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The Development of Intensive Care in the Military Environment
“The Development of Intensive Care in the Military Environment” Matthew J Roberts MA, BM, BCH, DMCC, FRCA PII: DOI: Reference:
S2352-4529(16)30066-4 doi: 10.1016/j.janh.2016.09.002 JANH 108
To appear in:
Journal of Anesthesia History
Received date: Revised date: Accepted date:
30 March 2016 31 May 2016 18 September 2016
Please cite this article as: , “The Development of Intensive Care in the Military Environment”, Journal of Anesthesia History (2016), doi: 10.1016/j.janh.2016.09.002
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ACCEPTED MANUSCRIPT “The Development of Intensive Care in the Military Environment”
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Dr Matthew J Roberts MA BM BCH DMCC FRCA Associate Professor of Anesthesiology
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Denver Health Medical Center
Corresponding Author Dr Matthew Roberts Dr Matthew Roberts
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Postal Address
Department of Anesthesiology
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Denver Health Medical Center
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777 Bannock Street
E mail
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Denver Colorado 80204 [email protected]
ACCEPTED MANUSCRIPT The Development of Intensive Care in the Military Environment
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“Arthur himself, our renowned King, was mortally wounded and was carried off to the Isle of
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Avalon, so that his wounds might be attended to.”
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Geoffrey of Monmouth. The History of the Kings of Britain c1136
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Throughout the history of human conflict, few battle casualties have benefited from the level of personal attention that legend has it was afforded to King Arthur 1 (Figure 1). Even where
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medical care was available on the battlefield, it was recognized that some casualties were injured beyond the scope of contemporary healers and resources should not be wasted on futile attempts
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at a cure. Machaon and Podalirius, the sons of Asclepius and surgeons with the Greek army at
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Troy, understood the necessity for triage; “If the men are sound, wine and cheese will not hurt
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them; if not, let them die and make room for better men” 2 (Figure 2).
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It is only in recent conflicts that the expertise, logistics and determination required to attempt to save the most seriously wounded casualties have come together to achieve in what in years gone by would have been regarded as miraculous cures.
This paper will examine how the care of the critically injured combatant has developed in a century and a half of conflict in the context of the evolution of intensive care in civilian and military practice.
ACCEPTED MANUSCRIPT As in so many other areas of military medicine the practice of critical care medicine in the military environment has paralleled the civilian experience, at times falling behind, at times
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leaping ahead. The fundamental and defining qualities of intensive care units are the deliberate
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concentration of the sickest patients is a defined area staffed by personnel with specialist training, and the application of advanced monitoring or therapeutic techniques. In 1962, Safar
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described intensive care as one end of a spectrum of “progressive patient care” in which hospital
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facilities are organized around the intensity of care required by groups of patients rather than by
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their common pathological diagnoses3.
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Early References to Critical Care Medicine
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An early reference to the policy of deliberately separating out certain patients for special care is found in Florence Nightingale’s Notes on Hospitals published in 18634. She observed that “it is
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not uncommon, in small country hospitals, to have a recess or small room leading from the
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operating theatre, in which the patients remain until they have recovered, or at least recovered the immediate effects of the operation.”4 This seems to be an early example of a post-anesthesia care unit, which is often considered one of the forerunners of the modern surgical intensive care unit. In more general terms, Nightingale referred to the necessity to allocate “special wards…completely separate from the other wards, because they are intended to contain either the most dangerous and important cases…”4 She also encouraged the separation of patients who were noisy and those with “offensive discharges”.4 Her justification for these special wards was to ensure “these cases that really required most nursing care from neglect”; she also demanded that they should be “placed under a completely appointed staff of their own.”4 So, here in the
ACCEPTED MANUSCRIPT middle of the nineteenth century, we have the most severely ill patients being grouped together to ensure adequate observation and cared for by specially appointed nursing staff. Whether these
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staff underwent any specialist training is unclear and although there was, in these cases, closer
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observation than was standard, no advanced monitoring or therapeutic techniques were available.
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(Figure 3).
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The First World War
One of the great medical challenges of World War I was the understanding and management of
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shock brought on by traumatic wounds WB Cannon’s treatise on the subject detailed descriptions and discussed the pathophysiology of wound shock 5. Although not quite identifying wound
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shock with hemorrhage, Cannon (Figure 4) understood the significance of reduced blood
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volume.Tthe cornerstones of his recommendations for the treatment of shock were restoration of blood volume, warmth and rest. Hypovolemia was managed by oral or rectal fluid administration
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and by the intravenous transfusion of blood until urine output equaled water intake. Cannon
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recognized that casualties who had been in shock, resuscitated and operated upon remained “in a precarious state….and should be attentively watched for unfavorable developments, and if they arise should be promptly treated.”5
In the early phase of World War I, which included the First battle of Ypres (1914), the British Army medical services were overwhelmed and needed to clear the lines of the wounded en masse. Many casualties did not receive surgical care until back in England, several days after injury. Critically injured patients did not survive that journey. As the situation became more
ACCEPTED MANUSCRIPT static, Casualty Clearing Stations near the front lines were enhanced in size and capability to
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cope with the number of casualties and the severity of their injuries6.
