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765 COLLECTION OF INVASION CASUALTIES - THE LANCET LONDON: : S.T ZJRD9.Y, DECED4BER 20, 1941 AUTHORITIES have been urged to cooperate with each other so that the combined machine for the collection of casualties shall work as smoothly as possible if we are invaded. There are three main schemes in operation, and each of them possesses aid- posts of different capacities, all of which, together with all the ambulances, are to be available for both civilian and military casualties. An attempt is -now being made to weld these services into one and to arrange their aid-posts on a network plan, which shall allow the least specialised to be ranged around those of more complexity, and these again around the general hospitals. The first or lowest class of aid-post may be either a detachment aid-post of the R.A.M.O.’ (consisting of one or two first-aid men and a small satchel of dressings), a civilian first-aid point, a Home Guard casualty collecting post, or a wholly unofficial private house or factory which may chance to have a certain amount of equipment. Walking casualties are expected to find their way to such points as these, and Home Guard stretcher bearers will also be ex- pected to carry their charges there, but civilian stretcher cases are to be taken by ambulance direct from the place at which they are injured to some post in the second or third class. The posts of this first class will not have a doctor in regular attendance. Between the first and second class of posts there comes an intermediate class which includes advanced dressing stations of the R.A.M.C., regimental aid- posts of the Home Guard and up-graded points of the civil services. The precise function of these units is likely to vary with the needs of the moment. Their equipment is simple and their staff extremely small. The second main class of aid-post comprises main dressing stations of the R.A.M.C., first-aid posts (mobile or fixed) of the civil services, and some of the smaller hospitals. These are intended for the treat- ment and temporary accommodation of cases which do not need specialist surgical treatment but are yet so severely injured as to need inpatient care or to be sent home to bed by ambulance. These posts will also deal with walking cases from their own vicinity or cases brought in from a distance without stopping at any lesser post. The third and last form of medical aid is to be given at casualty clearing posts of the R.A.M.C. or at fully equipped military or civilian hospitals. In so far as these may prove to be too near to the battle zone for reasonable safety, their patients will be cleared as soon as possible after operation by Green Line ambulance or hospital train to suitable refuges in remoter areas. These three classes include most but not all of the recognised posts. The normal course of a stretcher case from the time of wounding until he reaches hospital will vary according to whether he follows the R.A.M.C., the Home Guard or the civilian route of evacuation. The fact that he follows any particular route does not imply that he is either a soldier or a civilian ; each may follow any of three routes. The wounded soldier or the wounded civilian in a military area will be picked up on the battlefield by regimental stretcher bearers and carried to the nearest post of class I. In the case of the Army this will usually be an advanced dressing station or a regimental aid-post. Here he will be looked after until it is possible to load him on an ambulance. The ambulance will convey him, according to his needs, to a post of class 2, direct to a hospital, or perhaps an ambulance train for further transport away from the scene of action. Having re- _ ceived the best attention possible at the second class post he will if necessary be sent on to hospital. This will either be some special hospital-say for fractures or head cases-or a general hospital. 2. The Home Guard stretcher case will be picked up on the battlefield by H.G. stretcher bearers and carried to any post of class 1. If this is a H.G. casualty collecting post, the Home Guard must then establish contact with the civilian coiitrol centre and look after the wounded until ambulances arrive to take them .way. Home Guard responsibility will then cease and casualties will follow the civilian route of evacuation. 3. The wounded civilian will get into touch with the air-raid warden or the police who will in turn get into touch with the control centre. This will send out (if possible) both a first-aid party and an ambulance or ambulances. The wounded will then be taken to a post of the second class, to one of the intermediate class, or to a hospital according to the needs of the case as assessed by the’first-aid party. If a number of civilian casualties occur at one spot the control centre may send out a mobile first-aid post with orders to open up in some convenient building and deal with the cases on the spot. These are the main types of post and the main lines of evacuation at present planned, but their harmonious coordination is hampered by several factors. Many people suppose that it will not be possible to put ambulances on the road in invaded areas for periods which may be as long as a week. Some posts-for example the up-graded points now being established- are required to have accommodation and rations for a week while others, notably the Home Guard posts and ordinary civilian points, are established on the understanding that ambulances will always be available and that they will not be called on to retain patients. Until it is generally agreed whether it is wise to depend on immediate clearance by ambulance. no satisfactory cooperation is possible. If it should prove that ambulances are delayed for periods ranging from 24 hours to a week all posts of the first class would have to provide hasty and probably un- satisfactory accommodation, dressings and food. In a settled and well-populated country it ought not to be necessary to depend on last minute improvisations to this extent. A second obstacle to cooperation is the present distribution of medical man-power. As at present arranged, the civilian services claim to have the first call on all medical men, including those of the Home Guard but not those of the R.A.M.C., even if temporarily idle. , This claim includes the right to keep medical officers at duty points-such as a garage housing a mobile ambulance-even if there is no work for them to do and even if, as Home Guard or civilian doctors, there may be great need for them elsewhere. So long as one Service makes a claim of this sort there is bound to be a serious wastage of medical man- power and this wastage we can ill afford. What is needed is some form of clearing house for medical men under the control of a commission representing all three Services, which shall get to work before the emergency comes and continue to operate in time of invasion. A third difficulty arises because there is no agreement about decentralisation and dispersal of

