NATO-emergency-war-surgery.pdf

EMERGENCY WAR

SURGERY

NATO HANDBOOK

THIS DRAFT IS ONLY TO BE USE FOR REVISION

PURPOSES. IT IS NOT APPROVED FOR ANY OTHER USE

WORKING DRAFT

14 NOVEMBER 2000

EMERGENCY WAR SURGERY

WORKING DRAFT

FOREWORD

The success of any military health care system in wartime is directly related to the

number of casualties adequately treated and returned to duty with their units. This must be

accomplished as soon and as far forward in the theater of operations as possible.

The Second Battle of Bull Run near Manassas, Virginia, was one of the major

engagements of the United States Civil War. Three days after that great battle, three thousand

wounded men still lay on the field. Relatives traveled to the front and took their loved ones

home for treatment rather than leave them to the uncertain ties of military medicine. We have

made phenomenal progress in the century since that battle occurred.

I have had the privilege of being a physician for nearly forty years. Half of that time was

spent on active duty in the military services and the other half was spent in the civilian sector. I

have participated in the delivery of health care in every conceivable setting: in a battlefield tent

in Korea; on a hospital ship; in an air squadron; from austere county and state hospitals to large,

glossy high technology institutions. I have seen people strive for, and achieve, excellence in all

those settings. I see it now in the military health care system, and no one is more proud than I of

the accomplishments and the quality of that system and of the special type of men and women

who make the system work. Our system is not without its problems and its frustrations. It takes

a long time for equipment to be delivered; the personnel system doesn't always provide the

proper mix of people in a timely manner to get the job done; but with rare exceptions, the

medical mission is accomplished in exceptional fashion.

This handbook should serve as a constant reminder that ours is a high calling. We are

here to save lives, not to destroy them. We are committed to the future, not the past, and to the

primary mission of military medicine, which is to keep the soldiers, sailors, airmen and marines

alive and whole: in the words of Abraham Lincoln, to minister to "him who has borne the brunt

of battle."

This revised edition represents the contributions of talented and gifted health

professionals from the military services as well as from the civilian sector. All who contributed

have the grateful appreciation of the editorial board for the enthusiasm, dedication, and

perseverance which made this revision possible.

ILLI M ER, . .

Assistant Secretary of Defense

PREFACE

( ealth Affairs)

EMERGENCY WAR SURGERY

WORKING DRAFT

This edition of the Emergency War Surgery Handbook is written for and dedicated to the

new generation of young, as yet untested surgeons, who may be given the opportunity and the

honor of ministering to the needs of their fallen fellow countrymen. What is the likelihood that

you will be called to serve? The ancient Plato provided the answer: "Only the dead have seen

the end of war!"

Will you be adequate, will you be successful in salvaging the lives and limbs of those

comrades by applying the principles of the lessons hard-learned by countless generations of

combat surgeons that have preceded you? The answer is a resounding yes, for "I would remind

you how large and various is the experience of the battlefield and how fertile the blood of

warriors in the rearing of good surgeons" (T. Clifford Albutt).

What sort of wounds will you be expected to manage? The Wound Data and Munitions

Effectiveness Team (WDMET) data derived from the Vietnam battlefield provide some insight

into the types of wounds and the casualty mix that might be expected. The WDMET data

indicate that 100 combat casualties, who survive long enough to be evacuated from the field,

could be statistically expected to present the following casualty mix:

Thirty casualties with minor or superficial wounds, minor burns, abrasions, foreign

bodies in the eye, ruptured eardrums, and deafness.

Sixteen with open, comminuted fractures of a long bone, of which several will be

multiple and several will be associated with injury of named nerves.

Ten with major soft tissue injury or burns requiring general anesthesia for debridement.

Several will have injury of named nerves.

Ten will require laparotomy, of which two will be negative and several will involve

extensive, complicated procedures.

Six with open, comminuted fractures of the hand, fingers, feet, or toes.

Five will require closed thoracostomies and soft tissue wound management; at least one

will have a minithoracotomy.

Four will have major multiple trauma, i.e., various combinations of craniotomies,

thoracotomies, laparotomies, amputations, vascular reconstructions, soft tissue debridements, or

fracture management.

Three will be major amputations (AK, BK, arm, forearm). In three out of four, the

surgeon will simply complete the amputation.

Three craniotomies. Two will be craniectomies for fragments and one will involve

elevation of a depressed fracture.

EMERGENCY WAR SURGERY

WORKING DRAFT

Three vascular reconstructions, half involving femoral arteries. One-half will have

associated fractures, or venous or nerve injuries.

Three major eye injuries, one of which will require enucleation.

Two amputations of hands, fingers, feet, or toes.

Two maxillofacial reconstructions. Half will have mandibular injuries and most of the

remainder will have maxillary injuries.

