i
ii
iii

Emergency

War Surgery

THIRD UNITED STATES REVISION

2004
iv

“All the circumstances of war surgery thus do violence to civilian

concepts of traumatic surgery. The equality of organizational and

professional management is the first basic difference. The second

is the time lag introduced by the military necessity of evacuation.

The third is the necessity for constant movement of the wounded

man, and the fourth — treatment by a number of different

surgeons at different places instead of by a single surgeon in one

place — is inherent in the third. These are all undesirable factors,

and on the surface they seem to militate against good surgical

care. Indeed, when the over-all circumstances of warfare are

added to them, they appear to make more ideal surgical treatment

impossible. Yet this was not true in the war we have just finished

fighting, nor need it ever be true. Short cuts and measures of

expediency are frequently necessary in military surgery, but

compromises with surgical adequacy are not.”

—Michael E. DeBakey, MD

Presented at Massachusetts General Hospital

Boston, October 1946
v

THE THIRD UNITED STATES REVISION

of

EMERGENCY WAR SURGERY

IS DEDICATED TO THE

COMBAT PHYSICIAN
vi

Dosage Selection:

The authors and publisher have made every effort to ensure

the accuracy of dosages cited herein. However, it is the

responsibility of every practitioner to consult appropriate

information sources to ascertain correct dosages for each

clinical situation, especially for new or unfamiliar drugs and

procedures. The authors, editors, publisher, and the

Department of Defense cannot be held responsible for any

errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for

illustrative purposes only and does not imply endorsement

by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and

pronouns do not refer exclusively to men.

Library of Congress Cataloging-in-Publication Data

Emergency war surgery.-- 3rd U.S. revision.

 p. ; cm.

 Includes bibliographical references and index.

 1. Surgery, Military--Handbooks, manuals, etc. 2. Surgical

emergencies--Handbooks, manuals, etc. 3. War wounds--

Handbooks, manuals, etc.

 [DNLM: 1. Emergencies. 2. Wounds and Injuries--surgery.

3. Military Medicine. WO 800 E53 2004] I. Borden Institute

(U.S.)

