An4nnals of the Royal College of Surgeons of Englanid (I975) vol 56

A military

surgical

team

in

Belfast

N A Boyd OBE MS FRCS Lieuitenanzt-Colonel, Rolyal Army Aledical Corps

Summary This paper details the experiences of a military surgical team in Belfast from 1972 to early I974. The overall picture of the problem is given and the current management of 'war' injuries discussed. Up to February I974 over iooo servicemen have been injured in Northern Ireland as a result of the civil disturban ce. Over 2oo have died. Because of the close proximity of the hospital to many battle areas, casualties may arrive with massire injuries, requiring major resuscitation. Limb wounds have predominated. There is no short cut to adequate wound debridement, especially in the surgery of high-velocity mis'ile injury. Missile wounds of the large bowel requtire a colostomy. Formal thoracotomy is increasingly used for the through-and-through ('unshot wounds of the chest. Controlled ventilation is playing an increasingly important role in the management of some missile wounds of the head. Mine and bomb explosions frequently cause multiple injuries, requiring extensive surgery on any one

patient. Introduction The majority of our patients come from tunits in the city of Belfast. An appreciable number, however, also come from incidents near the border, which may be as far as 8o miles from our hospital. In the present conflict (up to February 1974) 1,371 service-

men have been injured, of whom 236 (I7%) have died. Our own unit has taken about half the total number of servicemen injured in Northern Ireland. War injuries form only a relatively small, though dramatic, proportion of the workload of the surgical team. In one year, October I972 to October 1973, there were I 373 surgical admissions to the hospital; 253 were the result of war injuries and 120 related to general and traumatic (road traffic accident) surgery. Missiles currently used in Northern Ireland range from bricks to bullets travelling at high velocity (Fig. i). Fragmentation weapons such as the claymore mine, which is nothing more than a box containing 6-inch (I5-cm) nails and high explosive, may cause serious injury, as the contents will be travelling at high velocity close to the explosion. Even a can of paint striking the windscreen of a vehicle may produce casualties. The soldier has many jobs on which he may be a target for gunmen or mines. These include patrols on foot or in vehicles, manning vehicle checkpoints, searches, mob control, and mounting observation posts. When he is wounded, in most cases, he is in a small group and his life may depend on the ability of his fellow soldiers to give first aid. More skilled medical help is given by the regimental medical orderly or by the regimental medical officer if he is close at hand.

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N A Boyd

Missiles used in Northern Ireland. Left to right: can of paint, glass milk bottle, brick end, rubber bullet,5 claymore mine., Armalite round.

FIG. I

Evacuation Evacuation of the wounded is either by ambulance or by helicopter. The modified Saracen armoured car (Figs. 2 and 3) has proved invaluable for the collection and transport of the wounded. Individual army doctors who travel with these vehicles are encouraged to organize their resuscitation equipment. Maintenance of the airway has top priority and to this end each vehicle is fitted with suction, a positive pressure ventilation system, and endotracheal intubation kit. It also carries intravenous fluids. Once this type of vehicle is under way, however, it is possible only to attend to the airway of the patient, for intravenous cannulation becomes too difficult. This type of amibulance is primarily used for the transport of the wounded soldier in Belfast or

the landing waiting.

zone

the helicopter is usually

Resuscitation Because of the close proximity of the hospital to the areas of civil disturbance wounded soldiers frequently arrive within io minutes of injury. Casualties who might otherwise have succumbed may present with massive injury but a weak grip on life. The usual priorities in resuscitation are the same in war injuries as in civilian practice. Medical orderlies are trained to maintain the essential airway. Most outstanding was the

Londonderry.

The border areas vary betwecnM 50 and io00 miles (8o-i 6o kin) distance fromi the hospital. Helicopters are used for the rapid 'casevac' of the injured soldier. Although at night some delay is inevitable, by the time the casualty is collected, given first aid, and taken to

FIG. 2

Modified Saracen ambulance.

