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THE FIELD AMBULANCE IN BATTLE.

WITH the beginning of an offensive the minor interests of medicine are discarded and all attention  concentrated on keeping the line clear of wounded, while affording them proper care and treatment during their rapid evacuation.


The existence of scabies, broken dentures and bad eyesight, together with all trivial ailments, is ignored at such a time. Only the seriously ill go to the casualty clearing while the middle class of ordinary sick are sent to the rest station. It is expected that a large percentage of casualties after applying the first field dressing, which
every soldier carries, will be able to look after themselves in so far as getting out of the lines and making their way to a designated rendezvous is concerned. 


They are called the" walking wounded," and in order to relieve the advance and main dressing stations of these, and also to facilitate  speedy transportation by the provision of another route of evacuation, a walking wounded station is established. Here these patients are collected, fed, attended to and forwarded by motor ambulance convoy cars, by motor lorries provided by the corps, or in some instances by the horse transport of the field ambulances, to the nearest casualty clearing station. The walking wounded station is frequently established by the corps at some convenient central point, to which such casualties are directed from their respective divisions.


At other times the assistant director of medical services of each division arranges for his own station. In the first instance the personnel and equipment are contributed by the field ambulances of one or more of the several divisions composing a corps; in the second, by one or more field ambulances of the division concerned. There is a good deal to be said in favor of either scheme, but for the present purpose it is supposed that the latter has
been decided upon. In like manner one main dressing station for all divisions is occasionally· instituted by the corps, for which there is perhaps but little to be said, so that here also it will be described as a divisional
arrangement.


In addition to receiving his instructions from the deputy director of medical services of the corps, who is his immediate medical superior, the assistant director knows all about the local geography and has carefully studied the traffic map. He has also ascertained the direction in which the division will attack, and its objective, and thus anticipated any change in the routes of evacuation of casualties resulting from an advance. .He has made arrangements to supplement the personnel of his three ambulances by medical officers brought from the less engaged units of the division. On the other hand, he informs himself as to whether he may be
called upon to supply medical officers and men to supplement the staff of the casualty clearing stations. With such knowledge he is in a position to use his field ambulances to the best advantage, and his arrangements can now be considered under the following heads:


1. The advance dressing station.


2. The walking wounded station.


3. The main dressing station.


THE ADVANCE DRESSING STATION.

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During an offensive the work of the field ambulance stretcherbearers is multiplied many fold. In its performance they may be distributed under either of two systems. The first is simply an enlargement of the peace time relay practice: the four bearers responsible for the transport of wounded from the regimental aid post to the first relay post are doubled or even trebled in number, while the relay posts also receive an increased personnel. It will be remembered that a field ambulance bearer subdivision has 36 stretcher-bearers, forming 9 squads of 4 men each, which is called a stretcher-bearer section and has a sergeant in charge. This non-commissioned officer will keep in touch with the group of aid and relay posts for which his section is responsible and see that the wounded are properly evacuated, while for each brigade area there is also a medical officer in charge of all bearers, who is detailed for this duty by his field ambulance, and here termed a stretcher-bearer officer.


In the second method the bearers work in parties covering the whole distance between the regimental aid post and the advance dressing station. They are then under the immediate charge of the stretcherbearer officer, who makes the journeys with them.


Each system has its advantages and its disadvantages. In the first the bearers work in small numbers and the non-commissioned officers and men have an opportunity of using their own initiative.


This scheme is also favored by the regimental medical officers, because their detail of bearers is never far from the aid post, and they feel that there is less danger of losing touch with the advance dressing station. On the other hand, the allocation of a sufficient number of men to each relay post ties bearers to individual points, some of which, with the progress of the offensive, may have more than they can do, while others will be comparatively idle. Under battle conditions there is also difficulty in the proper feeding of these scattered detachments. 


In the second system the stretcher-bearer officer has at all times close control of his bearers, and more immediate relief can be afforded to any overcrowded regimental aid post. He sees that his men are regularly fed, and relieved when necessary, at such times as they return to the dressing station.


The men gain knowledge of the country and can be detailed as guides to parties of prisoners, who often act as stretcher-bearers. The disadvantages are: the greater danger of losing touch with isolated regimental aid posts, and the increased work and responsibility of the stretcher-bearer officer, with the added danger of  disorganization should he be killed or wounded. To sum up, it may be said that the relay system is probably the better where only a short advance is expected and a small number of wounded are to be dealt with, while the second system is more suited to large numbers of wounded and a rapid advance.


