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

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, chaired by Brigadier General Sam F. Seeley of the United States. In 1958, the handbook was issued in the United Sates following suitable amendments. In April, 1959, the NATO Military Agency for Standardization promulgated the 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 issues to all active duty medical officers in the U.S. Armed Forces Medical Departments, was also forwarded to medical school surgical departments and libraries. At that the 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 force, 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 U.S. edition consisted of Real Admiral Edward J. Rupnick, MC, US Navy; Colonel Robert Dean, MC, USAF; Colonel Richard R. Torp, MC, USA; and Brigadier General Thomas J. Whelan, Jr., MC, USA, 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, Rance, the Federal Republic of Germany, the Netherlands, and Greece had been proceeding with minor chapter changes. The U.S. committee felt that the NATO committee might welcome the more extensive changes. Therefore, in 1973 the completed revision of the U.S. Handbook was presented to the committee. Within 48 hours there was a unanimous decision to accept the new U.S. edition with certain minor modification and to use it as the basic of a new edition for NATO nations. These modification 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 U.S. edition was published, and in 1977 it became the guide for all NATO forces, pursuant to a reissue of STANAG 2068. Now it is time for a third edition.

War surgery represent no crude departure from accepted surgical standards. A major responsibility of all military surgeons is to maintain these principles and practices as fully as possible, even under adverse physical conditions. The physical requirements are, however, relatively simple:

1. Experience surgeon, anesthetist, and operating room personnel. 2. Simple X-ray facilities. 3. Good lighting and water supplies. 4. Reasonable accommodations under shelter. 5. Well-trained nurses and other professional administrative staff. 6. Ability to retain post-operative patients in the hospital for at least a few days to allow stabilization. 7. Simple surgical equipment, supplemented by a few items of specialized equipment, such as Bovie units, defibrillators, ventilators, blood gas machines, anasthesia delivery equipment, and vascular and orthopedic instruments.

There are, however, differences between war surgery and surgery in the civilian setting: 1. The tactical situation may impose major constraints upon the performance of the indicated operation, and threats to the safety of the patient and medical personnel ay make appropriate care inconvenient, if not impossible. 2. The high-velocity weapons of war may produce tremendously greater tissue destruction than the low-velocity weapons producing civilian wounds. 3. There are few civilian wounds which resemble the multiple fragment wounds of artillery or mortar shells, bombs, booby traps, and landmines. 4. Wounds are cared for by many surgeons along an evacuation chain that extends from combat zone to home, rather than by one surgeon and his house staff throughout all phases of wound repair. 5. Casualties are frequently received in large numbers over a short time in combat hospitals. Although an occasional catastrophe of similar magnitude has occurred in a few metropolitan civilian hospitals, this is commonplace occurrence in forward combat hospitals. 6. During aeromedical evacuation, the casualty will require long flights during which lowered air pressure may complicate abdominal, chest, eye, head, and spinal wounds. The cabins of high-altitude aircraft are pressurized only to about 4,000-8,000 feet above sea level, and not to sea level pressures.

We are now faced with a fast-moving, highly mobile, remote control type of warfare which will require major changes in philosophy and management of war casualties. It may, for instance, be necessary to evacuate casualties much earlier than the organism's physiologic responses to injury dictate as optimal. The initial definitive surgery may be required aloft or on shipboard. Or because of noxious fume or radioactive dust, we may find it necessary to emulate the mole, remaining underground for protracted periods. We must not ever expect that the protected hospital environments of the Korean or Vietnam conflicts, bough with very necessary air superiority, will necessarily be present in future conflicts. Plans for the care of the wounded must be laced with a generous sprinkling of multiple alternatives and options, ranging from immediate air or surface evacuation with delayed suboptimal definitive surgical care to the more standard, early definitive treatment in a combat hospital with a 4-10 day retention period prior to further evacuation. the latter is optimal; the former, however, may be forced by the tactical situation.

As in any medical endeavor, prevention is fare more efficacious than treatment. This is true for wounds sustained in war. Unfortunately, there is no precedent to suggest that man and nations have learned to coexist without armed conflict. Although I, personally, and most military men, who "above all other people pray for peace, for they must suffer and bear the deepest wounds and scars of war" (quoted from General Douglas MacArthur's oration "Duty, Honor, Country"), would be profoundly grateful if this handbook might become superfluous, redundant, and unnecessary, it nonetheless continues to serve a useful purpose in these times. Furthermore, a reasonably standard, phased method of treatment of war wounds, to be enunciated in the remainder of this handbook, is imperative when many surgeons, of multiple national extractions, along long evacuation chains, care for those wounded in combat.

Thomas J. Whelan, Jr. Brigadier General (RET) Medical Corps, U.S. Army