A military surgical team in Belfast

I7

FIG. 3 Interior of Saracen ambulance. Note light, suction tube, and Ambu bag at head of stretcher bed.

ingenuity of Sergeant Watt RAMC in an incident for which he has since been awarded the BEM. At 4 o'clock in the afternoon of 27th October I973 a bomb exploded near the Royal Ulster Constabulary station at Crossmaglen. At that moment a private soldier, who was standing close to the explosion, received multiple injuries, the most serious of which was to his neck. Immediately after the explosion he was unable to speak or breathe. Sgt Watt was in a rest centre nearby and on hearing the explosion rushed out into the street. He saw the man lying on the ground, diagnosed airway obstruction, and performed a life-saving emergency tracheostomy, using a disposable scalpel that he kept in his jacket pocket. A tracheostomy tube was fashioned out of a syringe casing. The soldier's ordeal was not yet over, however, for it was 2 hours before he reached hospital. He was evacuated to

definitive flap tracheostomy was constructed and inspection of the wounds carried out (Fig. 4). There were I 2 wounds about his body, the most serious being a penetrating wound on the left side of the neck. The cervical structures were exposed through a transverse incision. Two metallic missiles had entered the neck just anterior to the midcervical portion of the left sternomastoid, traversed the larynx and right lobe of the thyroid gland, passed under the right sternomastoid, and lodged in the right supraclavicular fossa. The larynx was found to be

the Military Wing by helicopter. During the flight the makeshift tracheostomy tube dislodged repeatedly and had to be replaced many times, on each occasion the hole in the trachea being located by the finger before insertion of the tube. The sergeant used a 5-ml syringe as a sucker to keep the airway clear and the patient did not lose consciousness at any time. On arrival in our unit both were uttcrly exhausted by their ordeal; the sergeant's only words were, 'Thank God we're here'.

The patient was immediately taken to the operating theatre and under a general anaesthetic a

FIG. 4 Bomb blast injury to larynx

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N A Boyd

full of flak-jacket cloth ancd blood clot. Aftcr clearing the debris it was obvious that one vocal cord was comlpletely damaged and the other had suffered considerably. The missile had neatly removed the cricothyroid membrane, only slightly damaging the inferior edge of the thyroid cartilagc. Most of the right lobe of the thyroid had to be sacrificed. Fortunately the missile had passed just anterior to the right carotid sheath. Eight weeks after injury the patient wvas making a satisfactory recov-ery and was able to speak in a soft whispering xoice. It is interesting to speculate that had a doctor been on the scene of the incident and attempted endotraclieal intubation he would probably have failed owing to the intraluminal foreign bodies which would have been pushed further down the respiratory tree.

Radio contact ensures the presence of the resuscitation team with the all-important anaesthetist. Our resuscitation room has 3 bays, each with its own piped gases and suction. Intravenous fluids hang ready for use on disused curtain rails. In each bay there is a red plastic bucket which proves invaluable as a container for all the soldier's dirty clothing and personal belongings. The contents can be sorted later at leisure. Intravenous fluids are usually administered, especially to the more severely shocked, through a catheter inserted into a vein in the antecubital fossa. The catheter must be of large bore', only the largest sizes being of value in urgent resuscitation. An adequate cardiac output is produced and maintained with intravenous fluids in the proportion of 2 units of whole blood to I unit of plasma expander. In these relatively fit young men. however, a haemoglobin level as low as 8 g/ dl is sufficient to provide adequate tissue oxygenation provided normal cardiac output and venouis return are maintained2. Macrodex (Pharmacia GB) is used as the plasma expander; it can be rapidly infused and ensures adequate tissue perfusion. It has been

the custom to use only typed and crossmatched blood, thus avoiding the complications that occur even using uncross-matched Group 0 blood of low titre. Blood is obtained from the blood bank in Belfast. Because of the rapid utilization of blood in this city it is often received in our unit within 48 hours of donation. I am sure this has played a part in decreasing the incidence of disseminated intravascular coagulation.