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It was now appreciated that wards specializing in the treatment of shock should be established to facilitate the monitoring and prompt treatment of the most critically injured patients. Shock
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wards were staffed by specially trained shock teams consisting of a medical officer, a nurse and
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an orderly. The medical and nursing officers received training in the contemporaneous theories of shock, its manifestations, and the principles of treatment including the monitoring of blood
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pressure and the practicalities of blood transfusion. Surgical staff would visit the shock ward to decide when patients were adequately resuscitated to undergo surgery. As in modern intensive
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care units, it was appreciated that hopeless cases should not be admitted to the shock ward and
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use limited resources.
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Cannon also recommended that medical officers in the shock teams should be free of other duties
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that might distract them from their primary task and that “officers in charge of hospitals should understand that men badly wounded require special care and that medical officers who have been particularly trained to give that care should have, so far as possible, free rein in making proper arrangements.”5 Perhaps this was a herald of the “closed” intensive care units of the present day.
ACCEPTED MANUSCRIPT The Second World War Between the World Wars, with increasingly complex surgery being attempted, the requirement
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for specialist recovery units became more acute, and these units, such as the neurosurgical
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recovery room established at Johns Hopkins in 1923, became de facto surgical intensive care units albeit designed for a specific subset of patients. A more general unit was established by the
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German surgeon Martin Kirchner (1879-1942) at the University of Tuebingen, Tübingen,
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Germany. He recognized that increasingly complex techniques and the knowledge required to treat critically ill patients and those recovering from complicated surgeries demanded a
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specialization in its own right7. Advanced respiratory support was not a feature of these units.
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As is often the case, lessons learned during World War I had to be relearned during World War
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II, in particular the greater efficacy of blood transfusion compared to plasma alone in the treatment of shock. Casualty Clearing Stations were established to have the ability to separate the
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lightly wounded, who may be evacuated early, from the more severe cases that were treated in
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the operating rooms of the integrated Field Surgical Units. Severely ill patients were admitted to preoperative or resuscitation wards, analogous to the shock wards of World War I, run by transfusion officers who were internists or junior surgeons8. This concentration of the most severe cases facilitated the frequent visits by the senior surgeon to decide on priorities for surgical therapy.
One new concept that developed was the belief that surgery could, and in some cases should, be an integral part of resuscitation, particularly when internal hemorrhage made it inappropriate to postpone the operation until the vital signs were normalized. A similar policy of damage control
ACCEPTED MANUSCRIPT resuscitation and surgery has gained favor in recent years, especially in the presence of noncompressible hemorrhage9. After surgery, patients were moved to a post-operative ward reserved
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for the most severely injured who needed special attention.
Korean War
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During the Korean War (1951-1953), there was a significant reduction in the percentage of
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casualties dying of wounds in hospital (2.5%) compared with World War II (4.5%). This has been in part attributed to the unlimited availability of whole blood, and the utilization of the
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helicopter in the evacuation of casualties between medical units10. Because helicopters were not used in the retrieval of casualties from the point of wounding, or “dust off” role, as in Vietnam,
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there were still delays in getting casualties from the battle field to the forward medical units due
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to the rugged terrain. Fewer mortally injured cases reaching the medical services.
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A major step forward in the care of the critically injured in Korea was the introduction of
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hemodialysis for acute renal insufficiency. This was not available during World War II in which the mortality for post-traumatic renal failure was 91%. At the start of the Korean War the mortality for this condition was 80-90%. With the establishment of the Renal Insufficiency Center at Wonju, South Korea, and the utilization of hemodialysis, the mortality of patients with post-traumatic acute renal failure decreased to 53%. The challenge for military medicine was moving from the initial treatment of shock to the management of complications that ensue when resuscitation has been adequate to preserve life but not organ function (Figures 5&6).
