British-Canadian Combined Clinical Conference, 8th …jramc.bmj.com/content/jramc/119/4/190.full.pdfCOMBINED CLINICAL CONFERENCE 8th to 10th ... After some discussion with General

190

BRITISH - CANADIAN FORCES

COMBINED CLINICAL CONFERENCE

8th to 10th MAY, 1973

Royal Arm)' Medical College, Millballk , UJl1dol1

Introduction

ARISING out of conversations held during a visit to Canada by (then) Major-General J. P. Baird in April 1972, Major-General J. W. B. Barr, Surgeon General, Canadian Armed Forces, conceived the idea of holding the 141h Annual Canadian Forces Medical Services Clinical Conference in the United Kingdom in 1973 and when he wrote to Lieutenant-General Sir Norman Talbot, then DirecLOr-General of Army Medical Services, he was invited to hold the Conference at the Royal Army Medical College, Millbank. After some discussion with General Oarr at the D.G.A.M.s' Exercise in October 1972, plans went ahead to hold a British-Canadian Forces Combined Clinical Conference at M illbank during 8th to 10lh May 1973.

The Conference was attended by members of the Canadian Forces Medical Council, the Army Medical Advisory Board , 27 Canadian Forces Medical Service officers, 5 Canadian civilian consultants, and 34 British medical officers of all three services.

Protected by copyright.

on 9 June 2018 by guest.http://jram

c.bmj.com

/J R

Arm

y Med C

orps: first published as 10.1136/jramc-119-04-02 on 1 January 1973. D

ownloaded from

http://jramc.bmj.com/

British-Canadian Forces Combined Clinical Conference 191

It was opened by Lieutenant-General J. P. BaiM, Director-General of Army Medical Services, welcoming to the Royal Army Medical ~ollege the members of the Canadian Forces Medical Council, the members of the Army Medical Advisory Board, the officers of the. Canadian Forces Medical Service and the officers representing the medical services of the Royal Navy and the Royal Air Force. He conveyed greetings and good wishes for the success of the Conference from Lieutenant-General Sir Norman Talbot. He also expressed the hope that Canadian officers would again in the future, as in the past, be among officers attending courses at the College.

Major-General J. W. B. Barr, Surgeon General, Canadian Armed Forces, acknowledged General Baird's welcome and expressed appreciation of the help given in preparing and organising the Conference by General Taibot, General Baird and their staffs. He set the theme of the Conference as essentially that of medical subjects related to military operations, for example, in Northern Ireland, in Northern Canada, in Nepal, and on isolated or foreign duty under a variety of climatic and other conditions, and he expressed pleasure at seeing representatives of all three British Armed Forces Medical· Services present.

Conference Proceedings

The proceedings were held in three sessions on the morni~g of Tuesday 8th May, Wednesday 9th May and Thursday 10th May, the first session being devoted to Experiences in Surgery by British Army surgeons, particularly in relation to missile wounds and to surgery undertaken at the British Military Hospital at Dharan, the British Gurkha base in Nepal; the second session a series of six Canadian papers on a variety of military medical subjects, and the third session a further series of six papers by Canadian and British participants on a variety of clinical subjects, all with a distinct military emphasis.

A summary of the proceedings, with abstracts of papelS and brief mention of the· main points of discussion, follows hereunder.

EXPERIENCES IN MISSILE WOUNDS-l

Lieutenant-Colonel N. A. BOYD, M.B., M.S., F.R.C.S., F.R.C.S.(Ed.), D.T.M.&H., R.A.M.C.

The casualty figures for the past three and half years in Northern Ireland show that 1,133 servicemen were injured, of whom 192 died. Evacuation of the injured was by helicopter or armoured Saracen ambulances. The majority of war injuries were sustained in the City of Belfast itself.

The Military Wing of Musgrave Park Hospital and the Royal Victoria Hospital were the main receiving hospitals, our own unit (the Military Wing) taking 53 per cent of the injured servicemen. .

The time of evacuation from wounding to major resuscitation was often only ten minutes, as a result of which casualties who would otherwise have succumbed now presented with massive injuries but a weak grip on life. The problems associated with large intravenous injuries· and disseminated intravascular coagulation were illustrated by a severe bomb blast injury.

Three hundred and eighty-seven (387) soldiers received missile wounds to the limbs and there was only one death. The relief of tension in fascial compartments was



c.bmj.com

/J R

Arm

y Med C


ownloaded from


-

192 British-Canadian Forces Combined Clinical Conference

one of the most important aspects of wound debridement. Major blood vessel injury was discussed and illustrated by a case that had undergone arterial repair using vein grafting.

Of seventy-five (75) soldiers hit in the chest, thirty-six (36) died. Nearly all deaths resulted from the missile traversing the heart and great vessels from accurate sniper shooting. The problems of rubber bullet injury and blast injury to the lungs were also discussed.

There are three messages concerning missile wounds of the abdomen: a. There is no substitute for a colostomy in large bowel injuries. b. Every abdominal penetrating wound should be explored if only to remove

debris in the missile tract. c. Two complex intra-abdominal injuries exhaust a surgical team. Finally, head injuries were discussed, special reference being made to the prevention

of intra-cerebral tension associated with cerebral oedema by the early application of intermittent positive-pressure ventilation.

EXPERIENCES IN MISSILE WOUNDS-2

Colonel D. D. O'BRIEN, M.B., Late R.A.M.C.

