Private jack. wounded at the Western Front. Mattijn Buwalda Anesthesiologist-intensivist Medical & Educational Services

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1 Private jack wounded at the Western Front Mattijn Buwalda Anesthesiologist-intensivist Medical & Educational Services

2 The Great war - statistics under arms wounded killed Great Britain Canada France Belgium US Russia Germany Allied powers Central powers

3 The Western front

The Western front Comparison of Casualties from Major Western Front Battles Battle Year Allies German 1st Marne 1914 263,000 220,000 First Battle of Ypres 1914 126,921 161,921 134,315 Verdun 1916

4 The Western front Comparison of Casualties from Major Western Front Battles Battle Year Allies German 1st Marne , ,000 First Battle of Ypres , , ,315 Verdun , , , ,000 Somme , , ,294 2nd Aisne ,000 40,000 3rd Ypres , , , ,000 Spring Offensive Hundred Days Offensive , , ,069,636 1,172,075 Total Casualties ,619,838 4,077,838 3,370,731 3,684,025

5 WW1: a defensive war! machine gun field artillery stalemate - entrenchment superiority to the defence mass casualties during direct assault

6 Wounded Soldier Evacuation system Stretcher bearers Regimental Aid Post Doctor: stop bleeding, splinting, tourniquet, tetanus Advanced Dressing Station More docters; loosen tourniquets, stop bleeding, clean wounds Main Dressing Station Emergency surgery poor care for wounded in Crimean war the Boer war ( ) WW1: static conditions, mass casualties WW2: mobile war present: still in use but more flexible Casualty Clearing Station Full medical care surgery Rear Area Hospital

7 WW1 Role 1 The collecting zone Role 2 The evacuation zone Role 3 The distributing zone

8 Private jack private Jack born 1899 coal miners family started mining at 14 yrs of age enlisted in 1916 at the age of 17 he wanted to do his bit

9 West Yorkshire Regiment The Prince of Wale s own

10 Ypres - Passchendaele third battle of Ypres July-November 1917 heavy rain and mud many Australians West Yorkshire Regiment (Prince of Wales's Own)

11 Over the top

Wounded in action A bright flash, then there was the stench of cordite and rotten flesh, cries of pain, the rattle of machine gun fire, shell burst I feel weak, nauseated, can t get

12 Wounded in action A bright flash, then there was the stench of cordite and rotten flesh, cries of pain, the rattle of machine gun fire, shell burst I feel weak, nauseated, can t get up. My palls are passing by and seem to ignore me Advancing troops were not allowed to stop and care for wounded soldiers Jack was carried back to the British line by stretcher bearers

13 Stretcher bearers equipment: arm band and several dressings unarmed 4 SB per company (227 men)

Officer (RMO) basic equipment check, clean and dress

14 Regimental Aid Post (RAP) first echelon near the frontline sheltered 16 stretcher bearers one Medical Officer (RMO) basic equipment check, clean and dress wounds amputation splinting anti tetanus serum morphine

transport was issued with a revolver was not allowed to join the men

15 Regimental Medical Officer tasks: preventive medicine emergency medicine operative treatment was discouraged get wounded ready for transport was issued with a revolver was not allowed to join the men in battle! max 1 year Manual of injuries and diseases in war, London, HMSO, 1918, p2

16 Modern first echelon care US: Battalion Aid Station German: Truppenverband platz NL: Bataljons hulppost, de AMA opleiding

$Jack arrives at the RAP pale, weak complicated open fracture right leg bleeding!$

17 Jack arrives at the RAP pale, weak complicated open fracture right leg bleeding! shrapnel wounds in the abdomen laceration of his scalp tourniquet Thomas splint cleaning and dressing of abdominal wounds and scalp shock prevention: blanket encourage to drink!

