Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIV: War Surgery Within the Division

Position and Actions of the Surgeon During Engagements

United States Department of Defense

The battalion surgeon must be apprised of the battle plan and the changing tactical situation. Only with this knowledge can the surgeon plan the best possible medical support and have the medics in the right place at the right time. The battle plan, evacuation capabilities, proximity, and readiness of a surgical care facility will determine where the surgeon is best utilized.

When battle lines are fluid and air evacuation difficult or impossible, surgeons may be best placed at aid stations where they can receive, triage, resuscitate and evacuate casualties emerging from the battle zone. This implies a far forward location of the aid station and the constant ability to move with the troops to avoid encirclement and capture.

If air evacuation capability exists, the surgeon may choose to follow the battle with the battalion commander in the tactical operations center. When large numbers of casualties are generated, the surgeon may be dispatched by aircraft to the batde scene to provide on-site triage. Casualties requiring urgent lifesaving surgical intervention may be triaged directly to a surgical care facility. Other casualties are moved to the aid station and may be accompanied by the surgeon. As an alternative, the surgeon may elect to send the senior medic or physician assistant to the scene to provide the triage and direct casualties to the aid station or to the surgical facility.

If distances to surgical care are great and air evacuation is not possible, the surgeon may request a surgical team to augment aid station personnel and to perform resuscitative surgical procedures.

Much of the guidance referable to the tactical deployment of the battalion aid station is also applicable to the medical company. The medical company must be readily accessible, as it represents the major site of triage in the evacuation chain. It is also the first level at which there is a limited holding capability for casualties. Being responsible for clearing casualties from the brigade area requires proximity to and the ability to move with the maneuvering elements. The fact that in some units the medical company is organic to the support battalion rather than an element of a division medical battalion may place certain constraints upon carrying out the medical mission. These can be resolved only when the medical officer in command actively participates in planning and decision making. Overall, none of these factors will adversely affect the triage functions but they may limit both the sophistication of the medical care and the holding capability of the unaugmented medical company.

Not surprisingly, medical officers at the division level will find that their most difficult challenges result from the requirement to move the treatment facilities in accordance with the flow of the battle. In the attack, it is essential that the medical company be in proximity to the battalion aid stations. The medical company must move as far forward as the tactical situation allows. In deep penetrations, elements of one medical company or, ideally, two or more medical companies can be sequentially deployed or echeloned so as to provide continuous medical support. During withdrawals, medical companies or their elements deploy to the rear of each successive delay position, where they set up to receive casualties. Withdrawing medical elements "leapfrog" past them to more rearward positions where they in turn set up. Clearly, coordination with higher command levels, especially for the purpose of allocating additional medical assets, is essential. The unit and division level medical officer should be aware that the history of war contains many examples in which nontransportable casualties have by necessity been left to be taken prisoner. The decision to leave casualties behind is a command, not a medical, decision, and one that requires a decision as to how many and what types of medical personnel must remain with the casualties.

It is likely that forward surgical facilities will be co-located with selected medical companies in support of heavily engaged brigades. Surgical teams are also likely to be attached to the medical companies of airborne or air-assault divisions. In either situation, the medical company triage officer will be responsible for determining which casualties will be treated locally rather than being evacuated to the corps level for surgical care.

There are two broad indications for local surgical intervention: casualties in immediate danger of dying and casualties who will be significantly affected by a prolonged delay in evacuation occasioned by an unfavorable tactical situation. Casualties at risk of dying are those with abdominal or chest wounds who are in shock, those who are not responsive to resuscitation, those with closed head injuries showing rapid neurological deterioration, and those casualties with extremity wounds requiring a tourniquet for control of bleeding. Casualties with the second indication include those with open comminuted fractures of the femur and extensive soft tissue wounds in which anaerobic sepsis is likely to develop.

It is essential that the medical company triage officer be very selective in triage. Past experience indicates that, as a rule, no more than 5-10% of the total casualty population requires immediate surgery. At the other extreme of the injury spectrum are those casualties with minor wounds and the potential for rapid return to duty. This group is typified by a casualty with one or more superficial fragment wounds or a perforating gunshot wound of the extremity with small wounds of entrance and exit and no evidence of bone or neurovascular injury. Individual judgment must be exercised, but overevacuation of such casualties must not occur.

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Operational Medicine 2001

Health Care in Military Settings

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