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Civilian Progress: The 1950s
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While military physicians were honing their skills in the treatment of the critically ill in Korea, a
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revolution was occurring in civilian practice. One stimulus for this revolution were the polio epidemics of the late 40s and early 50s. The epidemic of 1948-1949 in Los Angeles prompted
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the use of tank respirators and blood gas analysis that reduced in mortality from respiratory
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failure from 79% to 17% (Figure 7). During the epidemic in Denmark of 1952, Bjorn Ibsen (1915-2007), the senior anesthetist at Copenhagen’s communicable disease hospital ,was asked
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for advice concerning the imminent demise of yet another victim of respiratory paralysis. His advice was to insert an endotracheal tube, perform an elective tracheostomy and initiate manual
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positive pressure ventilation. This management was successful and was adopted as the standard
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of care for the rest of the epidemic, leading to a a reduction in mortality from 87% to 40%11.
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The lessons learntedfrom the polio experience were soon applied to other clinical specialties
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where patients, medical or surgical, had established or anticipated ventilatory deficiency and by 1958 respiratory care units were born12. Just as the effective treatment of shock in World War II and Korea had led to the appearance of post-traumatic renal failure as a problem, the near elimination of acute airway obstruction and ventilatory failure on the respiratory care units soon resulted in the appearance of multiple organ failure and sepsis as major problems encountered in critically ill patients. These respiratory units soon merged with recovery units to share equipment and expertise, the result being the modern intensive care unit. Holmdahl, in his 1962 description of the organization and functioning of respiratory care units, pointed out that what such units are called is not important; what is important, he writes, is “that patients needing a
ACCEPTED MANUSCRIPT particular kind of treatment, independent of the basic illness, should be concentrated in a unit, the staff and equipment of which are specially oriented to this kind of care…these units can be a
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meeting place for different medical disciplines…”12.
Vietnam
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The first major conflict after these significant developments in civilian critical care was Vietnam.
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This war, from the American perspective, was characterized by very rapid evacuation from point of wounding to definitive care in static hospitals. The high quality resuscitation initiated in the
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field by corpsmen and continued during evacuation by helicopter medics resulted in many severely injured casualties arriving alive, albeit sometimes barely, at the mobile army surgical
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hospital, field hospital or evacuation hospital. Here was an opportunity to improve not only the
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care of those who in a prior conflict might have died of wounds in hospital but also to make inroads into that large group of casualties previously destined to die on the battlefield prior to
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retrieval to the medical services. Success depended on effective initial resuscitation, surgery and
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postoperative care. In these severe cases, surgery, as had been recognized in World War II, was required to be part of the resuscitation process and also, in what was then a new concept, the anesthesiologist would continue resuscitative efforts throughout the case and into the recovery room.
The requirement for postoperative intensive care was quickly appreciated by the clinicians involved but these facilities did not materialize overnight. Noble described in his account of a year’s tour of duty with an army evacuation hospital how two Bird Mark VIII respirators only arrived five months into the tour, after which the management of chest and abdominal patients
ACCEPTED MANUSCRIPT with pulmonary problems improved significantly13. In the year prior to December 1969, at the 24th Evacuation Hospital (US), a 300 bed unit with an average of 953 admissions and 385 major
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operations per month, 22% of post-operative deaths were due to pulmonary insufficiency and 16-
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25% were listed as seriously or very seriously ill at any given time.14 There was no surgical intensive care unit (SICU) and, on average, 9 patients were mechanically ventilated and were
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managed in various locations of the hospital. Initially requests for the creation of an SICU were
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met with a negative response on the basis that evacuation hospitals were not established for such an entity. Eventually the rules were circumnavigated by introducing a system of “graduated
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nursing”, whereby all the sickest patients were concentrated in one place and looked after by a consistent group of nursing staff; an SICU in all but name.15 Over the next six months the death
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rate due to pulmonary insufficiency decreased by 54%. Fleming et al14 reported this experience
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and wrote that “the advantages and feasibility of intensive care units in field combat hospitals have been demonstrated”14. In fact Lichtmann stated that “The recovery rooms of those large
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field hospitals did not differ greatly from the busy intensive care of a large urban hospital”16.
Once established, the intensive care unit were administered by the anesthesiology in terms of equipment and staff management, clinical policy was determined jointly by anesthesiology and surgery, and specific patient care remaining the surgeons responsibility. This is similar to “open” intensive care units in the United States. As well as mechanical ventilation of the lungs, the intensive care unit staff were now able to utilize central venous pressure monitoring by manometer and arterial blood gas analysis if required.
ACCEPTED MANUSCRIPT The experience of renal failure during the Vietnam War was different than that during Korea. The 629th Medical Renal Detachment (US) deployed to Saigon in 1966 in anticipation of a heavy
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workload. Although there were 24 admissions with renal failure occurring after trauma, renal
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failure presented several days after injury along with multiple complications. The acute renal failure occurring immediately after injury as seen in Korea and related to the delayed or
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inadequate treatment of shock had been eliminated in Vietnam10.