Analysis of 615 cases of missile wounds in Northern Ireland during 1971/1972 produced the following figures, and were compared with statistics of casualties in the United States Army in World Wars I and II (Table 1):-

Table I Analysis of missile wounds

Head and Neck Trunk Upper limbs Lower limbs Theatre (12 per cent)* (27 per cent)* (22 per cent)* (39 per cent)*

Northern Ireland 21 per cent 22 per cent 24 per cent 33 per cent World War I 11 per cent 8 per cent 36 per cent 45 per cent World War 11 12 per cent 25 per cent 23'per cent 40 per cent

* Proportion of whole body surface area in profile silhouette

Management. Sixty to seventy per cent of wounds occur in the limbs but surgical approaches to exploration oflimb wounds is not clearly defined in text-books or manuals.

Joining of entry and exit wounds is not usually recommended. Incisions planned to visualize the depths of a wound should where possible pay regard to Langer's lines, skin creases and cutaneous nerves. " Z " or " S " incisions are recommended to facilitate closure.

Postoperative complications, for example, contractures, painful scars, neuromas or anaesthesia are often the result of over-enthusiastic surgery rather than original injury. The area of excision should be limited to soiled, charred or devitalised tissue. Every track must be visualized in its entirety. Radiographs are recommended in all cases.

Illustrations. Examples were illustrated of complications arising from too conservative management which ignored some principles of surgery. Further illustrations were shown of effects of high velocity missiles striking the body from various ranges and in differing ways. Accidental discharges, causing wounds at the base of the second toe, were discussed, and finally, the value of protective clothing was illustrated ..



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British-Canadian Forces Combined Clinical Conference

RESEARCH INTO MISSILE WOUNDS

Lieutenant-Colonel W. G. JOHNSTON, M.B., F.R.C.S.(Ed.), D.T.M.&H., R.A.M.C.

193

Down through the ages military surgeons have been the acknowledged experts in the treatment of missile wounds. Pare in the 16th century can be considered the father of missile 'wound research and had. considerable influence in·the modification of treatment of missile wounds durin~ his lifetime.

Thereafter there were few drastic changes even after the introduction of gun powder . until the 19th century when development of small arms systems saw the gradual introductionof high velocity rifle bullets. These caused severe explosive wounds and the mechanism of their production was explained by Woodruff in 1898 when he described the phenomenon of " cavitation" produced by missiles as they decelerated in a target.

This phenomenon was demonstrated visually by Zuckerman et al in 1941 using a spark shadowgraph technique and later in the 1940's the perfecting of very high speed cinematography allowed the demonstration of the development of this pulsating temporary cavity in blocks of 20 per cent gelatine.

Thereafter teams from the R.A.M.C. carried out a series of projects, first to develop a method of producing a reproducible standard wound in experimental animals and then a method of consistently causing clostridial myonecrosis in these wounds. These methods formed the basis of a series of controlled experiments comparing the effectiveness of various forms of treatment of missile wounds.

Using the same basic technique, later workers studied the iinmediate and later physiological and biochemical changes in animals so wounded.

As well as the purely surgico-physiological studies the teams have been involved in the modification of weapon efficiency assessment techniques, and in the medical aspects of the development of new weapons systems, particularly the riot control weapons. Amongst many potential crowd control systems assessed, the anti-riot baton round (" the rubber bullet ") provided the most work, and some interesting observations on the effects of localised blunt trauma were made.

Many aspects of missile wounding have still to be investigated. The close co-operation of all teams working in this field is essential.

DISCUSSION ON'MISSILE WOUNDS

Lieutenant-Colonel W. C. MOFFAT, M.B., F.R.C.S., D.T.M.&H., R.A.M.C.

Perhaps the most dramatic advance in the management of missile injury emanating from our recent experience is the value of controlled hyperventilation in the treatment of major cranial wounds. There is no doubt that intracranial tension can be lowered and

. held low by this method and subsequent surgery greatly assisted. It needs to be stressed, however, that endotracheal intubation should be 'done in good circumstances by a practised operator. III judged attempts at intubation in poor circumstances can easily induce struggling, retching and vomiting, all of which raise the intracranial tension rapidly and make matters worse and not better.



c.bmj.com

/J R

Arm

y Med C


ownloaded from


194 British-Canadian Forces Combined Clinil:al COliference

The indications for thoracotomy in missile wounds of the chest are becoming more clearly defined. Evidence of continued intrathoracic bleeding or major lung parenchymal involvement should lead to early thoracotomy and the mortality rates for such wounds has been reduced -following the introduction of this policy. It remains true, however, that the majority of chest wounds can be managed by the institution of efficient thoracentesis.

The state of consumptive coagulopathy consequent upon disseminated intravascular coagulation in traumatic oligaemic shock presents problems in management. Maintenance of tissue perfusion by the use of adequate amounts of intravenous crystalloid should prevent the complication. Once developed it is at present a matter of fine judgement whether to use whole blood, fresh frozen plasma, heparin or epsilon-amino-caproic acid.

The choice of routine antibiotic for the wounded is under review. It may be that crystalline penicillin G will be replaced by a mixture of cloxacillin and ampicillin.

The question of head and body protection against penetrant missiles is under active review. A new and more acceptable helmet may soon be available. Using present materials no form of protection is likely to defeat the high velocity bullet.

In anti-riot weaponry, rubber baton rounds have been shown to produce a relatively small number of serious injuries and those are largely due to their inaccuracy. Baton rounds made of P.v.c. are probably superior and more predictable in use but it is as yet too early to comment on their effects.

EXPERIENCES OF A SURGEON IN NEPAL

Lieutenant-Colonel M. A. MELSOM, M.B.E., M.B., ER.C.S., D.R.C.O.G., R.A.M.C.

An illustrated talk was given showing the mountainous nature of the country of Nepal, its communications problems, and how porters carried on their backs sick people coming to the British Military Hospital (B.M.H.), Dharan, at the base of the foothills of the Himalayas.

