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PRIVATE FRANK NOLAN EXTRAORDINARY JOURNEY THE GREAT WAR MEDICAL SERVICES 1 MEDICAL SERVICES 2 AMBULANCE TRAIN MILITARY HOSPITALS
WAR AND MEDICINE WHEN THEY SOUND THE LAST ALL CLEAR GROUP CAPTAIN DOUGLAS BADER GROUP CAPTAIN DOUGLAS BADER CBE DSO '
THE MEDICAL MEMORIES ROADSHOW
‘To understand where we are today
We have to know where we have come from’
THE FIELD AMBULANCE IN PEACE WARFARE.
An assistant director of medical services is responsible for the work of the army medical corps in each division.
For the collection, care and evacuation of the sick and wounded he has three field ambulances in addition to the regimental medical establishments. He is the arbiter of their movement and assigns both the amount and character of the duties which each ambulance shall perform.
In order that this may be done to the best advantage he obtains information on certain important points when the division takes over a new part of the line. He ascertains if they are to occupy a one-, two-, or three-brigade front, the last being the most likely. during periods of trench warfare. He then finds out how many and what description of roads give access to this front; and here map-reading must be supported by a mastery of local geography, only to be gained by personal observation.
With adequate knowledge of these conditions he can determine how many advance dressing stations are necessary to clear the lines and the positions in which they may best be placed to accomplish this with a reasonable amount of safety. In selecting sites for his main dressing stations it is also very important that the traffic map be understood, as it is essential that they be established beside a road on which traffic flows away from the front and not toward it.
He will learn if the corps has made arrangements for a rest station to clear its several divisions of sick and wounded that are expected to be fit for duty within a couple of weeks. Likewise he will know if the corps provides a hospital for the treatment of scabies. If either or both of these be operated by the corps, he inquires as to what part or parts of his field ambulances must be contributed as his share in the work. If, on the other hand, the corps has made no arrangements for a rest station or the treatment of scabies he must look for suitable places in which to establish a divisional rest station and scabies hospital and decide what parts of his field ambulances shall be detailed to provide the necessary personnel.
From a sanitary stand-point he is also interested in the bath and laundry accommodation for the division; and if he be a pliable assistant director, may have to supply a portion of an ambulance, which is not fully occupied, to perform such pseudomedical duties as the operation of these establishments.
Of the many parts which a field ambulance in its time may play, those of purely medical import during peace conditions in the division are:
1. An advance dressing station.
2. A main dressing station.
3. A divisional rest station.
4. A divisional scabies hospital.
THE ADVANCE DRESSING STATION.
This station is located near a road at a point where fairly safe conveyance by vehicle begins. Its site might be called the temporary road head for ambulance transport. I t is therefore as near the front as good roads and enemy shell fire will permit. To it the sick and wounded are brought from the regimental aid posts, which it clears by stretcher-bearers, and usually by night. From it they are evacuated by ambulance at any time. The bearers may, of course, be assisted in their work by horse or light motor ambulances which push ahead under favorable conditions, but this is not the rule, and regular wheeled transport only commences at the advance dressing station.
As previously stated, there is a bearer post in the trenches adjacent to every aid post, to which is assigned a squad of 4 field ambulance stretcher bearers, supplied by the advance dressing station. Stretcher cases are handed over to these bearers by the regimental medical officer and carried by them toward the dressing station. The distance which they can comfortably accomplish varies with ground and weather, an average being 800 to 1000 yards. Relay posts are consequently established at fair intervals, each manned by its complement of 4 bearers. These take over the casualty from the others, and so the patient's journey to the rear is continued. When the regimental aid post hands over the sick or wounded man with his equipment to the field ambulance stretcher-bearers it receives a stretcher and blankets in exchange for those which go with him. This exchange is carried out at each stage of the patient's journey to the advance dressing station, and if he be comfortable and his wounds do not require further dressing he will in all probability reach the casualty clearing station on the same stretcher and in the same blankets with which he left the regimental aid post.
The plan of an advance dressing station progresses from the most simple, as in that first established in a newly captured area, to the elaborate arrangement of old standing. The latter generally occurs under peace warfare, but it will be more comprehensive if the different grades be here described and illustrated in the accompanying figures.