Casualty figures An analysis of internal security casualties amongst servicemen in Northern Ireland as a whole during the period under review shows a predominance of gunshot wounds of the limbs (see table). The issued flak jacket reduces the ntumber of trunk injuries. Multiple injuries following mine or bomb explosions often require lengthy surgical procedures. Figures for injury following riot or mob control are not accurate as frequently a soldier fails to report a minor incident and the injury goes unrecorded.

FIG. 5 Entry wound of high-i7elocity missile in forearm. FIG. 6 Tension in forearm fascial compartment (same case as Fig. 5).

FIG. 7 Entry wound of high-77elocity missile in groin. FIG. 8 Exit wound in buttock (same case as

Fig. 7). FIG. 14 Mine explosion causing cerivical wound in which wood was embedded. FIG. 15 Left arm full of wood following same mine explosion as in Fig. I4.

w

'

41,~~~~~~~~~~

I-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I

:Sv~ ~ ~ ~ J I

20

N A Boyd Gunshot wounds: Limbs Trunk IHead Bomb-blast/niine Riot Total

454 I87 I 08 281

33 % 14 % 8% 21 0, (/)

34I

24 %

I371

100%

Gunshot wounds to the limbs Four hundred and fifty-four soldiers received gunshot wounds to their limbs. There was only one death. Figure 5 shows the entry wound of a high-velocity missile injury to the right forearm; the exit wound was on the volar aspect. Both the radius and ulna were shattered. Wound debridement is performed on all missile injuries. The word 'debridement' means to 'debridle' or 'unleash'. It is the release of tissue under tension that is one of the most important facets of this operation. Tension in fascial compartments occurs especially in the forearm and lower leg. In the case illustrated in Figure 6 notice the tense, bulging haematoma beneath the incised deep fascia. In peripheral limb injuries, I frequently use the pneumatic tourniquet to make identification of important structures that much more easy in the macerated tissues. It save3 a lot of time. It is essential, of course, that the tourniquet be released during the operation to confirm that non-viable muscle has been removed. Bone is never sacnificed unless the fragment is extremely small and completely detached. Nerves are debrided if necessarv and their position is marked should further surgery be undertaken. It is important to record in the operation notes the exact description of the nerve injury. Ninety per cent of our wounds are not closed at time of debridement, delayed primary suture being carried out 3-5 davs later. Wound closure by split skin grafting is frequently employed at this time if there has been either skin loss or tissue tension. A high index of stispicion is required,

especially in gunshot wounds of junctional zones. The possibility of masked blood vessel or visceral damage may be overlooked. In one case the entry wound was in the femoral triangle (Fig. 7) and the exit wound in the buttock (Fig. 8), an especially dangerous area in respect of anaerobic contamination. At wound debridement an incision was used that allowed early exposure and proximal control of the major vessels should this have been required. In this case no such arterial damage was found, although the missile had passed close to the vessels. It is better to look and see and expose the danger in these wounds. The anatomy is often so distorted by the cavitational effect of the high-velocity missile that keyhole surgery is dangerous. Arterial injury The incidence of arterial injurv in limbs is low. During the last I 8 months of the period 3 soldiers were admitted to our unit with missile wounds to major limb vessels. In 2 the femoral artery was injured and in I the brachial artery. Two of the patients were exsanguinated on arrival and in one case the regimental medical officer was compressing the femoral artery just above the missile wound. All 3 required blood transfusions of over I'2 units. In each case arterial continuity was restored using a reverse long saphenous vein graft. Each kept his limb with good peripheral pulses. Three other patients were transferred from civilian hospitals with arterial injuries. It is recommended that injured blood vessels be debrided serially until the artery is grossly normal and a direct anastomosis achieved wherever possible. The failure and amputation rates in Vietnam' have been higher in those cases in which vein grafting as opposed to direct arterial suture has been employed. In each of our cases a vein graft had to be used and was covered by adjacent muscles, the rest of the wound being left open for subsequent closure 3 days later. It is important that asso-

