Second United States Revision of the Emergency War Surgery NATO Handbook/Preface

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 ear drums, 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, or 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 cranioectomies, 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 cranioectomies. Two will be cranioectomies for fragments and one will involve elevation of a depressed fracture.

Three vascular reconstruction, 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 casually 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 200 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 surgeons 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 has 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 NATO 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. Editor Brigadier General, U.S. Army