The first three of these show what may be done when time does not allow of extensive work. If a dressing station has been established, as in Fig. 10, an attempt should be made to construct some sort of shelters, as in Fig. I I or better still, a rough dugout, as in Fig. 12, just as soon as a lull occurs in the fighting. lt is imperative that something be got up at the earliest moment which will afford
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FIG. II.-Advance dressing station. First stage. A, area for patients awaiting attention; B, dressing table made by a stretcher or a few boards on trestles covered by oil silk or old sheet, also trestles to hold stretcher
while patient is being dressed; C, area for patients awaiting evacuation; D, area for ambulances to turn and wait.
warmth to patients not only in the dressing room but also while they wait attention and afterward evacuation.
The following points are kept in mind when selecting the site for such a station as here shown: It should be beside or near a road which
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FIG. 12.-Advance dressing station. Second stage. A, shelter for patients waiting, partly dug into bank, a brazier in corner to keep it warm; B, rough building made from material salvaged in vicinity; 1, "Sayer" stove to warm hut and heat water; 2, dressing table; 3, pile of blankets; 4, trestles for stretcher; C, bell tent erected for overflow; D and E, areas for ambulances to turn and wait.
is not in view from the enemy's trenches and can be used by wheeled transport both by day and night; it should be as close as possible to the route used by the infantry going to and from the trenches; it should not, ,during an offensive, be in a village or wood, as such places in newly captured ground receive marked attention from the enemy's gunners. Fig. 13 shows a dugout system off a communication trench.
Such a series of small dugouts is considered safer than a single large one. Leading down to it are saps, each provided with its gas curtain. The passage along the back greatly improves the ventilation and affords easier communication between the individual dugouts. Racks are constructed, each holding 3 stretchers, and the portion set apart for the accommodation of personnel may also be used for patients during an offensive, thus housing in all 36 stretcher cases.
The last illustration (Fig. I4) shows what may be done in arranging an advance dressing station in the cellar of a ruined factory or other good -sized building. It is partitioned into compartments.
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During trench warfare the dressing room and one of the other ·compartments only need be heated. If additional accommodation is required a second and third will also be warmed. Without these partitions it would be hardly possible to keep such a large space at a proper temperature with the amount of fuel ordinarily available. The space allotted to officers and other ranks of the personnel is turned over to patients during an offensive. The cookhouse is not shown, as it is usually situated on the first floor or in another building.
While trench warfare continues the advance dressing station will probably consist of one section of the field ambulance, which may, however, be reinforced by further personnel from a bearer subdivision should this be necessary.
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The sick usually come in during the morning, being sent down from the sick parades of battalions in the trenches and artillery batteries. They also come from detached parties, such as machine-gun companies, which have no medical officers and whose patients must therefore attend the sick parade at the nearest advance dressing station.
Wounded arrive at any hour of the day or night. An advance dressing station is merely a glorified aid post, in so far as treatment is concerned, but it has more personnel, more accommodation, more equipment and better facilities for making its patients warm and comfortable. When the wounded arrive they are immediately seen by the medical officers on duty, who ascertain their condition and do any further dressing that may be thought advisable. Casualties suffering from shock, except in the case of abdominal injuries, are retained and treated until sufficiently recovered to be safely moved. The severely wounded, particularly abdominal, head, and fracture cases, are sent direct to the casualty clearing station. The less seriously wounded and sick go by routine cars or walk to the main dressing station of the ambulance.
All patients receive at least 750 units of antitetanic serum, and have a large "T" marked with indelible pencil on one wrist to show this has been done. If morphine is given, a large "M," and the fraction administered, is marked on the forehead. Moribund cases are always held, and should the patient die, his persona] belongings are carefully collected, a list is made out, and they are parcelled for transmission by way of the main dressing station to the adjutant-general's branch at the base. The body is taken to the mortuary, the main dressing station of the field ambulance and orderly room of the patient's battalion are notified, particulars being given of name, number, religion and disposal of the body, so that arrangements may be made for burial by his regiment. A record of all patients dealt with is kept by means of a nominal rol1, which gives the diagnosis and disposal. An admission and discharge book" is kept for patients sent direct to the casualty clearing station and all dying at the advanced station.
In other words, there is an entry made in the admission and discharge book for every patient who does not go to the main dressing station, for the information of that station.
Two or more motor ambulances are at this dressing station, each with two drivers and one medical orderly, to transport casualties to the main dressing station and to the casualty clearing station.
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THE MAIN DRESSING STATION.
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This is also the headquarters of the field ambulance, so that whatever other fission or fusion takes place between subdivisions and sections it will be found that one tent subdivision, carrying the commanding officer,the quartermaster and the sergeant-major, always forms part of the main dressing station. With peace conditions the personnel will probably represent a section, while, should work be at all heavy, another tent subdivision may be added.. It is frequently established in a village, where a schoolhouse, chateau or factory, affording accommodation for some 100 patients, is occupied, the personnel being billeted near by. On the other hand, it may be situated in hutments or tents. Local geography largely determines position, but, as a rule, if at all possible it should not be more than three miles behind the front, otherwise transportation from the advanced station may be delayed.