Just as shock had been the feared complication of trauma in World War 1 and World War II and
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renal failure had been a great concern in Korea, “wet lung” was a new and significant cause of mortality in Vietnam17. (It had, in fact, been described during World War II18). This condition
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was probably multifactorial in etiology, but two factors were probably significant. First, the rapid
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evacuation and initial survival of casualties with very serious injuries led to patients with a significant systemic inflammatory response resulting in what was later coined adult respiratory
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distress syndrome. Second, the liberal use of crystalloid fluids in the resuscitation of casualties
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likely contributed to the reduction in post-traumatic renal failure19. Yet again another conflict had presented military physicians with another challenge, one which was met effectively with the increasingly sophisticated standard of critical care medicine available. Hardaway estimated that if the standards of medical treatment characteristic of the conflict in Vietnam had been available in World War II, 117,748 additional American lives would have been saved20.
The satisfaction that might have been felt in military medical circles concerning the success of casualty care in Vietnam would need to be tempered by the understanding that in some important ways this had been a very atypical conflict. Complete air superiority allowed rapid evacuation by
ACCEPTED MANUSCRIPT helicopter directly to field hospitals which were static units, able to build capability to suit their requirements as the conflict progressed. The question as to whether intensive care units were a
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feasible component of the rapidly deployed field medical units of an unstable and fluid battle
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The Israel Defense Force Experience: 1973-1982
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space had not been answered.
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Another example of an atypical series of hostilities has been, and remains, the Arab-Israeli conflict. The relative proximity of major civilian medical centers in Israel to the various
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frontlines and the air superiority enjoyed by the Israel Defense Forces (IDF) allowed the Medical Corps of the IDF to adopt a policy whereby all surgery is, whenever possible, performed in well
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equipped, well-staffed rear hospitals. It was recognized, however, that when the lines of
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communications were longer, such as on the Sinai front in 1973, emergency lifesaving surgery may need to be undertaken in forward field units. Surgery at this level was only contemplated in
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cases in which the most critically injured would not survive further evacuation without
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intervention. These severely ill patients remained at risk post-operatively. Davidson and Cotev concluded from their experiences in the war of October 1973: “It is obvious from the nature of the injuries encountered in the field hospital that intensive care facilities, including a blood gas laboratory, should be available in such a hospital. Arterial blood oxygenation in particular would provide valuable aid in the assessment of a patient’s suitability for evacuation.”21 They also noted that the effective treatment in the forward units in addition to rapid evacuation to the major centers in the rear increased the numbers of severely injured servicemen arriving alive. They felt the rapid evacuation resulted in a requirement for intensive care in up to 10% of hospitalized casualties. Another recommendation was, therefore, that intensive care units in civilian hospitals
ACCEPTED MANUSCRIPT that may be used as casualty receiving centers in time of war should be capable of rapid
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expansion.
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During the Lebanon war of 1982, the IDF took forward surgery and intensive care to another level of sophistication by deploying American made expandable iso-shelters that provided a
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controlled environment for an operating room and a 5-6 bed intensive care unit with
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sophisticated monitoring equipment22. These could be established ready for use within 8 hours of arrival in location. It was stressed that the temptation to undertake unnecessary surgery in well-
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appointed facilities in forward areas should be resisted in order to ensure availability for the most critical cases as they arose. It was also determined that with forward surgery and intensive care,
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which must coexist, the balance between maneuverability and medical capability was critical. It
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remained the policy of the IDF Surgeon General that the best procedure is one performed in an
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Israeli hospital.
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The United Kingdom Armed Forces Experience: 1972-1991 In the early 1970s, the UK government provided military assistance to the Sultan of Oman’s armed forces in the counterinsurgency operations in the Dofar, Oman, region. As part of this effort army and air force surgical teams provided medical support based at Salalah, Oman. This was in some ways similar to the Vietnam or Israeli model, although on a smaller scale, in that evacuation from wounding to the field surgical team was often achieved in less than one hour, and that the medical facility was static and its capabilities evolved over the course of the conflict. Again, rapid evacuation resulted in casualties reaching medical care who otherwise may not have survived to leave the battlefield. Dissimilarly, there were no intensive care facilities, no
ACCEPTED MANUSCRIPT capability for mechanical ventilation of the lungs post-operatively, and no measurement of blood gasses or electrolytes 23. The surgical team deployed between December 1972 and March 1973
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reported one case in which a patient died in part as a result of these deficiencies. Their
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recommendations for the equipping and staffing of an intensive care unit were heeded, and by 1975 Sharwood-Smith was able to report the use of one ward as an intensive care unit using
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positive pressure ventilation, blood gas analysis, and central venous pressure monitoring24. He
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commented that “The anaesthetist’s training in intensive care and the management of acute
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medical problems has a major part to play in a field hospital particularly in an isolated area.”24
The UK armed forces main efforts during the 1970s and 1980s were counterterrorism operations
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in Northern Ireland in which individual clinicians built considerable experience in the
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management of high velocity missile and blast injuries. In addition, the standoff in northern Europe with the Warsaw Pact countries involved the planning for a massive armored battle in
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which nothing less than national survival was at stake and the use of nuclear weapons was a real
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possibility. Overwhelming numbers of casualties were anticipated, and the medical plan would be to do the most good for as many as possible in the shortest time using overstretched facilities. With this approach of therapeutic minimalism, the very severely injured casualty, who in the Vietnam or Israeli wars reached the surgical team barelyalive but would have been resuscitated with the application of seemingly limitless resources, would not be saved. The British Army field hospital equipment scales and staff tables therefore did not provide for an intensive care unit. It was these field hospitals that would later deploy to the Persian Gulf for Operation Granby (Desert Storm).