Photographs were shown of various conditions seen by the speaker (Figs. 1 to 6). Tuberculosis of neck, skin, abdomen, bone and joints was common. The value of laparotomy in abdominal tuberculosis to confirm diagnosis, visualize the pathology, and deal with complications was emphasized.

Plastic surgery was often required and a gross popliteal fossa burns contracture and replacement of a full thickness facial defect due to cancrum oris were shown.

Neglected obstetrics produced many problems. Ruptureo uterus with extrusion of the foetus into the bladder and obstructed labour due to shoulder dystocia with development of foetal gas gangrene were shown.

Tumours were complicated by late presentation and the unavailability of radiotherapy. A large epithelioma of cheek before and after excision and a large thyroid carcinoma were shown. Tracheostomy after resection of massive thyroids was recommended in view of the softness and tendency of the trachea to -collapse.

Problems of trauma were demonstrated by a bill-hook impacted in a young girl's cervical spine, a difficult maxillofacial problem, a gross pneumothorax, a lO-day old



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British Canadian Forces Combined Clinical Conference 195

Fig. I. Twehe year old girl wi th a bill-hook impacted in body of cervical vcncbra. Exploration revealed no damage to other structures.

Fig. 3. Axillary T.R glands. Discharging after 2 years.

Fig. 5. Carcinoma of thyroid gland successfully resected .

Fig. 2. Kyphosis from old T.B. dorsal spine.

Fig. 4. Full thickness graft (cervicopectoral tube) for cancrum oris. Skin from upper trunk and

arms gives good colour match.

Fig. 6. Obstructed labour with foetal gas gangrene. Patient survived after vaginal delivery,

antibiotics and antisera.



c.bmj.com

/J R

Arm

y Med C


ownloaded from



perforating abdominal injury with bowel prolapse, and Clostridium we/chi; infections in wounds when primary treatment was delayed. In superficial clostridial infections, antibiotics, antiserum, and energetic excision and dressings sometimes helped to avoid amputation. Tetanus lOO was common and early intubation followed by tracheostomy and intravenous sedation with Largactil and Valium were recommended.

The importance of retaining a functional lower limb in a country where there is no alternative to walking and no limb fitting centre was emphasized; Syme's amputation was commended and a simple B. M. H.-made prosthesis shown.

Discussion

Brigadier Dignan noted that, although the B.M.H. Dharan was intended primarily for serving soldiers when built 10 years ago, the absence of adequate other medical facilities made it impossible not to treal the indigenous population. The advanced nature and complications of disease were due to unavoidable delay ill reaching hospital. When large numbers of patients overwhelmed the medical services it was preferable to adopt a policy of dealing Wilh as many people as possible rather than blocking beds with long-stay complicated cases. In reply to questions, bladder stone was noted to be common, appendicitis and V.D. uncommon, while peptic ulcer did occur but not in large numbers. In Clostridium welchii infection myonecrosis still frequently needed amputation. Local medicine men also practise and thankfully deflect some of the work load.

The difficulties of training service surgeons and surgeons for underdeveloped cou ntries to deal with such a wide spectrum of conditions was noted by the Directors of Army and Naval Surgery and by Sir John BrLlce, past Prcsident of lhe Roya l College of Surgeons of Edinburgh.

Acknowledgements

The author would like to thank all Briti sh and epali stafr at the B.M. H. and R.E.M .E. Workshops in Dharan during his tour, without whose help the cases shown could not have been undertaken .

PA RATROO P MEDICINE

Major J. P . RlNGWALD, M.D., C.F.M.S.

From the basis of experience as Regimental Medical Officer with the Canadian Airborne Regiment the following points were covered.

The building of all elite- the importance of a severe medical selection of candidates for a regiment which is considered as a spear-head, to prevent depletion of effeclives due to medical ailments which could have been corrected prior to joining the regiment.

Medical problems of extreme cold exercises- sta ti stical demonstration or the importance or prevention in the eradication of frostbi te, the clinical aspect or the Tent· Eye entity divided in 4 grades ror prognosis and exercise purposes, some precisions on the st ill obscure phenomena of" Arctic Arthritis ".

Medica( problems of tropical exercises covering briefly heat exhaustion , gas l ro~

enteritis, "cow~ilCh " and ,. fireweed ", venereal disease and associated conditions.



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British-Canadian Forces Combined Clinical Conference /

197

Some aspects of para-aeromedical medicine-the importance of alertness towards hearing conservation, the always present danger of carbon monoxide poisoning and intoxication in airlift of paratroops, the helicopter as an effective method of fighting pyrexia during evacuation in tropical environment, the danger of overheating in winter, long-range airlift and paradrops.

CLINICAL ASPECTS OF COLD INJURY

Colonel V. A. McPHERSON, C.D., B.A., M.D., F.R.C.S.(c.), C.F.M.S.

This paper stressed the importance of the duties of a military surgeon in maintaining a current interest in the problems likely to arise in any fighting force compelled to operate in a cold environment such as Northern Canad9.. Actual freezing injury was discussed primarily, but it was theorized that non-freezing injury due to cold presents a very similar clinical picture after rewarming occurs. The main pathological lesion is due to acute and chronic vascular changes. Management of acute cases, including the rapid rewarming method of treating the frozen limb, was discussed. Reference was made to the disabling features of the late sequelae, stressing that there is a high probability of permanent disability occurring.

While the paper dealt mainly with diagnosis and treatment of cases, the importance of preventive measures was also emphasized.

Discussion

Colonel J. C. Dunfield emphasized two -points-

a. That local cold injury can and should be fully preventable.

b. Since local cold injury is preventable, greater research efforts should be devoted to general cold injury (or general hypothermia). Laboratory methods of resuscitation from hypothermia must be adapted to field use. '

HEALTH ASPECTS OF EXTREME COLD WEATHER OPERATIONS

Colonel I. A. MARRIOTT, - C.D., M.R.C.S., L.R.c.P., M.I.H., C.F.M.S.