A military surgical team in Belfast

2I

the abdomen. Eight died. Several observations are pertinent. Penetrating wounds of the abdomen should always be explored, even in the absence of pain or tenderness. In one such case the missile was found at laparatomy to have entered the abdomen through the wing of the right ilium. The missile track was followed to behind the caecum and in front of the right ureter. No important structure was damaged, but a fairly large piece of flak jacket as well as the bullet was found in the root of the mesentery, a potential source of intra-abdominal infection. It is well known that missile wounds to the abdomen require a diligent search for injury, but it is the silent retroperitoneal areas to which special attention should be paid. There is no short cut to the management of missile wounds of the large bowel; they must always be treated with respect. With perhaps the exception of small uncontaminated missile wounds of the caecum there is no substitute for a colostomy of some description. If possible, resection of the injured large bowel is performed with the construction of a proximal colostomy and distal mucous fistula. Primary resection and anastomosis of large bowel without a drainage procedure courts disaster with wound infection and fistula and intra-abdominal abscess formation. An attitude towards renal conservation should be adopted initially in the majority of kidney wounds. I find that two complicated missile wounds of the abdomen can be very taxing for the whole surgical team. Missile,wounds of the chest Of the 9' soldiers hit in the chest, 43 died. FIG. 9 Soldier's boot--accidental discharge. This high nmortality from gunshot wounds to the thorax is due to the missile traversing the Gunshot wounds of the abdomen heart or great vessels from accurate sniper Fifty-six soldiers were admitted to hospitals shooting. The mortality from lung and pleura in Northern Ireland with gunshot wounds of involvement alone is low. The issued flak

ciated venous injuries receive attention, particularly in popliteal fossa wounds4. Preoperative arteriography has virtually no place as a diagnostic aid in gunshot wounds of the limbs. The delay to surgery that results from the investigation is not usually justified. A possible case, however, may be made out for arteriography in missile wounds at the root of the neck. There were Accidental foot injuries over 40 cases of accidental missile injury to the foot. The missile invariably traverses the base of the proximal phalanx of the second toe. This is the commonest site as a soldier tends to rest his weapon on the upper of his boot in the crease just behind the toe-cap to prevent the dirt from going up the barrel (Fig. 9). These injuries are not always as innocent as they might first appear. Invariably at wound debridement bits of boot are found embedded in the missile track. It is also of course the weight-bearing area of the foot.

2

N A Boyd

jacket stops only the low-velocity missile. In the management of chest wounds two venting tubes (Argyll catheters) are used, sometimes employing a Heimlich valve on the air vent. If these valves are used on the blood vent they may easily become blocked. During wound debridement an opportunity often exists for intrapleural exploration. Such an exploration is mandatory for continued bleeding, air leak, and mediastinal injury. Unlike Vietnam, however, there is an increasing tendency towvards formal thoracotomy in an attempt to stop bleeding and oversew the lung to prevent some of the undesired sequelae of airlock and lhaemothorax. Such surgery is well within the capability of most general surgeons. Pulmonary resection is only very rarely indicated. 'Wet lung' still poses a problem, especially with regard to aetiology. The soldier shown in Figure I o had a 9-mm pistol injury to the lower left chest and abdomen. The missile had traversed the pleura through the ioth intercostal space, not damaging the lung, and then passed though the diaphragm, through the hilum of the spleen, and lodged in the posterior abdominal wall. Fluid replacement was carefully controlled using a central venous pressure line. The patient underwent immediate splenectomy and a left pleural initercostal dr ain was inserted. Fortyeight hours after surgery he developed the wet lung syndrome, requiring mechanical ventilation for

I.L.

FIG. I o

Entry wound of low-velocity missile.

3 clays. In this case there was no cvidence of overtransfusion or pulmonary injury. It appeared that the condition of wet lung followed soft-tissue injury unrelated to the chest.