ACCEPTED MANUSCRIPT In the meantime, a UK taskforce was deployed to liberate the Falklands Islands from Argentine occupation. This campaign was inevitably littoral in character, all the logistic support for the land
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battles came from naval vessels off shore, and the small medical units ashore were supported by
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the hospital ship SS UGANDA (UK) (Figure 8). The shore-based surgical teams were provided by the Royal Marines Surgical Support Team and the Parachute Clearing Troops of the Royal
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Army Medical Corps, both traditionally lightly scaled units intended to provide life and limb
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saving surgery before rapid evacuation to field hospitals in the rear. Equipment and staffing did not allow for the establishment of an intensive care unit. Post-operative patients requiring further
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resuscitation or more than minimal observation were returned to the resuscitation area until fit for the ward or evacuation offshore. Most of these patients were evacuated by helicopter within
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24 hours.
This conflict was more typical of conventional warfare. The UK did not rapidly command the
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skies and the conditions pertaining on land made evacuating or even finding casualties difficult.
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Jowitt reports that only 40% of casualties were operated on within 6 hours of wounding, and 43% waited 10 or more hours25. Inevitably this delay in evacuation resulted in casualties not making it off the battlefield who, with rapid evacuation, would have made it to surgery and been at risk of dying in the peri-operative period. Ironically, the lack of critical care facilities ashore would have seemed less of a hindrance to survival than it was in Salalah in 1973, where the severely injured rapidly reached the medical facility. Rapid evacuation of the wounded to medical facilities and the provision of intensive care in those facilities clearly need to go hand in hand to be effective.
ACCEPTED MANUSCRIPT The SS UGANDA did have an intensive care unit with 20 beds, 5 with ventilators. At one stage, when more than five patients required respiratory support, Royal Marine bandsmen were
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recruited to ventilate patients’ lungs manually26.
As alluded to above, the field hospitals that deployed to the Gulf for the 1991 war to liberate
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Kuwait were equipped and staffed to the same scale that had developed during cold war
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planning. The paper describing the experience of anesthetists with 32 Field Hospital (UK) remarked on how the absence of an intensive care unit or any capability for post-operative
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ventilation resulted in prolonged stays in the recovery ward which led to delays in the subsequent operations27. The hospital never worked to its full capacity, minimizing this effect, but these
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delays would have been a significant problem in a mass casualty situation. Another advantage of
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the deployment of critical care facilities in the field therefore is to maintain casualty flow
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through the resuscitation and operating theatre departments.
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The situation was slightly different At 33 General Hospital (UK). Although there was still no scale for an intensive care unit even in this static unit in the rear, the medical staff undertook to improvise (following in the footsteps of the 24 Evacuation Hospital in Vietnam in 1969) and created a rudimentary intensive care unit in terms of equipment, although it was effective in terms of concentrating the sickest patients and the most experienced staff in one area28.
The United Kingdom Armed Forces Experience: 1991-2000 Since the first Gulf War in 1991 the doctrine of the Army Medical Services (AMS) has had to adapt to the change from cold war planning to the support for military operations of a more
ACCEPTED MANUSCRIPT expeditionary nature, perhaps where the national interest was less clear. Hawley, in his 1996 paper on battlefield trauma management, discussed in detail how society’s expectations have
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increased in terms of the survival of military casualties; certainly it would be politically
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unacceptable for British servicemen to die “unnecessarily” as a result of inadequate medical support29. The most significant development has been the declaration by the defense chiefs that
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servicemen, ill or injured, should be offered medical care to a standard equal to that which they
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would receive in the United Kingdom in peacetime. To that end, there has been an increased willingness to expend significant resources on the management of critically ill and injured
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battlefields of North West Europe.