In either system the stretcher-bearer officer must see that his men use what he' judges to be the safest route of evacuation, and that they are, if at all possible, regularly fed and systematically relieved. As soon as an advance justifies it, he applies to the officer in charge of the dressing station for wheeled transport to be used in front of that station; and when he finds that he is able to use such transport up to a place which appears suitable for a station farther advanced, he explains the situation to the officer in charge, who, if he approves the idea, sends a party forward to establish a temporary advance station. If the place is found satisfactory the whole personnel will move up. The stretcher-bearer officer therefore fills a responsible place, where judgment as well as knowledge is very requisite. Upon two things he must continually inform himself: The first is the geography of the area in which the division is situated and that over with it hopes to advance. 
The second is the position of the front line. The hour after sunrise is the safest period for his pursuit of information.


If for such reasons as lack of shelter or that the roads are under enemy observation the advance dressing station is situated at any considerable distance from the line, it may be necessary to relieve the work of the stretcher-bearers by opening a collecting station. It will be located near a road leading from the front or perhaps beside a trench tramway. In the former case casualties will collect here during the day and be evacuated by wheeled transport after nightfall, or it may only be used as a loading-point for ambulances at night, the patients being carried by hand direct to the advance station by day. In the latter the patients will be conveyed by trucks, either to the advance station or to a point where ambulances can be used. The plan of such a collecting point is essentially the same as that of one of the cruder advance stations previously figured.


As casualties arrive at the advance dressing station they are immediately attended to, classified and evacuated. Beef tea, hot coffee, etc., are provided, and those whose wounds require redressing are dealt with, while particular care is given to the proper splinting of fractures; but no elaborate surgical work is done, operative interference being reserved for cases of urgent necessity. During an offensive anti tetanic serum is not administered here, but at the walking wounded and main dressing. stations.


The wounded are classified and their transportation arranged as follows:


1. Walking wounded }Go to walking wounded


2. Slightly wounded sitting station.
 

3· More seriously wounded) Go to main dressing station.

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4. Stretcher cases
 

The stretcher cases and the more serious sitting cases are conveyed to the main dressing station by both motor and horse ambulances. The slightly wounded sitting are sent to the walking wounded station by horse ambulances and general service wagons. The walking wounded have most frequently to go afoot, finding their way by roads marked with directing flags. During a battle it is evident that many casualties will be able to apply their first field dressing, or get a comrade to do so, and will then leave the front and find their way toward the designated walking wounded station. In doing this they may turn up at a regimental aid post or a field ambulance establishment, at which, as was above seen, they are assisted and further directed to their collecting center. 

 

THE WALKING WOUNDED STATION.

 

Houses, huts, tents, or any combination that can be improvised by the field ambulance at a suitable place are utilized for this station. Whatever its composition may be its arrangement will emphasize the division, previously explained, into a place where patients are received, a place where they are treated and a place where they await evacuation. 

 

Such a station entirely constructed of tarpaulins, tents and other equipment carried by a field ambulance is shown in Fig. 17, by which the method and character of the work can be made clear under the following headings:


(a) The wounded arrive in three ways: they may come direct from the front line without having passed either through regimental aid post or advance dressing station; they may come from the regimental aid post without having called at the advance dressing station; they may come from the advance dressing station by horse ambulance, general service wagon or walking. They immediately enter the reception shelters, and while waiting treatment rest on benches and receive food from orderlies in attendance. Ordinary medical comforts are not sufficient for these patients,

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Fig 17.jpg

who frequently have eaten nothing for 12 to 18 hours, and require stew, bread and tea. The next most important desideratum is heat, for the wounded are always chilly, and even in summer it is advisable to have stoves or braziers going. 
 

(b) The treatment consists in the necessary surgical attention, the injection of antitetanic serum and possibly the administration of stimulants.


The dressings are carefully and thoroughly done here, and when possible suitable cases are marked "Need not be dressed for 24 hours," so that the casualty clearing station, if greatly rushed, may know that such cases are fairly safe for that period. While the patient is receiving treatment, orderlies, who act as clerks, take down the information necessary for the admission and discharge book.


(c) A certain number of walking wounded develop symptoms which render it advisable that they become stretcher cases. There is always a special tent set aside for these patients while awaiting evacuation. The great majority, who still remain walking wounded, also wait their transport in the ,tents of this section. All go to the casualty clearing station without delay, being conveyed by lorries and ambulances sent for the purpose by the motor ambulance convoy.

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Fig 18.jpg

THE MAIN DRESSING STATION.-A description of this field ambulance headquarters during an offensive will be more easily followed by reference to Fig. 18, which shows in a diagrammatic way the general scheme upon which it is usually arranged.