The combined effects of low temperature and high wind may lead to a rate of body cooling great enough that, despite the best protective clothing, military operations have to be conducted in a "survival" situation and may become virtually impossible. Environmental and logistic factors in a climate such as that of the Canadian North produce a number of health problems .. These include: cold injury (frostbite and hypothermia); the effects of ultra-violet light (sunburn and snowblindness); dehydration, due to the difficulty of obtaining enough water from melted snow; nutritional problems arising from limited rations; dry skin resulting from limited washing facilities and the dry atmosphere; and" tent-eye "-a chemical conjunctivitis from stove fumes.

Virtually all these problems are preventable. The soldier must first be given the proper clothing and equipment to enable him to survive and operate in this climate. He must be trained in the art of living in extreme cold, in the proper wearing of his clothing and use of his equipment, and in the requirements for personal health care.



c.bmj.com

/J R

Arm

y Med C


ownloaded from


198 B"itish~{:anadian Forces. Combined ClinicalCOlljemu;e

Finally, the leader must be aware of the capabilities and limitations of his men in these conditions, and must regulate his demands on them accordingly.

Areas where further research and development are required include energy expenditure and nutritional requirements, the true extent of dehydration, methods of drying clothing, and refinements of a number of items of clothing and equipment.

NOISE IN MILITARY OPERATIONS

Mr. S. E. FORSHA W, P.Eng.

Analysis of Canadian Forces (C.F.) personnel hearing-threshold data indicates that Combat Arms Troops (Armour, Artillery, Infantry) sustain a significantly greater incidence and degree of sensorineural hearing impairment than do other military career or trade groups.

Noise surveys show that drivers of tracked vehicles sustain noise exposures that far exceed the limits considered to be non-hazardous to the hearing of most individuals. Also, impulse noise overexposure is a routine occurrence among the crews and fire control personnel of most C.F. indirect-fire and many direct-fire support weapons.

Even with semi-automatic and automatic weapon open~range firing, the impulse noise exposures sustained by instructors and range control personnel at the Combat Arms School exceed by as much as four times the limits estimated to be non-hazardous in the long term.

There is an urgent requirement during weapon. firing for a hearing protection device that will protect troops from impUlse noise, and yet permit them to perceive low-level sounds normally. The present C.F. standard issue ear plugs and ear muffs attenuate all noise, as is intended. In impulse noise environments such as iiring ranges, where the steady-state background noise is at a relatively low level, voice commands and instructions cannot always be heard or understood correctly when such devices are worn. What frequently happens in these situations at present is that the men simply do not wear hearing protection during weapon firing.

As long as we are forced to accept excessive noise-exposure risks in routine training and operational activities, a safeguard programme of monitoring audiometry is the only way to protect individuals who are over~susceptible to noise"induced hearing loss, and who will otherwise end their military careers with permanent and significant hearing impairment.

Discussion

Lieutenant Colonel Novotny emphasIsed the following points as requiring attention:-

a. More considerate weapon design (to prevent damage to the weapon user).

b. III applied or neglected protection should be eliminated by diligent supply and enforcement of its use ...

c. Remustering affected servicemen when S.R.T. (speech reception threshold) falls below 25 dB ISO.

d. Detection of unusually'susceptible individuals can at theprese.\lt time.onlybe achieved by careful,periodicaudiometry ,by trained personnel, with reliable instruments~ .



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British-Canadian Forces Combined Clinical Conference

PSYCHIATRIC SCREENING FOR ISOLATED AND FOREIGN DUTY

Colonel W. L. L. BENNETT, C.D., B.Sc., M.D., F.R.C.P.(c.), C.F.M.S.

The screening of personnel on entry, during basic training, advanced training; normal service and even service in isolated or foreign stations must be kept under critical review. Questionnaires are useful in obtaining data for computer processing. Men. should be reviewed medically, psychologically and sociologically each year. Simple psychological reports have not proved useful because of the multitude of variables and psychiatric experience is necessary to give useful advice. Neurotics, psychotics in remission, psychosomatics and those with certain types of personality di~order are generally excluded.

The stresses include confinement, continuous presence of .the same associates, tension control, monotony, physical hardships and status limitations. Individual factors to be c~nsidered include emotional stability, motivation, social compatibility, leadershjp, overall effectiveness, personal effectiveness, ego str'ength and defence mechanisms. The individual must be evaluated in relation to the group.

Sources' of observation' described ranged from isolated Arctic duty stations to prolonged occupancy of radio-active fall-out shelters. The a.dditional problems arising when families accompany personnel were mentioned.

Discussion Major J. P. E. Desrocher discussed practical psychiatric intervention for postings'

to isolated areas or foreign countries .and involving troops or single individuals.

In general the psychiatric intervention is mostly as adviser, but exceptionally as a consultant. Most of the. screening is done first atthe unit from the personal records and at the Medical Inspection Room where the medical officer reviews the medical documents and examines each individual.

The screening is more extensive for Northern postings (Arctic) to ensure stability of the m~~ and his. family. He concluded with a quotation from Gunderson that military personnel adapt more easily~ to extreme conditions because of more inter-dependency in their job ,and socially while civilians tend to be isolated in the group.

THE MEDICAL ASS1STANTON iNDEPENDENT DUTY \

Colonel T. A, H. McCULLOCH, C.D., B.A., M.D., F.R.C.P.(C.), C.F.M.S.