Blood gas analysis plays an important part in detecting a ventilation-perfusion deficit before clinical signs are manifest. I am sure an increasing awareness and better monitored treatment will assist in keeping down morbidity and mortality in this condition. Missile wounds to the head and spine One hundred and eight soldiers were admitted to hospital with gunshot wounds to the head and 65 died. The high mortality not only reflects sniper shooting but also includes several cases in which the weapon has been held close to a soldier's head. The two chief requirements immediately after injury are controlled ventilation and adequate transfusion. It is essential that a satisfactory airway be established and to this end early endotracheal intubation is practised. Crockard5 has shown that many of these patients also benefit from moderate hyperventilation before surgery. This serves two functions: it guarantees oxygenation of the blood and removes carbon dioxide, such a potent cerebral vessel dilator. The rise in intracranial pressure associated with cerebral oedema may be reduced by controlled hyperventilation (Pco2 4-4.7 kPa (30-35 mm Hg)). Indeed it seems likely that dexamethonium and mannitol themselves shrink into insignificance if this technique is employed. It should be remembered, however, that with the exception of pupil signs, intermittent positive pressure ventilation abolishes all the normal parameters for the detection of a rise in intracranial pressure. In our unit we do not have either an echoencephalograph or facilities for carotid angiography. If controlled ventilation is used in the management of closed head injuries, therefore, I think burr holes become mandatory to exclude a remediable intracranial condition.

A military surgical team in Belfast

23

neural arch must be carefully inspected. If there is any suggestion of penetration the dura should be exposed to exclude a cerebrospinal fluid leak. Dural tears should be closed and the rest of the wound left open for delayed primary closure. Bomb-blast and mine injuries Two hundred and eighty-one soldiers received multiple injuries following bomb blasts or mine explosions, of whom io died. Close to such an explosion unstable fragments will be travelling at great velocity. The initial assessment of these soldiers in the resuscitation room is frequently difficult, as on arrival they are often covered in dirt and debris. Apart from airway maintenance it is sometimes not possible to commence resuscitation until the soldiers' clothes are removed, not always an easy task because of the protective clothing FIG. II Entry wound of low-velocity missile they wear. in forehead. The soldier shown in Figure I2 was involved in a Vietnam' has shown us that good-quality mine explosion on the border and sustained an exskull X-rays are essential for the location of indriven bone fragments, which are a source of intracerebral infection and epilepsy if not removed. During debridement of the brain continuous irrigation with saline and gentle sucking are used to remove pulped brain. Great efforts are made to close the dura7. The soldier shown in Figure i was hit in the right forehead by a low-velocity missile. The missile carried in several fragments of frontal bone to a depth of 5 cm and then crossed the falx cerebri and came to rest in the left occipital lobe. At wound debridement the frontal sinus was found to be breached. The missile track was followed to a depth of 5 cm in the right frontal lobe. Two millilitres of pulped brain were gently sucked out along with bone fragments. The missile was left. The patient made an excellent recovery postoperatively, although he was somewhat aggressive when retumed to England.

Over 20 servicemen sustained missile wounds to the spine, half with a neurological deficit. During the course of wound debridement the FIG. I 2

Facial trauma due to mine explosionl.

24

N A Boyd The soldier shown in Fig. 14 (p. I9) was on 'lollipop' patrol, standing by a wooden door seeing children across a pedestrian crossing. A charge placed on the inside of the door was detonated by remote control. The result was a neck wound and left arm wound full of indriven wood (Fig. I5, p. I9). Time-consuming surgery was required for the extraction of the wood from around the carotid vesscls and from the left arm. In fact, most of the left arm had to be laid open during wound debridement, severe tissue contusion making identification of the neurovascular bundles difficult. The neck wound was closed by primary suture and the arm left open for delayed closuire. Figure i6 shows the arm three weeks after injury.