 RD151.E56 2004

 617.9’9—dc22

 2004024800

PRINTED IN THE UNITED STATES OF AMERICA

10,09,08,07,06,05 2nd printing 6,5,4,3,2
vii

Contents

EDITORIAL & PRODUCTION xvi

EDITORIAL BOARD xvii

CONTRIBUTORS xviii

ACKNOWLEDGMENTS xx

FOREWORD xxi

PREFACE xxiii

PROLOGUE xxvii

Chapter 1: Weapons Effects and Parachute Injuries

Epidemiology 1.1

Mechanism of Injury 1.2

Antipersonnel Landmines 1.6

Small Arms 1.7

Armored Vehicle Crew Casualties 1.9

Unexploded Ordnance 1.13

Parachute Injuries 1.14

Chapter 2: Levels of Medical Care

Level I 2.1

Level II 2.2

Forward Surgical Team (FST) 2.3

Level III 2.6

Level IV 2.9

Level V 2.10

Chapter 3: Triage

Categories 3.2

Special Categories 3.4

Combat Stress 3.4

Triage Decision Making 3.8

Setup, Staffing, and Operation of Triage System 3.10

Chapter 4: Aeromedical Evacuation

Medical Considerations/Requirements 4.2
viii

Medical Evacuation Precedences 4.5

Phone Numbers 4.7

Critical Care Air Transport Teams (CCATT) 4.9

Chapter 5: Airway/Breathing

Initial Management 5.1

Orotracheal Intubation 5.3

Rapid Sequence Intubation (RSI) 5.3

Difficult Airway 5.5

Surgical Cricothyrotomy 5.6

Blind Intubation 5.8

Chapter 6: Hemorrhage Control

Stop the Bleeding 6.1

Tourniquet 6.3

Internal Bleeding 6.5

Hemostatic Agents 6.6

Chapter 7: Shock and Resuscitation

Recognition and Classification 7.1

Control Bleeding 7.2

Controlled Resuscitation 7.4

Transfusion Therapy 7.6

Walking Blood Bank 7.7

Chapter 8: Vascular Access

Subclavian Vein or Internal Jugular Vein 8.1

Greater Saphenous Vein 8.3

Chapter 9: Anesthesia

Induction of General Anesthesia 9.2

Rapid Sequence Intubation 9.3

Chapter 10: Infections

Diagnosis 10.1

Common Microorganisms 10.2
ix

Treatment 10.3

Empiric Coverage 10.5

Soft Tissue Infections 10.6

Intraabdominal Infections 10.7

Pulmonary Infections 10.7

Sepsis 10.8

Dosages 10.11

Chapter 11: Critical Care

Damage Control 11.1

Resuscitation From Shock 11.2

Traumatic Brain Injury 11.3

Pulmonary System and Ventilators 11.5

Cardiovascular System 11.7

Renal System and Electrolytes 11.9

Hematologic System 11.10

Gastrointestinal System and Nutrition 11.10

Immune System and Infections 11.14

Endocrine System 11.14

Musculoskeletal System 11.15

Preparation for Evacuation 11.15

Chapter 12: Damage Control Surgery

Phases 12.1

Chapter 13: Face and Neck Injuries

Airway 13.1

Bleeding 13.2

Fracture Management 13.3

Soft Tissue Injuries 13.9

Penetrating Neck Trauma 13.12

Specific Face and Neck Injuries 13.14

Vertebral Artery 13.15

Internal Carotid Artery 13.15
x

Internal Jugular Vein 13.15

Trachea 13.16

Esophagus 13.16

Otologic Injury 13.19

Chapter 14: Ocular Injuries

Triage 14.1

Open Globe 14.2

Anterior Segment Injuries 14.3

Cornea Chemical Injuries 14.3

Corneal Abrasions 14.4

Corneal Ulcer and Keratitis 14.5

Foreign Bodies 14.6

Hyphema 14.7

Retrobulbar Hemorrhage 14.7

Lateral Canthotomy 14.8

Orbital Floor (Blowout) Fractures 14.9

Lid Lacerations 14.10

Laser Eye Injuries 14.12

Enucleation 14.13

Chapter 15: Head Injuries

Types 15.1

Classification 15.2

Glasgow Coma Scale 15.5

Management, Medical 15.7

Management, Surgical 15.11

Chapter 16: Thoracic Injuries

Life-Threatening Injuries 16.3

Tube Thoracostomy 16.4

Resuscitative Thoracotomy 16.6

Median Sternotomy 16.9
xi

Specific Injuries:

Vascular 16.11

Heart 16.12

Lung 16.12

Esophagus 16.14

Diaphragm 16.15

Chapter 17: Abdominal Injuries

Indication for Laparotomy 17.2

Diagnostic Adjuncts 17.2

Abdominal Ultrasound 17.3

Diagnostic Peritoneal Lavage 17.7

CT Scan 17.7

Wound Exploration 17.8

Stomach Injuries 17.9

Duodenum Injuries 17.9

Pancreas Injuries 17.10

Liver Injuries 17.11

Spleen Injuries 17.12

Colon Injuries 17.12

Rectum Injuries 17.14

Retroperitoneal Injuries 17.15

Abdominal Closure 17.16

Chapter 18: Genitourinary Tract Injuries

Renal Injuries 18.1

Ureteral Injuries 18.6

Bladder Injuries 18.9

Urethral Injuries 18.10

External Genitalia 18.11

Chapter 19: Gynecologic Trauma and Emergencies

Vulva Injuries 19.1

Vagina Injuries 19.2
xii

Uterus/Cervix Injuries 19.3

Emergent Total Abdominal

Hysterectomy 19.4

Adnexa 19.5

Retroperitoneal Hematoma 19.6

Gynecologic/Obstetric Emergencies 19.7

Vaginal Hemorrhage: Not Pregnant 19.7

Vaginal Hemorrhage: Pregnancy 19.8

Precipitous Vaginal Delivery 19.9

Emergency Cesarean Section 19.11

Neonatal Resuscitation 19.15

Chapter 20: Wounds and Injuries of the Spinal Column and

Cord

Classification 20.1

Pathophysiology 20.2

Transport 20.4

Cervical Spine 20.5

Halo Immobilization 20.6

Thoracic and Lumbar Spine 20.8

Emergent Surgery 20.9

Pharmacologic Treatment 20.9

General Management 20.10

Chapter 21: Pelvic Injuries

Blunt Injuries 21.1

Penetrating Injuries 21.3

Chapter 22: Soft-Tissue Injuries

Presurgical 22.1

Wound Care 22.2

Crush Syndrome 22.6

Compartment Syndrome 22.9

Fasciotomy 22.10
xiii

Chapter 23: Extremity Fractures

Introduction 23.1

Transportation Casts 23.4

Shoulder/Humerus 23.8

Elbow/Forearm 23.8

External Fixation 23.10

Skeletal Traction 23.19

Chapter 24: Open-Joint Injuries

Signs 24.1

Treatment 24.2

Joint Infection 24.5

Hip Wounds 24.5

Shoulder Wounds 24.8

Chapter 25: Amputations

Indications 25.1

Technique 25.3

Postoperative Management 25.5

Transportation Casts 25.6

Chapter 26: Injuries to the Hands and Feet

Types of Injuries 26.1

Hand 26.1

Foot 26.5

Chapter 27: Vascular Injuries

Evaluation and Diagnosis 27.1

Management 27.3

Shunt Placement 27.6

Compartment Syndrome 27.8

Chapter 28: Burns

Point of Injury Care 28.1

Escharotomy 28.3
xiv

Estimation of Fluid Resuscitation 28.4

Rule of Nines 28.4

Management 28.6

Wound Care 28.7

Extremity Care, Escharotomy 28.9

Electrical Injury 28.10

Chemical Burns 28.11

Grafting: “How I Do It” 28.12

Chapter 29: Environmental Injuries

Cold Injury 29.1

Hypothermia 29.7

Heat Injury 29.11

Altitude Illness 29.22

Chapter 30: Radiological Injuries

Introduction 30.1

Triage 30.2

Decontamination 30.6

Chapter 31: Biological Warfare

Detection, Diagnosis 31.1

Decontamination 31.2

Evacuation Precautions 31.3

Bacterial Agents 31.5

Viral Agents 31.5

Toxins 31.6

Chapter 32: Chemical Injuries

Protection 32.1

Nerve Agents 32.2

Vesicants 32.3

Cyanogens 32.4

Surgical Treatment 32.6
xv

Chapter 33: Pediatric care

Anatomic and Physiologic

Considerations 33.1

Pulmonary 33.2

Cardiovascular 33.2

Burns 33.3

Gastrointestinal 33.3

Hematology 33.4

Renal 33.4

Modified Glasgow Coma Scale 33.5

Rapid Sequence Intubation 33.6

Equipment, Age and Weight

Matched Sizes 33.7

Commonly Used Drugs 33.7

Surgical Management 33.8

Chapter 34: Care of Enemy Prisoners of War/Internees