'The training of th€medical 'assistant in the Canadian Forces Medical Service IS a form of progression of increasingly ;oetailed and comprehensive' medical knowledge through the stages TL 3, to'TL6B. The intent is to eventually train an individual at the senior or TL 6B level to be capable of functioning on independent and/or isolated duty when called upon i()·do'So. The nature of this training graduates from a basic knowledge at the initial or TL 3 course, where the criteria of capability are judged at the work level of assisting, to supervisingatthe 6B level: knowledge level moves from basic to complete: skill move~ from limited to highly skilled; so that the senior medical assistant (TL 6B) has a work Jevel of super vi sot, knowledge revel of complete and a skill level of highly skilled. A considerable number of tasks are incorporated into' the -training that· enables



c.bmj.com

/J R

Arm

y Med C


ownloaded from



him to perform a large group of functions in various situations while working independently without direct supervision by a doctor or nurse. In this situation the Senior Medical Assistant can be expected to function in ships at sea, radar stations along the northern regions of Canada, at C.F.S. Alert which is 427 miles from the North Pole, Search and Rescue on parachuting to a wreck site, and in the role of Med. Air Evac. as required without the presence of a doctor or a nurse.·

In these situations the TL 6B may encounter the necessity of evaluating and making a tentative diagnosis of anything from appendicitis to severe head injury and carry out an emergency treatment programme while arranging evacuation for more definitive care or, in the occasional situation, of carrying out medical orders received via RjT, telephone or wireless.

Discussion

Dr. lain McKay made the following points:-

a. The TL 6B medical assistant is a potential partial answer to civilian problems of Health Care Delivery. .

b. Because of the 13 year service requirement for complete qualification, he would be ideal for employment as a Primary Care practitioner in remote areas as well as for organizational and instructional work in ambulance services and in industry.

c. The biggest problem is to write the terms of reference and achieve acceptability for the TL 6B medical assistant with the general public and with the nursing profession.

THE MANAGEMENT OF LIVER INJURIES

Colonel T. A. BRUCE, C.D., M.D., C.M., F.R.C.P.(C.), C.F.M.S.

Liver injuries are uncommon and many surgeons have little experience in their management. With an increasing incidence of motor vehicle accidents and civil strife these injuries will increase.

A useful classification of liver injuries is: Peripheral, Intermediate and Hilar. Peripheral injuries pose little problem in management and the mortality rate is low. Many hilar injuries are lethal due to major vessel damage. Intermediate type injury gives rise to most problems in surgical management.

The correct anatomy of the liver was demonstrated approximately 25 years ago when it was shown that the interlobar fissure extended from the gall bladder fossa to the vena cava. The right and left lobes are therefore approximately equal in mass. No significant inter-communication of the arterial and portal blood supply or the biliary radicles has been demonstrated between the right and left lobes. The middle hepatic vein however drains adjacent areas of both right and left lobes.

The diagnosis of liver injury can be obvious in penetrating or perforating wounds but obscure in cases of blunt trauma, particularly in the multi-traumatized or unconscious patient. Selective arteriography is helpful but not warranted where a laparotomy is indicated.

The serious nature of liver injuries has been recognized since the time of Hippo. crates, but operative intervention and attempted arrest of liver haemorrhage by packing was !lnknown until the latter part of the 19th century. The mortality rate from all liver wounds during Worlc;t War II was 66 per cent.



c.bmj.com

/J R

Arm

y Med C


ownloaded from



During World War I it was recognized that packing gave rise to a high incidence of sepsis and secondary haemorrhage and more intensive debridement and drainage was instituted with a significant reduction in mortality.

Over the past 25 years hepatic lobectomy has been employed. with increasing frequency for severe ,liver disruption, but it remains a formidable procedure for the average surgeon outside major trauma centres and particularly when blood supplies are limited.

The main cause of death in liver trauma is haemorrhage, either immediate or delayed, air embolism, and coagulopathy from massive blood transfusions (Mays 1966).

Recent clinical and experimental work has indicated that the liver can survive on portal blood alone provided hypovolaemia and hypoxaemia are prevented. Many reports of accidental and deliberate dearterialization of the liver and its lobes have been reported over the past 20 years without evidence of hepatic neqrosis developing.

A recent series of 16 cases of lobar dearterialization has been reported with only one death from coagulopathy. No patient developed liver necrosis, and follow-up arteriography in a few cases showed revascularization of the liver distal to the ligature. It is conjectured that filling occurred through sub-capsular vessels which opened following ligation and cannot be demonstrated in cadaver livers (Mays 1972).

The basic principles of the surgical management of liver injuries are:

a. Coilt:rol of haemorrhage;

b. Removal of all devitalized liver tissue;

c. Adequate drainage of the sub-hepatic space.

The supposition that decompression of the biliary tract reduces intra-hepatic ductal pressure has been recently questioned. A higher incidence of stress ulcer occurs in patients where bile is diverted from the duodenum.

Lobar dearterialization is suggested as a relatively easy approach to the control of haemorrhage from disruptive liver injury as it is generally conceded that the bleeding from the intra-parenchymal, hepatic and portal veins stops readily. The technique of dearterialization especially at the lobar level would appear to.have particular application for a mass casualty situation or in any case where hepatic lobectomy is precluded by circumstances.

Discussion

Major C. H. Whittle reminded the audience that wounds of the liver are important because this is the most frequently injured of the intra-abdominal solid viscera. Prompt diagnosis is important. .

Pre-, intra-, and postoperative careful J?1anagement and monitoring are essential.

Postoperative care includes management of:-

a. Hypoglycaemia, b. Hypoalbuminaemia, c. Haemorrhage or bleeding diathesis, d. Drains, e. Infection, f. Biliary fistulae, and g. Post-traumatic cysts.