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765

COLLECTION OF INVASION CASUALTIES

- THE LANCETLONDON: : S.T ZJRD9.Y, DECED4BER 20, 1941

AUTHORITIES have been urged to cooperate witheach other so that the combined machine for thecollection of casualties shall work as smoothly aspossible if we are invaded. There are three mainschemes in operation, and each of them possesses aid-posts of different capacities, all of which, togetherwith all the ambulances, are to be available for bothcivilian and military casualties. An attempt is -nowbeing made to weld these services into one and toarrange their aid-posts on a network plan, which shallallow the least specialised to be ranged around thoseof more complexity, and these again around thegeneral hospitals.The first or lowest class of aid-post may be either a

detachment aid-post of the R.A.M.O.’ (consisting ofone or two first-aid men and a small satchel of

dressings), a civilian first-aid point, a Home Guardcasualty collecting post, or a wholly unofficial privatehouse or factory which may chance to have a certainamount of equipment. Walking casualties are

expected to find their way to such points as these,and Home Guard stretcher bearers will also be ex-pected to carry their charges there, but civilianstretcher cases are to be taken by ambulance directfrom the place at which they are injured to some postin the second or third class. The posts of this firstclass will not have a doctor in regular attendance.Between the first and second class of posts therecomes an intermediate class which includes advanceddressing stations of the R.A.M.C., regimental aid-posts of the Home Guard and up-graded points of thecivil services. The precise function of these units islikely to vary with the needs of the moment. Their

equipment is simple and their staff extremely small.The second main class of aid-post comprises maindressing stations of the R.A.M.C., first-aid posts(mobile or fixed) of the civil services, and some of thesmaller hospitals. These are intended for the treat-ment and temporary accommodation of cases whichdo not need specialist surgical treatment but are yet soseverely injured as to need inpatient care or to be senthome to bed by ambulance. These posts will alsodeal with walking cases from their own vicinity orcases brought in from a distance without stopping atany lesser post. The third and last form of medicalaid is to be given at casualty clearing posts of theR.A.M.C. or at fully equipped military or civilian

hospitals. In so far as these may prove to be toonear to the battle zone for reasonable safety, theirpatients will be cleared as soon as possible after

operation by Green Line ambulance or hospital trainto suitable refuges in remoter areas.These three classes include most but not all of the

recognised posts. The normal course of a stretchercase from the time of wounding until he reacheshospital will vary according to whether he follows theR.A.M.C., the Home Guard or the civilian route ofevacuation. The fact that he follows any particularroute does not imply that he is either a soldier or acivilian ; each may follow any of three routes.

The wounded soldier or the wounded civilian in amilitary area will be picked up on the battlefield byregimental stretcher bearers and carried to the nearestpost of class I. In the case of the Army this will usuallybe an advanced dressing station or a regimental aid-post.Here he will be looked after until it is possible to loadhim on an ambulance. The ambulance will convey him,according to his needs, to a post of class 2, direct to ahospital, or perhaps an ambulance train for furthertransport away from the scene of action. Having re- _

ceived the best attention possible at the second class posthe will if necessary be sent on to hospital. This willeither be some special hospital-say for fractures or headcases-or a general hospital.

