdominal cases was recognised throughout the war to be of the utmost importance, and it was realised how difficult it was to give adequate treatment under the conditions of the mobile warfare experienced in the desert campaigns. At first in the Field Ambulances, where the abdominal surgery had to be carried out, no beds were available and the cases were nursed on stretchers. This made the retention of Fowler's position very difficult. Just before the Battle of Alamein beds were provided for these cases, both for the Field Ambulances and for the Field Surgical Units, with marked improvement in the comfort of the patient.page 253
At first when the abdomens were operated on in the Field Ambulances the personnel of those units were called upon to undertake the responsibility of nursing these very serious cases after operation. They nobly rose to the occasion and did very good work. Our units, however, had no trained nursing orderlies similar to those in the RAMC regular force.
Later, during the second Libyan campaign in 1941, orderlies with some nursing experience at the base hospitals were available in our Mobile Surgical Unit. In the pre-Alamein period nursing orderlies, as part of the light section from the CCS, were attached to the Field Ambulances, and this often happened afterwards when the Field Ambulances were called upon to deal with the abdomens. At the CCS sisters were always available for nursing the serious cases and they were also able to train the orderlies in this work. The presence of nursing sisters made it desirable, if conditions were at all favourable, to carry out the abdominal surgery at the CCS.
This is illustrated by the following report:
The NZ Field Surgical Unit functioned for the first time in Italy at the Sangro river with entirely new theatre personnel and new orderlies, and was attached to 4 MDS, who had no orderlies trained in nursing abdominals. The team operated on 32 abdominal cases in'twenty days. The nursing situation in a small inadequate Italian building in mid-winter rapidly became unmanageable and a nightmare to the surgeon. Two nursing sisters were sent up from 1 NZ CCS, and in the space of a few hours entirely transformed the situation and the appearance and comfort of the patients.
Fowler's position was utilised following operation up till the last year of the war. It was then suggested that the horizontal position was preferable. It had been observed that abdominal patients, nearly always very shocked following operation, had collapsed, and those who died often did so shortly after their return to the ward, presumably from circulatory failure. It seemed better to treat the patients for shock by laying them flat till the circulation had improved. They were also prone to develop chest complications, and Fowler's position was thought to contribute to this. Forward surgeons readily discarded the Fowler's position and were of the opinion that the horizontal position was definitely preferable and also made nursing easier.
Blood and Plasma
It was noted by the Canadian research unit that the mortality following operation was much higher than that occurring pre-operatively in the resuscitation ward. Lieutenant-Colonel Grant. page 254 of the British shock research unit, vividly pointed out the occurrence of shock following operation and the anxiety which must remain for at least twenty-four hours. He considered the patient required just as careful handling and resuscitation at this period as he did before operation. This corresponded to our experience that the majority of deaths occurred in the first forty-eight hours following operation.
Unfortunately the majority of the deaths were probably inevitable because of the severity of the original trauma, and when the operative trauma was added to this the man stood a very small chance of recovery. We learnt that further blood and plasma was essential at this stage in most cases, and in the later stages of the war blood and plasma were given much more freely. In addition to the immediate post-operative resuscitation, a pint of plasma or serum daily was given to the serious cases to counteract any protein deficiency.
Less than a week following operation there was commonly a secondary anaemia, so that further blood transfusions of from 1 to 2 pints was of the greatest benefit. The graphs of deaths showed that there was a small peak at the sixth day, and this was in keeping with clinical observation. In the severe cases a crisis was always expected about that time, and it was at that time that blood transfusion was of great value in increasing the resistance of the patient to infection.
The administration of intravenous fluids after operation was a routine in the abdominal cases from the beginning of the war. Solutions available were normal saline, 5 per cent glucose solution, and a glucose saline containing 3 per cent saline in the 5 per cent glucose.
It was recognised that an excess of chlorides was undesirable and that the bulk of the fluid should be given in the form of isotonic glucose. The total fluid given in the course of twenty-four hours was from 8 to 10 pints. The quantity of saline given was at first variable, but later became stabilised at 2 pints daily, plus replacement of the quantity of fluid removed by gastric suction by an equal quantity of saline. An output of 50 oz. of urine daily was aimed at. The presence of chloride in the urine was tested for when there was doubt as to the quantity of saline to be given.
Gastric suction was instituted early in the war and remained a regular routine. The tube was introduced through the nose at, or soon after, operation. Kyle's tubes were used at first, but as the page 255 supply was inadequate the larger tubing of the blood transfusion apparatus was utilised and found to be superior. The gastric fluid was drawn off regularly by means of a continuous suction through a bottle. It was continued till signs of peristalsis were present as shown by the stethoscope or by the passage of flatus. The average period was about four days.
Fluid by the Mouth
At first no fluid was given by the mouth till the gastric tube was removed, though the mouth was frequently rinsed and cleansed. Later it was realised that water by the mouth in the presence of the gastric tube could hardly be deleterious and would help the gastric lavage. The swallowing of the fluid gave great comfort to the patient. It was then found that water given by the mouth was partly retained without any deleterious effect, and helped in the necessary supply of fluid. This encouraged surgeons to give more fluid and gradually to introduce fluid nourishment, if the progress of the patient warranted this, even before the gastric tube was removed. Nourishment was given in the form of sugar, sweets, diluted milk, then Benger's Food, egg flips, etc., from forty-eight hours after operation. On the removal of the tube, fluid was given freely in small quantities and nourishment given and stepped up with the progress of the patient. The earlier administration of food led to the more rapid recovery of the patient, and the diminution of post-operative debility and vitamin deficiency.
Morphia was given without question when necessary.
Purgatives were not normally given. One of our surgeons gave small doses of liquid paraffin following the removal of the gastric tube and the re-establishment of peristalsis.
Enemata were given if necessary after peristalsis was present, generally after the fourth or fifth day. The lower bowel was very liable to become loaded with a mass of hard faeces. This was distressing to the patient and interfered with his recovery. Sometimes oil enemata were needed, and even manual removal was occasionally necessary.