Field ambulance unit originally designed for a mobile front to perform emergency surgery main task WW1: to relieve the RAP of sick and wounded motor ambulance cars horse drawn wagons ADS:

18 Field ambulance unit originally designed for a mobile front to perform emergency surgery main task WW1: to relieve the RAP of sick and wounded motor ambulance cars horse drawn wagons ADS: advanced dressing station inspection of dressings and splints MDS: main dressing station surgery classification for further transport rest, feeding, anti tetanus serum usually bypassed for CCS

19 Dressing station

20 Jack at the ADS dressings changed dislocated tourniquet lost more blood urgent evacuation to CCS by motor ambulance

21 Casualty Clearing Station CCS: primary surgery (life/limb saving) including intracranial and abdominal! close to the frontline (< 10 km) in proximity of railroad CCS: patients 1 ccs/division 1917: 59 CCS s in Western front usually 2-3 CCS s sited adjacently Tents & Nissen huts Staffing: 6 medical officers 2 surgical specialists 7 nursing sisters 120 orderlies Staff could de borrowed from other CCS s or base hospitals

22 admission/ triage walking wounded dressing tent for stretcher cases pre-op resus further treatment evacuation tent OR (Nissen hut) X-ray hut staff and logistics CCS

$pale, drowsy tachycardia open fracture right femur, swollen!$

23 pale, drowsy tachycardia open fracture right femur, swollen! tourniquet removed and reapplied abdominal wounds superficial transfer to shock ward (resuscitation ward) Jack goes for triage

Therapy of wound shock prevent exposure (hypothermia) because shivering agravates wound shock raise the foot of the bed in case of collapse shock ward to prepare for surgery 1914: saline solution 8

24 Therapy of wound shock prevent exposure (hypothermia) because shivering agravates wound shock raise the foot of the bed in case of collapse shock ward to prepare for surgery 1914: saline solution 8 ounces subcutaneously or per rectum 3 hourly glucose 5% en soda bicarb continuous per rectum or by mouth if possible 1916: IV administration NaCl solution (1831) hypertonic saline 6% gum acasia solution (1880) 1917: blood transfusion standarized Foëx BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation. Emerg Med J 2003;20:

25 The concept of shock wound shock symptoms: ashen skin, copious sweating, rapid pulse, dilated pupils, lethargic, withdrawn behaviour primary shock: signs within 20 min after wounding secondary shock: symptoms after a few hours Blood pressure measurement was rare < 1917 Captain Ernst Cowell, surgeon at CCS 23 started to use the sphygomanometer

colloid osmotic pressure (animal experiments, 1916) 6% gum Acasia solution IV Kloot W.

26 The first IV colloid... William Maddock Bayliss (US) Medical Research Committee 1917 included: Starling, Cannon significance of colloid osmotic pressure (animal experiments, 1916) 6% gum Acasia solution IV Kloot W. William Maddock Bayliss s therapy for wound shock. Notes Rec R Soc published online June 2, 2010, DOI: Bayliss WM. Viscosity and intra-venous injection of saline solutions. J. Physiol 1916;50, xxiii-xxiv

27 Crystalloids vs colloids...

Shock ward: candles to provide heat http://www.ourstory.

28 Shock ward: candles to provide heat Mobil Hospital No 6 American Expeditionary force

29 Blood transfusion < 1917: direct transfusion arterial- venous anastomosis syringe-cannula technique > 1917: preserved and stored red cells 500 ml donor blood + citrate and glucose in icebox after 4 days red cells were settled on the bottom storage up to 14 days (ice box) donors: lightly wounded (3 wks leave) only type IV blood (O) Robertson OH. Transfusion with preserved red blood cells. BMJ 1918;june 22:

30 Bottles and needles

31 X-ray tent Shattered right femur

32 Pre op CCS No. 36 standard preoperative instructions: removal of clothes previous night: castor oil enema and bladder emptied omnopon and scopolamine 1 amp cotton wool plugs in both ears Omnopon = alkaloid mixture morphine papaverine codeine Courington FW, Calverly RK. Anesthesiology 1986;65:642-53

33 Jack in the shock ward resuscitation under responsibility of the surgeon! almost no pulse palpable clothes removed warm water bottles & blankets two bottles preserved red blood cells