4

F4IG. I3 Facial wound as in Fig. I2 after

Not all blast injuries are associated with obvious wounding. Three lower limbs had to be decompressed owing to tissue tension associated with a crushing injury to the limb from falling masonry. The effect of bomb blast on the ears and lungs is interesting. In a fairly confined space, such as in the back of an armoured vehicle, a comparatively minor explosion may produce perforated ear drums in all the vehicle's

wound debridement and suture. j~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..

tremely severe facial wound, a left Monteggia fracture with an arterial problem, and a compound fracture of the right tibia. He arrived at the hospital from the border three-quarters of an hour after injury. It was a credit to the medical team who maintained his airway during the helicopter flight that he still remained a living problem. After massive intravenous fluid replacement (22 units) he was taken to the theatre. A tracheostomy was performed and wound toilet carried out on the face, arm, and legs. With the assistance of a faciomaxillary surgeon the facial wound was closed primarily (Fig. 13). The forearm was decompressed and wound debridement carried out on the right leg. Owing to a coagulopathy he bled profusely from his wounds towards the end of an exhausting operating session. After a further transfusion with 6 units of fresh blood adequate tissue perfusion was obtained and the bleeding diathesis controlled. Although he improved initially he died 3 days later of an intracerebral haemorrhage associated with pulped brain that had occurred at the time of the blast injury.

-

e :. FIG. i6 Same left arm as zn 3 weeks after surgery.

Fig. I5 (p. I9)

1 military surgical team in Belfast

occupants. Impairment of cochlear function also occurs owing to hair cell damage8. Blast injuries to the lungs, however, are surprisingly uncommon. In a series of 587 patients seen at the Royal Victoria Hospital with suspected blast injury Io developed chest symptoms, 4 requiring assisted ventilation9. Of the many soldiers admitted alive to our particular unit following explosions haemorrhages on the tympanic membranes, perforated ear drums, and conjunctivitis were common, but only 2 developed blast lung characterized by shortness of breath, cough, and haemoptysis 12 hours after injury. The application of intermittent positive pressure ventilation should be considered if the Po2 falls below 6.7 kPa (50 mm Hg) or if the Pco., rises above 8 kPa (6o mm H.,0). A positive expiratory end pressure of 5-15 cm H20 (0.5-I.5 kPa) is recommended.

25

thc care and devotion they have given to many of our injured soldiers. The author and the Editor of the Annals gratefully acknowledge the assistance afforded by Pharmacia (Grcat Britain) Ltd which has made possible the reproduction of some of the illustrations in colour.

References I

2 3 4

5

At the enid of their stay in our unit many of the injured scrvicemen are casualty-evacuated by the 6 Royal Air Force to specialist military hospitals in England. In-flight attendance by a respiratory team 7 is occasionally required. This 'casevac' service is 8 grcatly appreciated. I should like to thank the medical, nursing, and administrative staff of the Military Wing at Musgrave Park Hospital for always rising to the occasion and for the happy atmosphere that has prevailed 9 in spite of considerable pressures. Finally there is that special gratitude to the staff of the civilian hospitals in Northern Ireland for

Knight, R J (I968) Lancet, 2, 665. Dudley, H A F (i173) Journal of the Royal College of Surgeons of Edinburgh, i8, 67. T'hird Conference on War Surgery (I969) Dcpartment of Defencc, Pacific Command, US Army, p. 20. Ardill, B L, Livingston, R H, and Irwin, J W S (I973) Meeting of Royal Society of Medicine at the Royal Victoria Hospital, Belfast, May '973. Crockard, H A (1973) in Recent Advances in Surgery, ed. S Taylor, 8th edn., p. 330. Edinburgh and London, Churchill Livingstone. Hammon W (I969) USARV Medical Bulletin, PAM 40- I 8, i. Gordon, D S, Personal communication. Smyth, G D L, and Stewart T J (I973) in Recenit Advances in Surgery, ed. S Taylor, 8th edn., p. 337. Edinburgh and London, Churchill Livingstone. Gray, R C, and Coppel, D L (1973) in Recent Advances in Surgery, ed. S Taylor, 8th edn., p. 339. Edinburgh and London, Churchill Livingstone.

A military surgical team in Belfast.

An4nnals of the Royal College of Surgeons of Englanid (I975) vol 56 A military surgical team in Belfast N A Boyd OBE MS FRCS Lieuitenanzt-Colone...
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