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patients who previously would have been treated offered little more than comfort care on the
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In the last few years of the 1990s, the UK Surgeon General’s Department undertook a major update in equipment allocation for medical units in the field, particularly fo r anesthesia and
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intensive care. The increasing recognition in civilian practice of intensive care medicine as a
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specialty in its own right prompted the UK armed forces to take the nursing staff and medical officers’ specialist qualifications and experience into account when planning deployments.
Another motivator for change was the perceptions in the late 1990s of an increasing threat in the Middle East, with particular concern about the potential use of chemical and biological weapons. The latter especially was seen as having the potential for generating many very sick patients who would have to be managed within the theater of operations to avoid spreading disease throughout the United Kingdom. To help counter this threat, a Biological Intensive Care Unit was developed and equipped to manage critically ill patients for an extended period. In doing so,
ACCEPTED MANUSCRIPT they had to manage the major complications of sepsis including septic shock, acute lung syndrome, renal and multiple organ failure. This unit was never deployed in anger and its
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conception may indeed have been flawed, but the concept of managing the critically ill in the
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field beyond the immediate post-operative period had been established.
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In the mid to late 1990s, there was much discussion within the UK Defense Medical Services of
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the requirement to provide resuscitative surgery in forward units including the Field Ambulances, soon to become Close Support Medical Regiments. The experience in Vietnam,
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Israel, Salalah and indeed the major civilian trauma centers of the United States dictated that where such heroic surgery is undertaken, post-operative intensive care is mandatory. The clinical
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experience developing in Bosnia during this time was based chiefly on small but static medical
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facilities, which gradually improved in sophistication over the years. This experience did not reflect the limitations of maneuver warfare, and the question remained as to the practicality of
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deploying a sophisticated level of critical care in small forward units that were required to
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remain as mobile as possible.
In early 1999, a two-table field surgical team was deployed by 23 Parachute Field Ambulance (UK) (23PFA) to Macedonia to provide surgical support to troops on Operation AGRICOLA (prior to the entry into Kosovo) 30. The initial configuration included a four bay resuscitation department, a two table operating theater and a four bay post-operative department which included one intensive care bay (with available mechanical ventilation ), one high dependency bay (without available mechanical ventilation), X-ray, diagnostic ultrasound scan, and simple laboratory support, along with a telemedicine link to UK. Two six bed wards were added in due
ACCEPTED MANUSCRIPT course. Deployed under canvas, this unit could be extalbished and open to receive casualties in
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ninety minutes and taken down and ready to move in three hours (Figures 9 & 10).
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The equipment deployed was of a standard of sophistication that would have not been out of place in a civilian UK hospital; however, it had all been selected with simplicity of operation and
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versatility in terms of power supply in mind. Although not subjected to the caseload of a high
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intensity battle, this unit proved itself in terms of maneuverability and the level of critical care it
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provided to severely sick or injured servicemen.
The lead in time for Operation AGRICOLA allowed the 23 PFA to acquire the necessary
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equipment (on the shelves at the main medical supply depot and intended for the Biological
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Intensive Care Unit) in order to achieve this standard of care. This was not typical of other small scale deployments during this period.The 22 Field Hospital (UK) deployed a Medical Support
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Team to Kuwait in 1994 (Operation DRIVER), the 23 PFA deployed a Field Surgical Team to
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Brazzaville in the Congo in 1997 (Operation DETERMINANT), and 16 Close Support Medical Regiment (UK) deployed to Sierra Leone in 2000 (Operation PALLISER) – on none of these deployments provided anything other than a rudimentary, improvised “Cold War” level intensive care. Perhaps inevitably, the results of the Surgeon General’s equipment review were slow to arrive at field units.
Notwithstanding these delays, as the millennium drew to a close, both the political and military will and the capability to confront the challenge of providing a high standard of critical care on
ACCEPTED MANUSCRIPT military operations were in place. The conflicts in the 2000s and 2010s tested this capability was
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to the limit31, 32. The story of how this challenge was met is worthy of a further paper.
ACCEPTED MANUSCRIPT 1. Geoffrey of Monmouth. The History of the Kings of Britain (c1136). London; The Folio Society 1969
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2. Laffin J. Combat Surgeons. Stroud UK, Sutton Publishing, 1970
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3. Safar P, DeKornfeld TJ, Person JM: The intensive care unit. Anaesthesia 1961;16: 275 4. Nightingale F: Notes on Hospitals. 3rd Ed. Longman, Green, Longman, Roberts and Green, 1863,
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p.89.