One formal thoracotomy.

One neck exploration (usually negative).

One casualty statistically is delivered up by the computer as "miscellaneous."

If this surgical handbook is on the mark in achieving its objective, we will have provided

you with specific guidelines or general principles governing the management of the foregoing

100 randomly selected battle casualties.

There are some who, as they study the chapters that follow, will perceive this handbook

guidance as overly regimented, too rigid or prescriptive, and leaving too little room for the

individual surgeon's judgment. On the contrary, these lessons and countless others have had to

be learned and relearned by generations of surgeons pressed into the combat surgical

environment. These very standardized approaches are necessitated by the echeloned

management of casualties by many different practitioners at several different sites along a

diverse evacuation chain, as opposed to the civil sector in which an individual surgeon can hold

and manage an individual patient throughout that patient's entire course. Historically, these

standardized approaches have repeatedly provided the highest standard of care to the greatest

number of casualties.

Several chapters have been completely rewritten and two new chapters have been added

to this edition. In an attempt to maintain perspective and continuity between this and the First

United States Edition of the Emergency War Surgery NAT0 Handbook, Professor T.J. Whelan

was asked to write a "bridge" between his and this edition. The advice, counsel, and

contributions of this outstanding soldier, surgeon, and citizen are truly appreciated. His prologue

to the Second United States Edition follows forthwith.

THOMAS E. BOWEN, M.D.

Brigadier General, US Army

PROLOGUE

iii

Editor

EMERGENCY WAR SURGERY

WORKING DRAFT

This is a handbook of war surgery. Its lessons have been learned and then taught by

combat surgeons—"young men who must have good hands, a stout heart and not too much

philosophy; he is called upon for decision rather than discussion, for action rather than a

knowledge of what the best writers think should be done."

In a world where multinational forces may be thrown together on one side in a large war,

a need was clearly seen for standardization of equipment and techniques among nations expected

to fight as allies. In 1957, SHAPE (Supreme Headquarters Allied Powers Europe) published the

first Emergency War Surgery Handbook, familiarly known as the NATO Handbook. This was

the product of a committee of the surgical consultants of the United Kingdom, France, and the

United States (US), chaired by Brigadier General Sam E Seeley of the United States. In 1958,

the handbook was issued in the United States following suitable amendments. In April 1959, the

NATO Military Agency for Standardization promulgated NATO Standardization Agreement

(STANAG) 2068, which retrospectively placed a stamp of approval on the Emergency War

Surgery Handbook of 1957 by agreeing that NATO Armed Forces would standardize emergency

war surgery according to its contents and tenets. This handbook, in addition to being issued to

all active duty medical officers in the US Armed Forces Medical Departments, was also

forwarded to medical schools surgical departments and libraries. At that time, the MEND

(Medical Education for National Defense) program was active. This was an excellent program,

instituted in all university medical schools by the universities and the armed forces, in which a

faculty representative, normally a surgeon, was selected to be briefed on a regular basis by the

medical departments of the armed forces and, in turn, to teach principles of care of military

casualties at their respective schools. Much of the early exposure of these individuals dealt with

the concept of mass casualties and thermonuclear warfare.

In 1970, Dr. Louis M. Rousselot, Assistant Secretary of Defense for Health and

Environment, an outstanding surgeon himself, realizing that, during the Korean and Vietnam

conflicts, new surgical information had been learned or relearned and that this new information

required broad exposure, tasked the Army Surgeon General to update the Emergency War

Surgery Handbook. The editorial board for the new US edition consisted of Rear Admiral

Edward J, Rupnick, MC, US Navy; Colonel Robert Dean, MC, US Air Force; Colonel Richard

R. Torp, MC, US Army; and Brigadier General Thomas J. Whelan, Jr., MC, US Army, who

chaired the board. Chapters were rewritten, and the format changed to include chapters on

aeromedical evacuation, mass casualties in thermonuclear warfare, and reoperative abdominal

surgery. The final paragraphs on mass casualties in each chapter of the original handbook were

excluded. At the same time, a NATO Handbook Revision Committee chaired by Colonel

Tommy A. Pace, RAMC, and with representatives from the United Kingdom, France, the

Federal Republic of Germany, the Netherlands, and Greece has been proceeding with minor

chapter changes. The US committee felt that the NATO committee might welcome the more

extensive changes. Therefore, in 1973, the completed revision of the US Handbook was

presented to the committee. Within 48 hours there was a unanimous decision to accept the new

US edition with certain minor modifications and to use it as the basis of a new edition for NATO

nations. These modifications were proposed by the representative from France; they related to a

description of an external fixation device for use in open fractures and to a minor change in the

management of chest injuries. It seems certain that no NATO accord ever came so swiftly or

easily. The goodwill on both sides was exemplary and heartening. In 1975, the new US edition

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