Immediate Care of the Wounded Clifford C. Cloonan, MD, FACEP COL (ret) U.S. Army Associate Professor Department of Military & Emergency Medicine Uniformed Services University of the Health Sciences Introductory Thoughts “It will be tragic if medical historians can look back on the World War II period and write of it as a time when so much was learned and so little remembered.” Beecher H. Early Care of the Seriously Wounded Man.1,2 “It is highly desirable that anyone engaged in war surgery should keep his ideas fluid and so be ready to abandon methods which prove unsatisfactory in favour of others which, at first, may appear revolutionary and even not free from inherent danger.”3,4 Bailey H, ed. Surgery of Modern Warfare. 2nd ed. “Fight on, my men,” Sir Andrew says, “A little I’m hurt, but not yet slain; “I’ll but lie down and bleed awhile, “And then I’ll rise and fight again.” Ballad of Sir Andrew Barton, author unknown, c. 1550 1 Immediate Care of the Wounded Introductory Thoughts Clifford C. Cloonan, MD Introduction knowledge of what I didn’t know and youthfully confident in my skills and This text represents a thirty year culmi- knowledge of combat casualty care. I nation of my thoughts about pre-hospital was to never have the opportunity to combat casualty care. learn my shortcomings as a combat medic since the Vietnam War wound My earliest introduction to this topic down faster than I completed my train- came in 1973 when I attended the 91A ing. It was this training and experience Combat Medic course in San Antonio as a Special Forces medic that sent me Texas, a necessary pre-requisite before I on the path to become a military physi- could attend the 300 F-1 Special Forces cian. Medic course. It was mostly poorly taught and improperly focused and for- What I learned in the ensuing years is tunately I never had to take care of any- that most often: one in, or out of, a combat situation us- ing only the knowledge gained in that • The simple answer is the right an- course. It was run by nurses and the swer, academic focus of the course was on • Well-performed basic techniques nursing care skills that were mostly ir- are usually better for the patient relevant to pre-hospital combat casualty than more complicated and “so- care, presumably the realm of the com- phisticated” techniques, bat medic. Some of the combat skills • Conscious inaction is better than instruction provided by veteran combat mindless action, medics with experience in the Vietnam • Training is more important than War was a notable exception. equipment, and • The day I graduated from the Spe- The 300 F-1 Special Forces Medic cial Forces Medic Course I was Course that followed was exactly the “smarter” than I would ever be opposite; it remains to this date the best again because mostly what I and most intense medical instruction I learned later was all the things have ever received. I learned more rele- that I didn’t, and would never, vant medical information in the short know. span of that course than I would ever again learn in a similar time span. Upon What I also learned in my nearly thirty completion of that course I was left years in military medicine is that most wondering why it took physicians four people believe that all relevant history years of college, four years of medical began the day they were born and there- school and several more years of intern- fore nothing much of use for the present ship and residency training to learn what or the future can be learned from the I had learned in less than a year; I was past. Nothing could be further from blessedly unencumbered with the 2 Immediate Care of the Wounded Introductory Thoughts Clifford C. Cloonan, MD the truth -- there is actually very little What then is the basis for modern day that is completely new in the realm of pre-hospital combat casualty care? It is a military medicine. If you are looking for composite of battle proven, albeit anec- the solution to a problem the first place dotally supported, procedures and tech- to look is in the past because there is a niques combined with civilian EMS good chance that someone else either standards of care (whether appropriate already solved the same or a similar to combat casualty care or not), some of problem or at least was able to find out which are based upon well done studies, what didn’t work. many of which are not. Throughout my career in military medi- This text represents my best efforts to cine I spent a considerable amount of glean from the pages of military medical time as a trainer/educator; I observed history and from such civilian pre- how people learn, what motivates them hospital care and other relevant studies to learn, what they are likely to remem- as have been done the evidence, weak ber, and what they are likely to forget. I though it may be, that supports or re- learned that it is much better to create futes the performance of various proce- systems (educational or otherwise) that dures in a pre-hospital combat casualty take into account and accommodate care environment. probable human behavior than it is to try to shape or modify human behavior. In the interest of full disclosure I admit to the reader certain biases that I have I also learned that much, if not most, of acquired as a result of the observations, what is believed to be true has not been experiences, and education I have de- proven true and further it is likely that scribed above. One of these biases is within my lifetime much of what I have against teaching pre-hospital combat been taught will be proven to be false – casualty care providers complex and this as certainly been the case over the potentially hazardous medical proce- past thirty years. I discovered that al- dures even when there is no alternative most everything that is believed to be (e.g. cricothyrotomy); another is a bias true about pre-hospital combat casualty in favor of better training over better care is completely unproven; this cer- equipment. I also have a bias that some- tainly does not mean it is false, just that times the most important thing is to it has not been, and will likely never be, know what not to do and when not to do proven true. The reason for this is be- it. cause, for obvious reasons, there are no randomized, double-blind, prospective I independently observed that there is studies of pre-hospital combat casualty strong psychological predisposition to- care; and there are remarkably few such ward action over inaction among pre- studies of civilian pre-hospital care. hospital personnel, a predisposition that is certainly characteristic of Special Op- erations medics/corpsmen. I had also 3 Immediate Care of the Wounded Introductory Thoughts Clifford C. Cloonan, MD observed that when a procedure is as to what should be taught and to taught, particularly one that seems “he- whom, and what material should be pro- roic” (e.g. cardiac massage), that the vided to those who provide pre-hospital procedure will be performed much more combat casualty care. often than indicated. This observation being epitomized by the often used, The material in this book was originally tongue-in-cheek, comment by emer- written for inclusion in an unpublished gency medicine residents that the indica- book, Combat Surgery, to be part of the tion for a particular procedure they had multi-volume “Textbook of Military performed was that the RANDO criteria Medicine” series published by the U.S. had been fulfilled (Resident Ain’t Never Army’s Office of the Surgeon General. Done One). Unfortunately this book was never com- pleted despite its obvious importance as I later found that these concepts had a key volume in any series on the sub- been previously well-described by one ject of military medicine, and the whole of the fathers of modern emergency Textbook of Military Medicine project medicine, Dr. Peter Rosen, in a rather has, I am told, been discontinued. Thus obscure July 1981 publication, Topics in as I finished my military career I was Emergency Medicine, titled, “The left having done a considerable amount Technical Imperative: its definition and of work for a book that, it seemed, was application to pre-hospital care.” The never to be published. technical imperative and its implications are defined and described in the early So the situation remained until I was portion of the “Airway” section in this contacted about a year ago by CAPT text and I would encourage readers to (fmr) Mike Hughey MD, a fellow mili- obtain and read the original article for tary medicine educator and friend. Mike greater detail (unfortunately it is hard to has a medical education website, find in most libraries – I eventually found a copy in the library of the Na- http://www.brooksidepress.org tional Fire Academy in Emmitsburg Maryland). that provides military medicine oriented educational material. He inquired as to One of the reviewers of this material whether I had any unpublished material suggested that it be re-written to appeal on the subject of military medicine that I to a larger audience, noting that it is pre- would like to get published? I replied sented in the manner of a textbook. I that I certainly did and provided him was pleased by this comment because with several megabytes of material that I that is exactly what I intended.