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5. Canon WB: Wound Shock. In: The Medical Department of the United States Army in the World War. Vol 11. Washington, DC: Government Printing Office; 1927: Chap 7:185-213
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6. Bricknell MCM: The Evolution of Casualty Evacuation in the British Army 20th Century (Part 1) – Boer war to 1918. J R Army Med Corps 2002; 148:200-2007
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7. Hilberman M: The evolution of intensive care units. Critical Care Medicine 1975; 3: 159-165 8. Bricknell MCM: The Evolution of Casualty Evacuation in the British Army 20th Century (Part 2) –
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1918-1945. J R Army Med Corps 2002; 148:314-322
153:299-300
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9. Hodgetts TJ, Mahoney PF, Kirkman E: Damage Control Resuscitation. J R Army Med Corps 2007;
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10. Whelton A, Donadio JV: Post-Traumatic acute renal failure in Vietnam: A comparison with the Korean war experience. Johns Hopkins Medical Journal 1969; 124: 95-105 11. Anderson EW, Ibsen B: The anaesthetic management of patients with poliomyelitis and respiratory paralysis. British Medical Journal 1954; 1: 786-788 12. Holmdahl MH: The respiratory care unit. Anesthesiology 1962; 23:559-568 13. Noble MJ, Bryant T, Ing FY: Casualty anesthesia experiences in Vietnam. Anesthesia and Analgesia 1968; 47: 5-11 14. Fleming WH, Petty C, Gielchinsky I: Evolution of an intensive care unit in Vietnam. American Surgeon 1973; 39: 422- 423
ACCEPTED MANUSCRIPT 15. Petty C, Taylor W. Inhalation therapy: Experience in an Army Evacuation Hospital in Vietnam. Military Medicine 1971; 136: 891
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16. Lichtman MW. Vietnam. In: Military and battle anesthesia. In: Trauma anesthesia and critical
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care under conditions of environmental and circumstantial extremes. In: Grande CM, ed. Textbook of Trauma Anesthesia and Critical Care. St Louis, Mo: Mosby-Year Book; 1993: Part 13:
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Chap 107; Part 1: 1297-1306.
Archives of Surgery 1971; 102: 400-405
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17. Gieger JP, Gielchinsky I: Acute pulmonary insufficiency; treatment in Vietnam casualties.
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18. Burford TH. Wet Lung. Surgery in WWII– Thoracic Surgery Vol II 1965; Chapter V p 207 19. Walker L, Eiseman B. The Changing Pattern of Respiratory Distress. Annals of Surgery 1975;181:
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693-697
20. Hardaway RM: Wartime Treatment of Shock. Military Medicine 1982; 147: 1011-1017
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21. Davidson JT, Cotev S: Anaesthesia in the Yom Kippur War. Annals of the Royal College of
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Surgeons of England 1975; 56: 304-311 22. Gasko OD: Surgery in the field during the Lebanon war, 1982: Doctrine, experience and
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prospects for future changes. Israeli Journal of Medical Sciences 1984; 20: 350-354 23. Melsom MA, Farrar MD, Volkers RC: Battle casualties. Annals of the Royal College of Surgeons of England 1975; 56: 289-303 24. Sharwood-Smith G: Anaesthetist in Salalah: Experience in a field surgical team. Anaesthesia 1976; 31: 1049-1053 25. Jowitt MD, Knight RJ: Anaesthesia during the Falklands campaign; the land battles. Anaesthesia 1983; 38: 776-783 26. Bull PT et al: Anaesthesia during the Falklands campaign; the experience of the Royal Navy. Anaesthesia 1983; 38: 770-775
ACCEPTED MANUSCRIPT 27. Adley R et al: The Gulf war: anaesthetic experience at 32 Field Hospital Department of Anaesthesia and Resuscitation. Anaesthesia 1992; 47: 996-999
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28. Ward P. Personal communication
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29. Hawley A: Trauma management on the battlefield: A modern approach. Journal of the Royal Army Medical Corps 1996; 142: 120-125
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30. Roberts MJ, Salmon JB, Sadler PJ: The provision of intensive care and high dependency care in
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the field. Journal of the Royal Army Medical Corps 2000; 146: 99-103 31. Roberts MJ, Fox MA, Hamilton-Davies C, Dowson S: The experience of the intensive care unit in
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a British army field hospital during the 2003 Gulf conflict. Journal of the Royal Army Medical Corps 2003; 149: 284-290
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32. Lockey D.J, Nordmann G.R, Field J.M, Clough D and Henning J.D.R. The deployment of an
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2004; 62: 261-265
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intensive care facility with a military field hospital to the 2003 conflict in Iraq. Resuscitation
ACCEPTED MANUSCRIPT Legends for Figures The Death of King Arthur. James Archer
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Machaon, son of Asclepius, treats Menelaos who has been struck by an arrow.
