Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIV: War Surgery Within the Division
United States Department of Defense
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Physicians assigned to the unit and division levels may have the most arduous duties of any medical officer. From a medical treatment standpoint, the environment is relatively austere and the spectrum of responsibility broader. However, medical service at this level can result in great personal and professional satisfaction. Although much emphasis is placed upon the ability of the unit and division level medical officer to perform life-sustaining resuscitation during combat casualty care, the nature of combat wounds is such that the actual potential for such intervention is usually not great. The medical officer at the unit or division level will find that the major contribution to combat casualty care during battle will be to control the flow of casualties by effective triage and preparation of casualties for evacuation.
Triage of casualties at the, unit and division levels is designed to recognize three categories of casualties: first, those who need immediate resuscitation and surgical intervention (e.g., shock from internal hemorrhage); second, those who have incapacitating but not immediately life-threatening injuries and are unlikely to return to duty (e.g., fractures); and third, those who can be promptly returned to duty (e.g., minor soft tissue fragment wounds).
About 10% of all wounded can be expected to be in frank shock. Three percent have severe dyspnea arising from thoracic wounds, about 1% have upper airway obstruction resulting from facial or neck wounds, and about 1% require airway management because of severe neurologic trauma. About 15% of all casualties leaving the battlefield require immediate resuscitation or surgery. Perhaps one-half of the remaining casualties will also require evacuation beyond combat zone medical treatment facilities. Assuring the stability and relative comfort of these casualties is an important part of the unit and division medical officer's duty. Casualties who have the potential for return to duty within the specified time constraints of the evacuation policy should be segregated from casualties with more severe wounds. The American experience in Vietnam was that casualties who could return to duty within a few days constituted the largest single fraction of the total combat casualty population. The unit and division level medical officer makes an important contribution to the conservation of our fighting strength by preventing the overevacuation of such casualties.
Certain basic tasks need to be performed on every casualty arriving at the aid station or medical company. First and foremost, a determination needs to be made whether the casualty constitutes a threat to the medical troops or other casualties. This is true not only when chemical or biological agents have been employed, but also in conventional warfare in which there is a need to be certain that the casualty is not carrying explosive ordinance. Sufficient clothing should be removed to allow the medical officer to inspect the wounds and to determine whether immediate life-threatening conditions such as airway obstruction, inadequate breathing, or hemorrhage are present. The level of consciousness, blood pressure, pulse, respiratory rate, and the time should be recorded on the field medical card. The time, dose, and route of administered narcotics, if any, should be noted. The prevalence of dehydration in combat casualties must be appreciated. If necessary, dressings and splints should be applied and preparations made for evacuation to the next echelon. Figure 22 is a flow diagram depicting some of the important combat casualty care decisions that need to be made at the unit or division level.
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