UN and Geneva Convention 34.1

What Healthcare Providers Should Do 34.2

What Healthcare Providers Should Not Do 34.3

Recusal 34.3

Planning 34.6

Medical Photography 34.9

Security 34.10

Envoi E.1

Appendix 1: Principles of Medical Ethics A1.1

Appendix 2: Glasgow Coma Scale A2.1

Appendix 3: Theater Joint Trauma Record A3.1

Index xxxi
xvi

Editorial & Production

Borden Institute

Walter Reed Army Medical Center

Washington, DC

Andy C. Szul

Developmental/Production Editor

Lorraine B. Davis

Production Editor

Bruce G. Maston

Illustrator/Layout Editor

Douglas Wise

Layout Editor

Linette R. Sparacino

Production Editor

Jessica Shull

Illustrator
xvii

Editors

Editorial Board

Army Medical Department Center & School

Fort Sam Houston, Texas

2000–2003

David G. Burris, COL, MC, US Army

Paul J. Dougherty, LTC, MC, US Army

David C. Elliot, COL, MC, US Army

Joseph B. FitzHarris, COL, MC, US Army

Stephen P. Hetz, COL, MC, US Army

John B. Holcomb, COL, MC, US Army

Donald H. Jenkins, LTC, MC, US Air Force

Christoph Kaufmann, LTC, MC, US Army

Peter Muskat, COL, MC, US Air Force

Lawrence H. Roberts, CAPT, MC, US Navy

***

Borden Institute

Walter Reed Army Medical Center

Washington, DC

2003-2004

Dave Ed. Lounsbury, COL, MC, US Army

Matthew Brengman, MAJ, MC, US Army

Ronald F. Bellamy, COL, MC, US Army (Ret.)
xviii

Contributors

Keith Albertson, COL, MC, US Army

Rocco A. Armonda, LTC, MC, US Army

Kenneth S. Azarow, LTC, MC, US Army

Gary Benedetti, LTC, MC, FS, US Air Force

Ronald F. Bellamy, COL, US Army (Ret.)

William Beninati, LTC, MC, US Air Force

Matthew Brengman, MAJ, MC, US Army

David G. Burris, COL, MC, US Army

Frank Butler, CAPT, US Navy

 Mark D. Calkins, MAJ, MC, US Army

Leopoldo C. Cancio, LTC, MC, US Army

David B. Carmacke, MAJ, MC, FS, US Air Force

Maren Chan, CPT, US Army

David J. Cohen, COL, MC, US Army

Jan A. Combs, MAJ, MC, US Army

Paul R. Cordts, COL, MC, US Army

Nicholas J. Cusolito, MAJ, NC, US Air Force

Daniel J. Donovan, LTC, MC, US Army

Paul J. Dougherty, LTC, MC, US Army

David C. Elliot, COL, MC, US Army

Martin L. Fackler, COL, MC, US Army (Ret.)

John J. Faillace, MAJ, MC, US Army

Gerald L. Farber, LTC, MC, US Army

Joseph B. FitzHarris, COL, MC, US Army

Stephen F. Flaherty, LTC, MC, US Army

Roman A. Hayda, LTC, MC, US Army

John B. Holcomb, COL, MC, US Army

Michael R. Holtel, CAPT, MC, US Navy

Stephen P. Hetz, COL, MC, US Army

Jeffrey Hrutkay, COL, MC, US Army

Annesley Jaffin, COL, MC, US Army

Donald H. Jenkins, LTC, MC, US Air Force

James Jezior, LTC, MC, US Army

Christoph Kaufmann, LTC, MC, US Army

Kimberly L. Kesling, LTC, MC, US Army

Thomas E. Knuth, COL, MC, US Army

Wilma I. Larsen, LTC, MC, US Army
xix

George S. Lavenson, Jr., COL, MC, US Army (Ret.)

James J. Leech, COL, MC, US Army

Dave Ed. Lounsbury, COL, MC, US Army

Christian Macedonia, LTC, MC, US Army

Craig Manifold, MAJ, MC, US Air Force

Patrick Melder, MAJ, MC, US Army

Alan L. Moloff, COL, MC, US Army

Allen F. Morey, LTC, MC, US Army

Deborah Mueller, MAJ, MC, US Air Force

Peter Muskat, COL, MC, US Air Force

Mary F. Parker, LTC, MC, US Army

George Peoples, LTC, MC, US Army

Karen M. Phillips, LTC, DC, US Army

Ronald J. Place, LTC, MC, US Army

Paul Reynolds, COL, MC, US Army

Lawrence H. Roberts, CAPT, MC, US Navy

David Salas, Msgt, US Air Force (Ret.)