REFERENCES. MAYS, E T. (1966) Bursting Liver Injuries. Arch. Surg. 93, 92. MAYS, E. T. (1972). Lobar I;>earterialization for Exsanguinating Wounds of the Liver J. Trauma 12, 397



c.bmj.com

/J R

Arm

y Med C


ownloaded from



EXPERIENCE WITH AORTO-CORONARY BY-PASS PROCEDURES

Dr. G. M. FITZGIBBON, C.D., L.R.C.P., L.R.C.S.(I.), F.R.C.P.(c.), F.A.C.P.*

The National Defence Medical Centre, Ottawa

The experience gained with aorta-coronary by-pass procedures at the National Defence Medical Centre, Ottawa is the subject of this paper and a detailed analysis is given.

Age distribution of patients The following age groups are shown giving percentage rates for each group:-

Age group 35-39 40-44 45-49 50-54 55-59 Percentage 10 23 28 5 6

The above represents 85 per cent aged 49 and below with a mean age of 45.5 years.

Coronary by-pass operations During the period November 1971 to April 1973, a period of 18 months, there

were:-

Operations-73 in 72 patients. Total by-passes-182 (average of 2.5 per patient). In-hospital deaths-2 (a mortality of 2.7 per cent): One-2 X by-pass + renal

replacement-" post-pump" lung (5 days -postoperative). One-3 X by-pass-transfusion reaction, renal failure, bowel necrosis (10 days postoperative).

Postoperative infarction: 3 + 1 left bundle branch block= 4/70 = 5.7 per cent.

By-passes performed , Saphenous vein grafts-I77, internal mammary-coronary anastomoses-5 (right

mammary 2, left mammary 3: to anterior descending 1, to diagonal branch 4), a total of 182 by-passes, of the anterior descending system '43 per cent, right coronary and branches 33 per cent and margino-circumfiex system 24 per cent.

By-pass procedures The number of by-pass procedures performed were:-single 11 (in 10 patients)

-15 per cent, doubles 22-30 per cent, triples 33-45 per cent and quadruples 7-10, per cent. Five by-passes were lost by the death of 2 patients and 177 remained, of which 5 were mammary anastomoses.

Endarterectomy Endarterectomy operations performed were:-complete (all right coronary)-3,

local: right coronary-12, posterior interventricular-I, anterior descending-6, a total of 22 in 18 patients.

All had saphenous vein grafts to treated vessels.

Associated operations Associated operations consisted of:-ventricular aneurysm-resection 5, plication

6, a total of 11 : valve replacement-mitral 1 (died), aortic 1, a total. of 2.

* With Co-Authors Dr. W. J. KEON, Dr. A. J. LEACH and Dr. J. H. LENIS. ,



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British-Canadian Combined Forces Clinical Conference 203

Internal mammary implants There were 50 left and 6 right in 51 patients. Seventy per cent of operations included

a Vineberg implant.

By-pass patency grading By-pass patency gradings were :-' A ' excellent, ' B ' run-off stenosis greater than

50 per cent, ' 0 ' occluded. These were almost always determined by distal anastomosis.

By-pass patency The by-pass patency is shown in Table I below:-

Vessel

Right coronary and branches (58} Anterior descending and branches (77) Margino-circumfiex system (42)

(83 per cent to marginal branches)*

Total

Table I By-pass patency

Grade' A'

91 .4 per cent 88.3 per cent

60.0 per cent

I 83.6 per cent

I

* Fifty-six per cent of all occluded by-passes were grafted to these vessels

Overall by-pass patency

Grade 'B' '0 'ccluded

5.2 per cent 5.2 per cent

21.4 per cent

7.4 per cent 9.0 per cent

There were 16 vessels occluded in 177 patients surviving (9 per cent). Seventy-five per cent of occluded vessels were associated with triple procedures and 50 per cent of all occluded vessels were grafted to marginal branches of the margino-circumflex system.

Note: There were 177 (100 per cent) by-passes opacified selectively during postoperative study.

Patency of by-passes by procedure The percentage patency of by-passes by procedure is detailed in Table JJ:-

Table 11 Patency of by-passes by procedure

Procedure Percentage I Procedure Percentage

Singles (11) -'A' 82 Triples (32) -'A' 'A' 'A' 53 'B' Nil 'A' 'A' 'B' 22 '0'

I 18 'A' 'A' '0' 12.5

'A' '0' '0' 12.5 Doubles (21)-'A' 'A' 86 Quadruples (7)-'A' 'A' 'A' 'A' 57

'A' 'B' 14 'A' 'A' 'A' 'B' 14 '0' Nil 'A' 'A' 'A' '0' 29 ,

Treadmill tests Thirty-six patients had POSItIve treadmill tests (85 per cent predicted maximum

heart rate (PMHR)) before negative tests (89 per cent PMHR) after operation.

Six patients had negative tests. before and after operation (92 per cent PMHR both tests).



c.bmj.com

/J R

Arm

y Med C


ownloaded from



Five patients had positive tests before and after operation but PMHR rose from 89 to 93 per cent.

One patient (2/3 by-passes occluded) had a negative test (81 per cent PMHR) before and a positive test (95 per cent PMHR) after operation.

lnternal mammary implants (early assessment) Of 51 vessels studied selectively 71 per cent were functioning in the myocardium.

Emergency operations (13) In thirteen emergency operations there were no deaths or myocardial infarctions.

Further details are:-

Emergency cases: postoperative coronary occlusion-13/34 (38.2 per cent). Elective cases: postoperative coronary occlusion-14/I43 (9.8 per cent). There were 13 coronary occlusions after 13 emergency procedures, 14 coronary

occlusions after 58 elective procedures-58/13 = 4.46/1.