2. The Home Guard stretcher case will be picked upon the battlefield by H.G. stretcher bearers and carried toany post of class 1. If this is a H.G. casualty collectingpost, the Home Guard must then establish contact withthe civilian coiitrol centre and look after the woundeduntil ambulances arrive to take them .way. HomeGuard responsibility will then cease and casualties willfollow the civilian route of evacuation.

3. The wounded civilian will get into touch with theair-raid warden or the police who will in turn get intotouch with the control centre. This will send out (ifpossible) both a first-aid party and an ambulance orambulances. The wounded will then be taken to a postof the second class, to one of the intermediate class, orto a hospital according to the needs of the case as assessedby the’first-aid party. If a number of civilian casualtiesoccur at one spot the control centre may send out amobile first-aid post with orders to open up in someconvenient building and deal with the cases on the spot.

These are the main types of post and the main linesof evacuation at present planned, but their harmoniouscoordination is hampered by several factors. Manypeople suppose that it will not be possible to putambulances on the road in invaded areas for periodswhich may be as long as a week. Some posts-forexample the up-graded points now being established-are required to have accommodation and rations for aweek while others, notably the Home Guard postsand ordinary civilian points, are established on theunderstanding that ambulances will always beavailable and that they will not be called on to retainpatients. Until it is generally agreed whether it iswise to depend on immediate clearance by ambulance.no satisfactory cooperation is possible. If it should

prove that ambulances are delayed for periodsranging from 24 hours to a week all posts of the firstclass would have to provide hasty and probably un-satisfactory accommodation, dressings and food. Ina settled and well-populated country it ought not tobe necessary to depend on last minute improvisationsto this extent. A second obstacle to cooperation isthe present distribution of medical man-power. As at

present arranged, the civilian services claim to havethe first call on all medical men, including those of theHome Guard but not those of the R.A.M.C., even iftemporarily idle. , This claim includes the right tokeep medical officers at duty points-such as a garagehousing a mobile ambulance-even if there is no workfor them to do and even if, as Home Guard or civiliandoctors, there may be great need for them elsewhere.So long as one Service makes a claim of this sort thereis bound to be a serious wastage of medical man-power and this wastage we can ill afford. What isneeded is some form of clearing house for medicalmen under the control of a commission representingall three Services, which shall get to work before theemergency comes and continue to operate in time ofinvasion. A third difficulty arises because there is noagreement about decentralisation and dispersal of

766

medical equipment and first-aid workers. It mustfirst be agreed, of course, whether circumstances will orwill not compel the dispersal of casualties and whetherconcentration of casualties in defended towns and otherdanger spots should be permitted. There are boundto be differences of opinion and no official decision willcommand universal approval, but these points shouldat least be discussed and a line of action should beagreed on by the heads of all three Services. Other-wise the Services themselves can never cooperate ina way to command the confidence of the public.

THE MAN IN THE IRON LUNGTHE Drinker type of respirator, so beloved of public

fancy, has only a limited use in this country wherewidespread epidemics of anterior poliomyelitis are

rare. Therare patients, however, whose lives de-

pend on its use, and their management calls for highlyskilled medical supervision and nursing. In Americasuch cases are more common. SCHMITT and SELDON/of the Mayo Clinic, discussing practical points in

management, say that negative pressure should notexceed 20 cm. of water, and that positive pressure isneeded only when the patient is being taught to cough.Negative pressure should be increased to 25-30 cm.of water for a few minutes every four hours, to keepthe costochondral joints from getting stiff. The

respiratory rate is kept at 18-20 a minute, and rateand pressure should be the lowest possible to keep thepatient comfortable and of a good colour. His headis kept lower than his feet, making an angle of some20° with the horizontal, and mucus and secretiondraining into the throat as a result of this posture areaspirated by gentle suction. Portholes in the