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Wherever it be located, in buildings, huts or tents, its arrangement is planned with a view to the definite division of labor into: (a) the reception ·of casualties, (b) their treatment, and (c) their evacuation. This differentiation may be noticed in the preceding diagrams of advance dressing stations, and is attempted in all medical organizations, ranging from the regimental aid post to the casualty clearing station. During an offensive it would be impossible to deal with the large number of wounded, and prevent the mingling of treated with untreated patients if such a separation were not made. This feature in its organization might be thought unnecessary to the successful handling of the ordinary sick and wounded under peace conditions.
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Remembering, however, that raids or a gas attack may result in its being called upon to deal with numbers, which for a short time approach, if not equal, those dealt with under battle conditions, this arrangement may be considered as a measure taken to prevent disorganization during emergencies.
The plan of a main dressing station varies so much in detail on account of the variety of buildings that are used for accommodation that it is inadvisable to attempt any diagram of its general scheme other than such as might be afforded by Section II of Fig. 15, given later to illustrate a rest station.
It has been seen how the advance dressing station roughly divides the foot from the wheeled transport, and the main station is also a point of demarcation in the carriage of casualties. The field ambulance cars convey them to it, while the motor ambulance convoy, which is an army unit, collects patients from it and is responsible for their further movement to the casualty clearing station.
It has also been seen that to facilitate rapid transport to a thoroughly equipped hospital the severely wounded are generally sent direct from the advance dressing to the clearing station, while those suffering from shock and the moribund are retained. It may thus happen that only the ordinary wounded, which are, of course, the large percentage of all, and the sick go to the field ambulance headquarters.
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To these are added the sick which come in from battalions in the rest areas and various other units in the vicinity. Patients, as they arrive, are seen by a medical officer in the reception room, and classified into three groups:
(a) Those who will be fit for duty in two to four days. These go to the wards for treatment.
(b) Those who may be expected to recover in from four to fourteen days. These are transferred
to the rest station.
(c) Those who will not be fit within fourteen days. These are evacuated to the casualty clearing
station.
In practice it will be found that the wards of the main dressing station form a little cul-de-sac off the channel of evacuation of casualties, where those suffering from minor ailments, and admitted as sick, receive attention during their short stay.
As the average number from a division in the field of those ill enough to require hospital care is not high, the dressing stations can accommodate all . needing not more than four days' treatment, while passing others to the rest station and those more seriously affected to the casualty clearing station.
It therefore follows that so far as the wounded are concerned the ambulance headquarters is simply a place where they are sorted for casualty clearing or divisional rest station, are fed and made comfortable, their wounds redressed if necessary, and antitetanic serum given should its injection have been previously omitted.
The motor ambulance convoy people send a dispatch rider at noon each day to ascertain the numbers of sitting and lying cases to be disposed of from the main dressing station, and at 2 P.M. send the necessary cars to transport them.
The headquarters is the center for all records in regard to patients of the field ambulance, and the admission and discharge book kept here is completed by. that from the advance dressing station, which notes patients not evacuated to the headquarters. The records will show the eventual disposition of all admissions as: evacuated to casualty clearing station; transferred to rest station; discharged to duty or died in the field ambulance.
THE DIVISIONAL REST STATION.
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The function of this establishment is to drain from the general run of sick and wounded such as are expected to be fit again in from four to fourteen days, and meanwhile require but little medical treatment. These are thus expeditiously returned to their respective uni ts, instead of cumbering the casualty clearing station, and being evacuated from it to the base with consequent delay. The type of case that here receives attention may be illustrated by a few ailments taken haphazard from the wards: trench fever; muscular rheumatism; severe cold; sprained ankle; inflamed eyes; boils; barked and bruised shin. From this it is evident that it is more the sick and injured than the sick and wounded who are here cared for.
It may be situated in a chateau or other building or possibly be an enlargement of a former dressing station.
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The bed capacity is generally something over 200. Various essential points are brought out in Fig. 15, which represents it as occupying hutments.
Under Section I is the transport with horse lines and vehicle parks.
Under Section II are the administrative buildings, originally forming a main dressing station during trench warfare, but later converted to the present use. •
Huts Band C have been added· for the accommodation of those requiring more particular medical treatment, one of these being reserved for senior non -commissioned officers.