Joseph C. Sniezek, MAJ, MC, US Army

Scott R. Steele, CPT, MC, US Army

Allen B. Thach, COL, MC, US Army Reserve

Johnny S. Tilman, COL, MC, US Army

John M. Uhorchak, COL, MC, US Army

Steven Venticinque, MAJ, MC, US Air Force

Ian Wedmore, LTC, MC, US Army
xx

Acknowledgments

Sections of this Handbook underwent review and comment

by COL Michael Deaton (for the Surgeon General’s Integrated

Process Team on detainee medical care), LTC Glenn

Wortmann, LTC Chester Buckenmaier, LTC Peter Rhee, COL

(USAF) William Dickerson, and MAJ Clayton D. Simon.

Mr. Roy D. Flowers and Mr. Ronald E. Wallace deserve

thanks.

Although entirely unsolicited, COL Eskil Dalerius of the

Swedish Armed Forces accomplished a thorough and

insightful proofread of the Handbook, for which we are very

grateful.

The interest, efforts, and selfless service of Dr. Matthew

Brengman (formerly MAJ, MC), COL Stephen Hetz, and Dr.

Paul Dougherty (formerly LTC, MC) superseded their written

contributions, were above and beyond the call, and deserve

especial recognition.

Dave Ed. Lounsbury, MD, FACP

Colonel, MC, US Army

Director, Borden Institute
xxi

Foreword

It is an honor for me to acknowledge the time, efforts, and

experience collected in this third revision of Emergency War

Surgery. Once again a team of volunteers representing the

Military Health System and numerous clinical specialties has

committed itself to delimiting state-of-the-art principles and

practices of forward trauma surgery.

War surgery, and treatment of combat casualties at far

forward locations and frequently under austere conditions,

continue to save lives. Military medical personnel provide

outstanding health support to those serving in harm’s way.

As the face of war continues to evolve, so must the practice of

medicine, to support those who so selflessly fight the global

war on terrorism. Today, American military men and women

face a new terrain of mobile urban terrorism and conflict.

Despite advances in personal and force protection provided

to our forces, they remain vulnerable to blast wounds, burns,

and multiple penetrating injuries not usually encountered in

the traditional civilian setting. This publication expertly

addresses the appropriate medical management of these and

other battle and nonbattle injuries.

The editors of this edition are to be congratulated for drawing

on the experiences of numerous colleagues recently returned

from tours of duty in Southwest Asia in order to provide as

current a handbook as possible.

I wish to publicly extend my gratitude, and that of the

American people, to the courageous men and women who

serve in the medical departments of our Armed Services. I

commend your dedicated service and acknowledge your
xxii

sacrifices, and those of your families, to provide the best

health care attainable to those who protect our nation by their

military service. I, and all Americans, are indebted to your

service.

William Winkenwerder, Jr., MD

Assistant Secretary of Defense

for Health Affairs
xxiii

Preface

It is time for another revision of the Emergency War Surgery

(EWS) handbook! In addition to the fundamental advances in

the management of victims of trauma since the 1988 edition,

the format of the earlier versions was distinctly “user

unfriendly.”

This edition contains new material that updates the

management of war wounds and is filled with over 150

specially drawn illustrations. Equally important is the use of

an outline, bulleted format that is so much more concise than

the verbosity of the previous editions. Additionally, emphasis

in this edition is on the all-important “Emergency” in

Emergency War Surgery—surgery performed at levels II and III

—that constitutes the raison d’être for military surgery. Our

intent is that if given a choice of bringing a single book on a

rapid or prolonged deployment, today’s military surgeon

would choose this edition over any other trauma book.

The last revision of the Emergency War Surgery handbook was

published in 1988. Since then, world events have profoundly

affected how the US Armed Forces fight and how their

medical services provide combat casualty care. The threat of a

massive conventional war with the Soviet Union has been

replaced by a new enemy: those who espouse global

terrorism.