respirator make it possible for ordinary nursing careto be given without removing the patient, but for anycomplicated measure it may be necessary to take himout. If the respiratory muscles are not completelyparalysed he may be able- to breathe withoutmechanical aid for a few minutes ; otherwise if themachine is opened respiration must be maintained insome other way, and SCHMITT and SELDON havedevised a simple technique of giving oxygen through aface mask and bag. When the machine is stopped, oropen, the mask is applied, and the bag is squeezedrhythmically 18-20 times per minute. In this waythe patient is able to remain out of the machine longenough for essential nursing and medical attention tobe carried out thoroughly.Between 400 and 500 patients suffering from polio-

myelitis were treated in respirators in the UnitedStates last year. Two-thirds of them had bulbar

paralysis with pharyngeal paralysis, and two-thirds ofthese died. WILSON,2 SCHMITT and SELDON agreewith the English findings that better results may beobtained in bulbar paralysis from measures directedto maintaining the patency of the air-passages thanfrom treatment in the respirator. - WiLsoON mentionsthe use of tracheotomy in selected cases. He saysthat the respirator is clearly indicated only when therespiratory difficulty is due to intercostal or dia-

phragmatic paralysis and that a third of the 400-500cases fell into that category, of which less than 20%died. Although it is sometimes questioned whetherthe use of the respirator is justified for patients who,ifthev survive. mav be so severelv naralvsed that their

1. Schmitt, G. F. and Seldon, T. H. Proc. Mayo Clin. 1941, 16, 453.2. Wilson, J. L. J. Amer. med. Ass. 1941, 117, 278.

lives will be of little value to themselves or othersWILSON points out that at the time when the use of therespirator must be begun it is impossible to estimatethe future degree of paralysis and thus every patientshould be given his chance of survival and recovery.He emphasises the importance of instituting treat-ment in the respirator early if there is evidence ofweakness of the intercostal muscles and diaphragm,in the belief that the weakened muscles can be restedand protected by treatment in the respirator and sopossibly less strain put on the damaged anterior-horncells. He suggests that the patient should beexamined for weakness of the neck and shouldermuscles, which is invariably associated with inter-costal and diaphragmatic paralysis, and he believesthat the respirator should be used long before cyanosis,dyspnoea and air-hunger appear. SCHMITT andSELDON give as the chief indications for placing thepatient in the respirator: restlessness, monosyllabicspeech, inereased respiratory rate and a vital capacityof less than 250 c.cm. of air.In America it is difficult to make the ideal early

decision for treatment in the respirator because thereare not enough machines, and there it is hoped thatsome cheap, readily portable and effective respirator,perhaps of the cuirass type, will be developed. The

position is different in Britain where Lord NUFFIELDhas ensured that respirators are available in almostevery hospital.

WHERE THE WARD ROUND RUBSPATIENTS probably cared little enough for the

attentions of medical students even before Martial, inthe first century A.D., wrote :Languid I called on you, Symmachus, quickly you heard me,Quickly you came with a hundred raw students behind.They earnestly pawed me all over with hands like the arctic :I was free from the fever before, but now-by Apollo !

I’m burning.Certainly this restive spirit in the clinical material hasnot changed since.- Repeated examinations are notthe only harrying part of the business : the patientmay be perturbed by other aspects of the ward round- buy anticipation, by the conflicting opinions of hisexaminers, or by his own misinterpretation of sometechnical term which he is too frightened to ask about.Dr. JOHN ROMANO has investigated 100 unselectedpatients at the Peter Bent Brigham Hospital before,during and after the Saturday morning teachinground and has shown some of the ways in which the

patient may be unwittingly dismayed. On theserounds one or two patients from each of the fourmedical wards are presented to a group of 50-70people, including members of the staff, visiting doc-tors, students and nurses. The patient’s bed is placedin the centre of the ward, the history is given, thepatient is questioned and examined, and finally hiscase is freely discussed. The occasion thus has an

important publicity and the patient may have to waitfor a period ranging from a few minutes to an hourfor the ward round to reach him. The patientsinvestigated were all prepared for the experience bythe senior house-officer who told them,.;Jt on the daybefore the round, that they were being shown to alarge group of physicians because their cases presenteddifficulties which would be better understood andi-,re,at(,d after gent-ral discussion- The -nersonalitv of

1. J. Amer. med. Ass. Aug. 30, 1941, p. 664.