Fig. 3 Evacuation Chain. Operation Crusader.

 

SURGERY: 8 hour rule

 

Major-General Ogilvie, the surgical consultant to the Middle East Forces, listed the requirements for these forward surgical units (11):

 

1. It should be able to take 2 stretchers at a time and a third in an emergency.

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2. The floor should be at or below ground level (for protection from shrapnel).

 

3. It should have room for traffic to pass without touching the operating team.

 

4. It should be kept as clear as possible, the sterilising and cleaning being relegated to an annex.

 

5. It should be well lit, yet lightproof, and have light traps at entry and exit.

 

6. It should be easily concealed from air observation.

 

7. It should be easily and quickly erected by members of the team without other help.

 

8. It should be packed up even more easily and quickly.

 

Two types of forward surgical units were used in the Middle East, canvas ‘lean-tos attached to standard 3 ton lorries and specially designed operating lorries. Whilst the operating lorry seemed to offer a bespoke solution, in fact it met very few of the criteria above. Any mechanical fault in the lorry meant the loss of all the fitted equipment.

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However large they were, they were always too small. The operating theatre was about 4 feet above the ground, necessitating a lift of this height for every patient (10). If the unit is the target of air or artillery attack, all members of the team felt very vulnerable so high off the ground (6).

 

SURGERY: specially designed operating theatres vulnerable to mechanical failure.

 

The experience in the Middle East informed the development of Army field medical units for subsequent campaigns. The need for a variety of medical units, organised by function, that could be grouped together to meet the requirements of a particular operation were self-evident. The attachment of a field surgical unit to a light field ambulance dressing station provided the simplest operating unit. This grouping was inefficient as the lone surgeon was likely to be overwhelmed and the whole organisation was not designed to hold or nurse the serious cases that were the raison d’etre of such an organisation. Furthermore, two additional services, resuscitation and radiography were required for all but the most exceptional circumstances. It was also established that the output of a single field surgical team was much less than half of two grouped together.

 

The combination could rotate turns of duty and have a proper rest, and nursing, done by orderlies, could be better observed (6).

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SURGERY: surgical teams should work in pairs.

 

Whilst the conditions in the desert allowed post-operative casualties to be nursed in austere conditions on stretchers under a tarpaulin suspended over goal-post-like frames from the back of a lorry, this was a rather dismal setting for the seriously ill. It was clear that field surgical teams should be supported by a small number of beds for post-operative nursing with suitable shelter.

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Overall, the most effective organisation for such a unit was formed from the Dressing Station of the Corps field ambulance, the light section of a CCS, additional surgical teams, and mobile specialist units such as a transfusion unit, X-ray unit and bacteriological laboratory (9). An example of the internal design of a Field Surgical Team in the Middle East was contained in the Field Surgical Pocket Book published in 1944 (11) and is shown in Figure 4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Fig 4. Internal plan of a Field Surgical Unit in the Middle East.

 

SURGERY: surgical capability requires resuscitation, radiography and post-operative holding.

 

The 8th Army put these principles into practice for the Third Libyan Campaign, starting at El Alamein in October 1942. The field surgical team and the field dressing station recommended by the Hartgill Committee (vide infra) were formally introduced.

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Some CCS's were made completely mobile by reducing the equipment scales but retaining the clinical capability. In the series of set battles that preceded retreats by the Germans, CCSs were sited well forward to receive the bulk of casualties until the breakthrough was achieved. The field surgical units and field dressing stations were kept packed and moved forward close behind the advancing troops, ready to set up and receive casualties if pockets of resistance were encountered.

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