There are ongoing conflicts against terrorists in both Iraq and

Afghanistan, under conditions that differ radically from

Operations Desert Shield/Storm of 1990–1991. In Iraq there is

continuous urban warfare against fanatics who hide amongst

the civilian population, while in Afghanistan isolated and

sporadic but fierce small unit actions take place in

mountainous terrain. Both tactical scenarios are quite

different from what occurred in Vietnam and Operation

Desert Storm, and in what was expected for a European war

against the Soviet Union upon which the 1988 edition was

predicated.
xxiv

Military surgeons must assume a leadership role in combat

casualty care especially when faced by such changing

conditions of practice. The physicians must know what to

expect, and how to configure and prepare the team in an

austere and rapidly changing tactical environment with

available and necessary equipment. They must know how to

take care of an unfamiliar battlefield wound or injury and

manage mass casualties. Finally, they must understand the

next echelon of care, including any available capabilities, and

how to safely evacuate their patient to the higher level. This

handbook provides much of the information needed to

answer these questions.

One of the most dramatic ways in which military surgery

differs from civilian trauma management is the staged

provision of care; emergency surgery is carried out at one

locale, while definitive and reconstructive surgeries take place

at different sites. This traditional aspect of military surgery

has found new meaning in the increasing use of damage

control surgery for the most critically wounded. Here, the

initial operation is designed only to prevent further blood loss

and contamination after which resuscitation and completion

of surgery takes place, sometimes at larger, more capable

medical treatment facilities remote from the battlefield. The

US Air Force’s fielding of Critical Care Air Transport Teams

(CCATT) has revolutionized casualty care by transporting

such stabilized patients to higher levels of care during active

resuscitation. Efforts to standardize equipment across services

are in place, with the use of smaller, lightweight diagnostic

and therapeutic devices. Joint interdependence in the

treatment and evacuation of the wounded is now the

cornerstone of combat casualty care.

As a result of such advances, the Army has been able to

restructure field medical facilities essentially making them

small and mobile “building blocks.”

Despite the changes in the conditions of practice, a military

surgeon is far more likely to be deployed today than at any
xxv

other time in our nation’s history since World War II. In the

1988 version of this handbook, BG Thomas E. Bowen quoted

Plato about the likelihood of future conflict: “Only the dead

have seen the end of war!” As military surgeons, will we be

capable and prepared to render the level of combat casualty

care befitting the sons and daughters of America? This

revision of the Emergency War Surgery handbook provides the

information needed to save the country’s and military’s most

precious resource: our soldiers, sailors, airmen, and marines.

Kevin C. Kiley, MD

Lieutenant General, Medical Corps, US Army

The Surgeon General
xxvi
xxvii

Prologue

Although called the Third United States Revision, this issue of

Emergency War Surgery represents an entirely new Handbook.

Format, intent, and much of the content are new. None of the

chapters of the Second Revision has been preserved verbatim.

All material has been rewritten by new authors. Flowing

prose has been largely replaced by a bulleted manual style in

order to optimize the use of this Handbook as a rapid

reference. Illustrations are featured much more prominently

than in the earlier edition. Lastly, this text is widely available

(perhaps even more so than the printed version) electronically

on the World Wide Web and as a CD-ROM; a format neither

available nor imaginable when the second Revision was

released in 1988.

In 2000, the Surgeon General of the US Army called on the

Medical Department to revise Emergency War Surgery,

published in 1988 as the Second United States Revision and

Emergency War Surgery NATO Handbook. Responsibility for

this revision was given to the Senior Clinical Consultant in

the Directorate of Combat and Doctrine Development. He

then collaborated with the Surgeon General’s Consultant

(General Surgery) to develop a plan. These two called upon

consultants from all the Services and established an Editorial

Board of volunteers committed to a complete overhaul of the

previous Handbook. Through a series of on-line and personal

meetings coordinated by the Senior Clinical Consultant,

format and content were established. All of the chapters were

drafted and underwent review and edit by the assembled

Board at Fort Sam Houston, Texas.

Following terrorist attacks of 11 September 2001 on the

United States, US military forces were mobilized and

deployed to Afghanistan in 2001 and Iraq in 2003. The process

in place to complete this now essential Handbook was

necessarily disrupted by reassignments and deployments of

the very people who had volunteered to produce it. In lieu of
xxviii

a completed text, Borden Institute hastily published and

distributed (on-line and CD) the unedited draft manuscripts

then available as Emergency War Surgery Handbook, 2003 Draft

Version. This issue saw wide use in Southwest Asia in 2003.