Emergency py-pass operations Emergency by-pass operations on 13 patients were:-quadruple 1, triple 7, double

4 and single 1, a total of 34 by-passes.

Gradings were' A '-85 per cent, '0 '-9 per cent. Ten patients (77 per cent) had all ' A ' by-passes.

Surviving patients There were 70 patients followed for a total of 45.4 patient-years. During follow-up

there were no deaths but 2 myocardial infarctions.

One year follow-up (consecutive cases) Early study

'A' 20 17 One year study

. A' 17 (74 per cent)

'B' . 3 -.::::-_2 __ ~...::....:,--_~' B' 3 (13 per cent)

'0' o , 0' 3 (13 per cent)

Totals 23 23

Evolution The evolution of operations for six month periods is shown in Table IlI:-

Six month period

November 1971 to April 1972 May 1972 to October 1972 November 1972 to April 1973

Table III Evolution of operations

Operations

13 34 26

Grafts per patient

1.85 2.32 3.04



c.bmj.com

/J R

Arm

y Med C


ownloaded from


British':Canadian Forces Combined Clinical Conference 205

Discussion

Major-General R. G. MacFarlane asked Dr. Fitzgibbon to outline the criteria by which physicians in peripheral hospitals could select patients for coronary angiography and subsequent aorto-coronary by-pass procedures.

. ENVIRONMENTAL ·TRIALS OF· THE HYDROPHILIC CONTACT LENS

Lieutenant-Colonel B. ST. L. LIDDY, C.D., M.A., M.B., F.R.C.S.(c.), C.F.M.S.

Climatic variations of cold temperatures, heat or high humidity can aggravate the problems that spectacle wearers meet, especially those of "fogging~'. Fogging is particularly bothersome if a spectacle wearer must use other optical devices such as are found in many items of military and navigationai equipment in present day armies. Twenty per cent of soldiers may be obligatory spectacle wearers.

This paper describes a method of reducing the visual problems of spectacle wearing by the use of hydrophilic or soft contact lenses. The concept was tested by:

a. Ensuring bacteriological safety under infected field conditions.

b. Performance of controlled environmental studies.

c. Field trial in the Canadian North in February, 1973, with ambient temperatures of between minus 20°F and minus 80°F.

The results indicate that hydrophilic lenses do confer undoubted visual benefits· in obligatory spectacle wearers in cold environments.

The limitations of these lenses are recognized, but it is felt that with improved technological advances they may have a wider application.

Discussion

Dr. C. McCulloch said Dr. Liddy had demonstrated that the new, soft contact lens is acceptable under many service conditions. Increased wearing time and comfort are the reasonS underlying the success of this new type of lens. Its potential is greater than Dr. Liddy suggested, including-as a bandage lens after injury, as treatment for certain diseases (\f the anterior segment of the eye and as an optical aid for some special visual tasks.

BLOOD SUPPLY FOR MASS CASUALTIES

Lieutenant-Colonel J. G. WINWICK, M.B., M.R.C.Path., D.T.M.&H., R.A.M.C.

The problem that in a nuclear war in Europe it may be that 20,000 plus units of blood would be required in the first week was outlined.

Methods to fulfil this need were discussed and the conclusion was reached that a deep freeze method of stockpiling was the only rational answer at present.

Criteria for the ideal process were defined:--:-

a. The preparation of blood for freezing should be simple.

b. The storage should be capable of lasting years and during any crisis should not depend on esseptial services.

c. The thawing and processing of blood to the point of transfusion should be quick, easy and require little training.



c.bmj.com

/J R

Arm

y Med C


ownloaded from



d. The processed blood should last several days.

The range of methods available at present were reviewed and the reasons why the Krignen-Rowe method had been adopted, although it did not meet all the above requirements, were outlined.

The hopes that the adoption of a method using the K-R hardware but replacing glycerol with hydroxethyl starch as the cryoprotective agent were discusseq.

Finally, the use of "artificial blood", exemplified by the potential advantages inherent in a group of substances known as fluorocarbons, was put forward as a possible answer, though it was stressed that this was pure speculation and in. any case a matter for the distant future.

Discussion

Major-General, H. C. Jeffrey made the point that there was considerable peace-time application of this project-an application to which the Army Blood Supply Depot was already greatly committed.

ASPECTS OF MALARIA

Lieutenant-Colonel J. D. CORMACK, M.B., F.R.C.P.(Ed.), R.A.M.C.

Random observations on platelet levels in thirty-two male patients with naturally / occurring malaria from West Malaysia were presented. There were eighteen cases of Plasmodiumfalciparum and seven of Plasmodium vivax malaria; seven had a mixture of these two malarial infections.

None of the patients was seriously ill and their length of history of illness was short. Only three patients had levels of parasitaemia above 150,000 per mm3

•

Platelets were counted early on admission and twenty-nine patients had levels below 160,000 per mm3

. Twenty-two of these had levels below 80,000 per mm3, and

seven had counts under 40,000 per mm3. Six patients with Plasmodium vivax malaria

had significant thrombocytopenia. Four patients had low counts recorded before they received any medicines .

. Five patients showed evidence of bleeding-epistaxis in three soldiers, subconjunctival haemorrhage in one case and haematuria in one case.

The platelet level was not influenced by the presence of splenomegaly. Early enlargement of the spleen occurred most often in Plasmodium vivax malaria. The platelets recovered with great speed, rising by 40,000 per mm3 per day after treatment. There was no relationship between the fall in the platelets and the degree of parasitaemia. Platelet depression appeared to occur at all levels of parasitaemia.

In a brief discussion of the literature it was emphasised that the thrombocytopenia described was a different syndrome from the picture of serious illness in advanced Plasmodiumfalciparum malaria, when capillary obstruction with parasitised erythrocytes, haemolysis and intra-vascular coagulation with thrombocytopenia occurred.