34 Jack goes for surgery 21 hours post wounding, mid thigh amputation Marshall apparatus 1917 ether, O 2 N 2 O bubble flow meters mask and balloon Marshall G. Anaesthetics at a casualty clearing station. BMJ June 2, 1917

35 CCS operating theatre 3 teams 8 h work 4 h rest 2 active teams round the clock Bricknell MCM. The evolution of casualty evacuation in the British army 20 th century (part1) Boer war to JRAMC 2002;148:

36 CCS

37 the anaesthetist At the onset of WW1: usually MO with no special training or skill transferred after 6 months no continuity of expertise > 1917: One expert anaesthetist (permanent posting) to supervise & train young MO s to maintain the apparatus and supplies to provide (difficult) anesthesia

induction (5min) maintenance with ether blow over 1917: Marshall apparatus (ether, O 2, N 2 0)

38 Anaesthetic techniques in WW1 1914: same techniques as in civilian world ether, chloroform open technique 1916: Shipway s apparatus warm anaesthetic vapours ether/chloroform mixture to shorten induction (5min) maintenance with ether blow over 1917: Marshall apparatus (ether, O 2, N 2 0) Shipway FE. Advantages of warm anaesthetic vapours, and an apparatus for their administration. The Lancet Jan 8, 1916

Anaesthesia of patients in shock I Sir Geoffrey Marshall 1887-1982 Pre war: demonstrator physiology Served 3 yrs at No 17 CCS Ypres

39 Anaesthesia of patients in shock I Sir Geoffrey Marshall Pre war: demonstrator physiology Served 3 yrs at No 17 CCS Ypres Salient Spinal anaesthesia stovocaine gram safe in lightly wounded patients but not in shocked patients! rarely used in a CCS

40 Anaesthesia of patients in shock II Ether open technique Postoperative hypotension Iv ether postoperative hypotension

41 Boyle s machine ether, O 2, N 2 O stable anaesthesia in severely wounded patents mortality 90 > 25% apparatus made by Coxeter UK Evans B. A doctor in the Great War- an interview with Sir Geoffrey Marshall. BMJ 1982;285:

42 No 1 field surgical pannier Anaesthetic equipment: 1400 ml chloroform ether 2 drop bottles hypodermic case drip set mouth gag tongue forceps skinner mask tracheotomy set

43 The surgeon civilian surgeons + assistant surgeons biggest challenge was preventing wound infection

Preventing wound infection Experiences from the last war: the Boer war wound infection not a big problem expectant surgery mind set: a bullet wound is sterile South Africa: dry rocky soil Western

44 Preventing wound infection Experiences from the last war: the Boer war wound infection not a big problem expectant surgery mind set: a bullet wound is sterile South Africa: dry rocky soil Western front: gas gangrene and tetanus huge problem Belgium/ France: dirty muddy, wet soil need for immediate surgery, cleaning of wounds etc Initially expectant surgical policy.. then: drainage + carbolic & H 2 O 2 irrigation, hypertonic salt solution What did help was: complete excision of wounds ASAP prevention of shock (to maintain tissue perfusion) continuous irrigation with the Carrel-Dakin solution (bleach)

45 Base hospital rear area train station good roads existing buildings

46 non urgent surgery recuperation active service convalescent hospital England Base hospital

47 General hospital

48 Private Jack goes home Army pension...

Bookmarks An orthopedic surgeon s storty of the great war: http://libcudl.colorado.edu/wwi/pdf/i73730658.pdf Diary of an assistant surgeon: http://www.

49 Bookmarks An orthopedic surgeon s storty of the great war: Diary of an assistant surgeon: gstation.htm WWI The medical front: This lecture can be downloaded at ISBN

Medicine on the Western Front-Personal Learning Checklist

Medicine on the Western Front-Personal Learning Checklist If you can answer all of these questions your knowledge of this topic is really good. Practice answering the questions and get someone to test