In winter 2003 – 2004 Borden Institute took up the task of

completing a final version of the Handbook. With numerous

surgeons returning from yearlong tours at Combat Support

Hospitals and Forward Surgical Teams in Iraq and

Afghanistan, the decision was made to seek timely comment

on the draft manuscript. Several surgeons with fresh field

experience volunteered their subspecialty review. Substantial

updates and changes were made to many chapters including:

Anesthesia, Shock and Resuscitation, Infections, Damage

Control Surgery, Face & Neck Injuries, Extremity Fractures,

Abdominal Injuries, Burn Injuries, and Head Injuries.

At the same time material drawn from a Department of

Defense Task Force on detainee medical care (July 2004) was

adapted for the Care of Enemy Prisoners of War/Internees

chapter of this Handbook. The chapter on Triage was

expanded to include consideration of combat stress casualties.

The result of this two-stage process is this Handbook. Its

intent, and the single-minded determination of the

contributors, is the retention of lessons learned from recent, as

well as past, battlefield surgery. War surgery in the 21st

Century is not a jury-rigged art of accommodation and

compromises. Although it can include these, it is a science,

grounded on fundamentals of trauma surgery, which

recognizes as well the overriding unique principles of harsh

and austere environments, mass casualty, blast and

penetrating injury, multiple trauma, triage, staged

resuscitation, damage control surgery, time, and aeromedical

evacuation. The adage that these principles have to be

relearned by every generation of military surgeon is probably

less true than in the past. Emergency War Surgery is a

safeguard to assure this.
xxix

Mais, plus ça change, plus c’est la meme chose. (The more things

change, the more they seem to remain the same.) Remarkable

as the enormous changes in surgical diagnostics and

therapeutics have been in the 16 years since the last edition of

the Handbook, as noteworthy – and humbling – are what

have not changed. Wound ballistics are the same and often

injuries are due to the same projectiles used 35 years ago in

Vietnam. The ghastly penetrating wounds, blast trauma, and

burns produced by present day conventional and improvised

weapons are essentially unchanged from those produced in

the last half of the 20th Century. The automatic rifle, rocketpropelled grenade, mortar, and improvised explosive are

widely available, easy to obtain, simple to use, ferociously

lethal, and not confined to the arsenals of disciplined soldiers.

Bearers of these arms today include suicidal fanatics, women,

and children.

It is equally discouraging that although losses due to disease

have plummeted, salvage rates from severe battlefield trauma

sustained in conflict (ongoing as this Handbook goes to press)

are similar to previous wars despite improvements in armor,

surgery, critical care and evacuation. The died of wounds (%

DOW) rate during the American campaign in northwestern

Europe of 1944 – 1945 (approximately 3%) was markedly

better than that of the American Civil War (14%) nearly a

century earlier. But enormous advances in medicine and

surgery have not been reflected in substantial improvement in

lives saved in forward combat surgical facilities since then (in

World War II and Vietnam the rates were 3.5% and 3.4%

respectively).

Penetrating wounds of the head and chest are as lethal today

as they were in biblical times. Extremity fractures are still best

stabilized with external fixators, albeit a newer model.

Human blood components, with a short demanding shelf life,

have not yet been replaced despite longstanding forecasts of

synthetic products. Whole blood continues to be collected and

transfused in forward medical units as it was in the Second
xxx

World War. Bacteriologic capability to identify wound and

cavity contaminants is still unavailable in forward facilities.

Meanwhile, antibiotic resistance of numerous pathogens,

Gram negative and Gram positive, is a growing problem no

longer confined to level IV referral hospitals in the rear.

Though one can hope that major strides in these and other

areas of trauma resuscitation will be reflected in a future

edition, our more fervent hope is for mankind’s dream of

peace and the exercise of his better Angels, ... whereby this

Handbook becomes altogether unnecessary.

Dave Ed. Lounsbury, MD

Colonel, Medical Corps

October, 2004

Washington, DC