Reference was made to further studies carried out in collaboration with LieutenantColonel P. J. Beale)nd Major T. B. N. Oldrey; and to some change in immunoglobulin levels in early malaria.



c.bmj.com

/J R

Arm

y Med C


ownloaded from



Discussion

Brigadier W. O'Brien commented that, though previ~usly described, the thrombocytopenia in acute malaria is little known. He gave reasons to suggest it might \ be due to a maturation defect in the bone marrow rather than an immunological reaction.

ARMY PSYCHIATRY IN NORTHERN IRELAND

Lieutenant-Colonel R. J. WA WMAN, M.B., M.R.C.Psych., D.P.M., R.A.M.C.

Ingeneral, the morale of military personnel in Northern Irel~nd is high. Psychiatric morbidity is low and the current facilities available to deal with casualties adequate. Men work long hours on tasks which are often tedious and negative. Their accommodation is sometimes less than ideal and there is little or no opportunity to leave many locations.

Men may work intensely for virtually the whole of an emergency tour, and in this situation fatigue, tension and personal worries can all be potential stresses; consequently all three together lead to stress disorders, usually on a basis of personality weakness. Good man management should help to exclude the unstable, keep fatigue to a minimum, reduce anxiety and assist with personal problems as they arise. Where a measured response to a delicate situation is essential, attention to such factors is of great importance.

Discussion Major-General J. McGhie complimented Lieutenant-Colonel Wawman on his

paper and reminded the audience that officers at all levels, including commanding officers and staff officers, were SUbjected to the same stresses while serving in Northern Ireland. He quoted an example of one officer case and pointed out that, unless medical officers at all levels had the ability to take the necessary correct action promptly, there might be tragic consequences.

CLOSING REMARKS

Major-General Barr complimented all who presented papers on the quality of their presentations and also the three chairmen on their handling of their sessions. He also thanked those who participated in the discussions for helping to sustain the high level of interest evident throughout the Conference. He particularly appreciated the benefit to the Canadian participants of the British presentations reflecting experiences not at present available in the Canadian Forces Medical Service, for example those on missile wounds, and expressed the hope that, on the other hand, the Canadian papers on subjects such as cold weather operations and cold injury would be of value to the British participantS. He further hoped that these mutual benefits could be extended, through publication of the proceedings of the Conference in the Journal of the R.A.M.C., to those officers of the British and Canadian Forces Medical Services unable to be present. He added the hope that this Conference would be only the first of a series of such meetings and that the next might be held in Canada, and concluded by expressing the warm appreci- . ation and thanks of all the Canadian participants to their hosts, in particular to General Baird and General Carrick. He then presented to General Baird as a memento of this Conference and as a token of appreciation from all the Canadians present a gilt-framed, gold embroidered replica of the badge of the Canadian Forces Medical Service, for retention in the Royal Army Medical College.



c.bmj.com

/J R

Arm

y Med C


ownloaded from


208 British~Canadian Forces Combined Clinical Conference

Lieutenant-General. Baird, in reply, thanked General Barr fDr his kind wDrds and fDr the memel)tD, which wDuld remind thDse WhD IDDked at it frDm time tD time .Of what had been a very successful meeting and visit tD. the RDyal Army Medical CDllege by .Our Canadian cDusins.

He cDnsidered the prDfessiDnal part .Of the meeting had been first class and added his persDnal thanks tD thDse .Of General Barr tD all WhD had presented papers and participated in the discussiDns. He .Offered a wDrd .Of encDuragement tD the yDunger .Officers present-that, if they wDrked hard, studied, IDDked up their references cDrrectly and presented gDDd papers .Over many years, the time might eventually CDme when all they wDuld have tD dD wDuld be tD .sit on the frDnt bench and listen tD .Others. General Baird added his thanks tD the chairmen .Of the sessiDns and reminded the cDnference .Of

the wide prDfessiDnal SCDpe .Of the papers presented-frDm the explDits .Of the IDne surgeDn in Nepal tD the sDphisticated heart surgery undertaken in the superbly equipped NatiDnal Defence Medical Centre in Ottawa-but stressed that this widescDpe was what military medical practice really meant and was a principal factDr bDth in attracting keen YDung dDctDrs intD the medical services .Of the Armed FDrces and in making the mDre mature men decide tD serve .On fDr a lifetime career in the services. He cDncluded by thanking thDse respDnsible fDr the DrganisatiDn .Of the· CDnference, the administrative arrangements and excellent catering prDvided, wished a safe jDurney hDme tD all the Canadian participants and hDped they wDuld return .On an .Other visit.

The cDnference then adjDurned tD the R.A.M.C. Headquarter Mess.

Adviser and Tutor in General Practice

The fDllDwing appDintments have been annDunced:Adviser in General Practice

Lieutenant-Colonel-A. P. Grimbly, T.D., M.B., M.R.C.G.P., D.T.M.&H., R.A.M.C., at present at the RDyal Army Medical CDllege, Millbank, assumed the appDintment as Adviser in General Practice as frDm 1 June 1973. Tutor in General Practice

Major K. H. M. Young, M.B., M.R.C.G.P., D.T.M.&H., RA.M.C., at present at the RDyal Military Academy, Sandhurst, assumed the appDintment as TutDr in. General Practice as frDm 14 June 1973.



c.bmj.com

/J R

Arm

y Med C


ownloaded from


Documents

British-Canadian Combined Clinical Conference, 8th …jramc.bmj.com/content/jramc/119/4/190.full.pdfCOMBINED CLINICAL CONFERENCE 8th to 10th ... After some discussion with General