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DESCRIPTION OF FIG. 15.
Section I:
A. motor ambulances;
B. wagons. etc.;
C. feed house;
D. harness room:
E. farrier:
F. latrine:
G. horse line.
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Section II:
A • latrine;
B. N. C. O.'s;
C. temporary patients;
D. quartermaster's stores;
E. dispensary;
F. office
G. reception room:
H. pack store;
I. cook house;
J. dining room;
K. work shop;
L. incinerator;
M. latrine;
N. ablution benches.
Section III:
A. B. C. D. wards;
E, dressing room;
F. G. H. I. wards;
J. dining room;
K. recreation room;
L. ablution benches'
M. kitchen:
N, dining room:
0, cook house:
P, bath house;
Q. latrine:
The quarters for the personnel might .be shown under this heading, but may be in other buildings. Under Section III are the additional wards, kitchens, etc., provided when this site was chosen for a rest station.
The path in front of the huts is wide enough to be used by motor cars, so that if necessary the rest station can be transformed into a main dressing station during an offensive.
For purposes of records it may be regarded as two units: (a) a field ambulance and (b) a rest station operated by a field ambulance. The field ambulance holds a morning sick parade for men from detachments and small units in the vicinity and for those sent in by the medical officers of troops in the area. Those who require hospital
treatment are shown on the books of the field ambulance as admissions, and if sent to the casualty clearing station are shown as evacuations to it.
If, on the other hand, they are sent to the wards they are shown as transferred from the field ambulance to the rest station. It is therefore evident that patients are not admitted directly to this station. The medical officers in charge of wards make rounds every morning, order treatment, select patients who are fit for discharge to duty and those who. require further treatment in a casualty clearing station,
When the rounds are finished, all men to be discharged to duty are paraded, inspected and supplied with new clothing where necessary. They are then warned to be ready next morning for transportation to the various units to which they belong. At noon each day a wire is sent to the assistant director of medical services of the division stating the number of vacant beds that will be available next morning. Each field ambulance, at the same hour, advises the assistant director as to the number of patients there awaiting admission to the rest station. From the information obtained by these wires the assistant director makes out his own list and at 6 o'dock notifies the rest station as to the number of patients they are to collect from each field ambulance the following morning, and also each field ambulance the number of patients which will be collected. As in the case of the main dressing station, a dispatch rider from the motor ambulance convoy calls daily at noon to ascertain the number of cases awaiting transport to the casualty clearing station, and at 2 P.M. these are collected by the
motor ambulance convoy cars.
THE SCABIES HOSPITAL.
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In some corps patients suffering from itch are treated in the rest stations; it is, however, much more common to find a separate establishment for the care of this disease. It is usually a small hospital of 50 to 100 beds, and must have good bath accommodation and a large disinfector. The average clientele varies, being larger
in winter than in summer, but would probably be about .50 men per division. Officers suffering from this disease are sent to a casualty clearing station for treatment.
The average stay in hospital is about ten days, but should an offensive occur, all patients are turned out to full duty, and none suffering from the disease are admitted until active warfare ceases.
THE MOTOR AMBULANCE CONVOY has been frequently alluded to. It does not belong to the division nor even to the corps, but to the army. It is at present a medical unit under the command of an army medical corps officer, who is also provided with certain personnel from the' same corps. These are, however, a small minority of the total strength, which is necessarily made up mainly of attached officers and other ranks from the army service corps.
A convoy consists of 50 motor ambulances, 2 motor cars, supply and workshop lorries, together with motor cycles for the dispatch riders.
There are several convoys with each army in the field, and they receive instructions from the director of medical services of the army with which they happen to be. He details convoys to be responsible for the evacuation of casualties from specified areas.
These convoys, under normal conditions, transport the sick and wounded from main dressing stations, rest stations, and, during an offensive, walking wounded stations to the casualty clearing station.
They also do much work in relieving the last named by the further conveyance of wounded. The movement of casualties to the rear, whether by hand or wheeled transport, has so frequently been mentioned that it seems advisable here to recapitulate in diagrammatic form the facts already given. Fig. 16 shows upon whom rests the responsibility for transportation of patients, at each stage in their journey, from the trenches to the casualty clearing station, during conditions of trench warfare. It also illustrates how certain patients are returned for duty to their units, and how others, judiciously selected, are side-tracked for treatment in the divisional area, thus reducing to a minimum the sick wastage of a division. For if a casualty once pass through the clearing station toward the base, he is struck off the strength of his battalion and so lost to the division; a reinforcement being required in his place.
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