The admitting Section A is seen to have greater accommodation than the evacuating Section C, for if any block occurs it is usually because patients cannot be attended to as rapidly as they arrive. In the treatment Section B there are two dressing tents or huts, in each of which there are medical officers and orderlies, with two or more tables for dressing the wounded. There is also a tent or hut, well heated, for the detention and care of moribund
cases; and finally a tent used for a mortuary.


The evacuating Section C consists of tents or huts where patients are retained while awaiting evacuation to a casualty clearing or rest station. As the ambulance cars arrive from the advance dressing station the wounded are seen by a "spotting officer," who distributes them in the following way:


1. Some may have died on the journey and are sent to the mortuary.•

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2. The apparently hopeless cases are sent to the moribund ward, where they are made comfortable, kept warm and given stimulants. Under this treatment many patients recover who would otherwise die.

 

3. Fracture cases and other seriously wounded are sent to wards E, F and G, Section A, to await dressing in the hut or tent B, Section B, reserved for their treatment.

 

4. Less seriously 'wounded are sent to wards A, B, C and D, Section A, to await dressing in the hut or tent A, Section B. The orderlies in charge of Section A make the patients as comfortable as possible and give them tea, oxo, etc., with the exception of those to be operated upon immediately. Here, unlike the walking wounded station, it is mainly medical comforts which the patients require and ask for. 


It is unwise to allow them solid food, as many will be given an anesthetic soon after they reach the clearing station. As it is impossible, when dealing with such large numbers of casualties, to select those who will  certainly be operated upon, it is doing the greatest good to the greatest number to limit them all to medical comforts, of which tea is probably the best.


In the treatment Section B, all dressings are done and the patient's particulars taken meanwhile by the clerks, for entry in the admission and discharge book of the establishment. Fractures or other cases which are not here being operated upon, but who will most certainly be operated upon at the casualty clearing station, are not redressed if comfortable and the wound not bleeding. Others are dressed as well as possible, and suitable cases labeled" Need not be dressed for 24 hours." Anti tetanic serum is also injected, this being given here and at the walking wounded station during an offensive instead of at the advance dressing station, as in times of trench warfare.


Someone has said that the field ambulance should act as a "drainage company" in its surgical work as well as in its function of emptying the regimental aid posts; that its operators should open rather than close a wound, and, by providing for the full escape of discharges, counteract the almost inevitable infection that occurs in such battle injuries.

 
The patient is rendered immune to lockjaw by his dose of serum, and will generally be saved severe wound infection by free drainage and careful dressing while on his way to the casualty clearing station. 


Be this as it may, it is certainly incumbent upon the field ambulance to see that casualties leave its stations in as good condition for later operation as may be possible. In this connection the most urgent consideration is to combat "shock" "from which all wounded suffer in more or less degree.


As the main factors in its development are pain, cold, and loss of blood, the longer these are at work the greater the danger of death or subsequent widespread infection. Careful splinting of fractures, without undue movement; morphine; hot-water bottles; hot drinks; plenty of blankets, will save the lives of many. In regard to heamorrahge, it should be the ideal of every field ambulance that no patient leaves with a bleeding wound, or, what is worse, a tourniquet.


As soon as dressings and other treatment are completed, patients are moved into the various wards of  evacuation Section C and there await the cars of the motor ambulance convoy, which, during active warfare, call for them at frequent intervals.


In the foregoing account of the movement of casualties through the advance, walking wounded and main dressing stations the sick have, for the sake of clearness, been omitted. As a matter of fact, heavy fighting seems one of the best remedies for most of those who would otherwise appear at sick parade, and the chart showing curves for sick and wounded in a division will prove that as the latter index goes up the former goes down.

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There are, however, a certain number who feel too ill to continue, and so are forced to report·; and it must be remembered that even during the fiercest fighting there remain several divisional units not engaged which continue to send in their sick. Again, it should be explained that as each battalion moves into the trenches it leaves behind, at the transport lines, about 100 men under a senior officer to form the nucleus of its further existence should it meet with disaster. This is called its "B. Echelon," and will also contribute its quantum of sick.

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The seriously sick arriving at the advance station are sent to the main dressing station and through it to the casualty clearing station. The ordinary sick, whether sitting or walking, go from the advance to the walking wounded station. The latter station also holds the sick parade for men from the "B. Echelons" and various other transport lines. From here again the seriously ill go to the clearing station, while all ordinary sick are evacuated to the rest station by field ambulance cars if the motor ambulance convoy is unable to supply the necessary transport.

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