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Florence Nightingale (1820-1910) with her candle making the night round of the wards at Scutari hospital. Florence Nightingale. Mezzotint by C.A. Tomkins, 1855, after J. Butterworth.
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Walter B Cannon (1871-1945)
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11 Evacuation Hospital, Wonju Korea, to which the Renal Insufficiency Unit was attached. US Army Medical Department, Office of Medical History
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Artificial kidney (Kolff type) in operation at the Renal Insufficiency Center. US Army Medical Department, Office of Medical History
Figure 7
Iron lung ward filled with polio patients, Rancho Los Amigos Hospital, California 1953. Food and Drug Administration, US.
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SS Uganda as a hospital ship during the 1982 Falkland Islands campaign.
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Mobile field surgical unit including intensive care, Operation Agricola, Macedonia 1999
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Mobile intensive care. Operation Agricola, Macedonia 1999
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ACCEPTED MANUSCRIPT “The Development of Intensive Care in the Military Environment” Highlights
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1. Military intensive care has developed in parallel with the civilian specialty
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2. The military environment has presented additional challenges to intensivists
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3. As clinical challenges have been met, others are often revealed amongst survivors
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4. In recent years there has been a significant increase in expectations as to the level of care available to injured and sick servicemen
S2352-4529(16)30066-4 doi: 10.1016/j.janh.2016.09.002 JANH 108
To appear in:
Journal of Anesthesia History
Received date: Revised date: Accepted date:
30 March 2016 31 May 2016 18 September 2016
Please cite this article as: , “The Development of Intensive Care in the Military Environment”, Journal of Anesthesia History (2016), doi: 10.1016/j.janh.2016.09.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT “The Development of Intensive Care in the Military Environment”
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Dr Matthew J Roberts MA BM BCH DMCC FRCA Associate Professor of Anesthesiology
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Denver Health Medical Center
Corresponding Author Dr Matthew Roberts Dr Matthew Roberts
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Postal Address
Department of Anesthesiology
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Denver Health Medical Center
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777 Bannock Street
E mail
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Denver Colorado 80204 [email protected]
ACCEPTED MANUSCRIPT The Development of Intensive Care in the Military Environment
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“Arthur himself, our renowned King, was mortally wounded and was carried off to the Isle of
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Avalon, so that his wounds might be attended to.”
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Geoffrey of Monmouth. The History of the Kings of Britain c1136
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Throughout the history of human conflict, few battle casualties have benefited from the level of personal attention that legend has it was afforded to King Arthur 1 (Figure 1). Even where
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medical care was available on the battlefield, it was recognized that some casualties were injured beyond the scope of contemporary healers and resources should not be wasted on futile attempts
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at a cure. Machaon and Podalirius, the sons of Asclepius and surgeons with the Greek army at
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Troy, understood the necessity for triage; “If the men are sound, wine and cheese will not hurt
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them; if not, let them die and make room for better men” 2 (Figure 2).
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It is only in recent conflicts that the expertise, logistics and determination required to attempt to save the most seriously wounded casualties have come together to achieve in what in years gone by would have been regarded as miraculous cures.
This paper will examine how the care of the critically injured combatant has developed in a century and a half of conflict in the context of the evolution of intensive care in civilian and military practice.
ACCEPTED MANUSCRIPT As in so many other areas of military medicine the practice of critical care medicine in the military environment has paralleled the civilian experience, at times falling behind, at times
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leaping ahead. The fundamental and defining qualities of intensive care units are the deliberate
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concentration of the sickest patients is a defined area staffed by personnel with specialist training, and the application of advanced monitoring or therapeutic techniques. In 1962, Safar
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described intensive care as one end of a spectrum of “progressive patient care” in which hospital
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facilities are organized around the intensity of care required by groups of patients rather than by
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their common pathological diagnoses3.
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Early References to Critical Care Medicine
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An early reference to the policy of deliberately separating out certain patients for special care is found in Florence Nightingale’s Notes on Hospitals published in 18634. She observed that “it is
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not uncommon, in small country hospitals, to have a recess or small room leading from the
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operating theatre, in which the patients remain until they have recovered, or at least recovered the immediate effects of the operation.”4 This seems to be an early example of a post-anesthesia care unit, which is often considered one of the forerunners of the modern surgical intensive care unit. In more general terms, Nightingale referred to the necessity to allocate “special wards…completely separate from the other wards, because they are intended to contain either the most dangerous and important cases…”4 She also encouraged the separation of patients who were noisy and those with “offensive discharges”.4 Her justification for these special wards was to ensure “these cases that really required most nursing care from neglect”; she also demanded that they should be “placed under a completely appointed staff of their own.”4 So, here in the
ACCEPTED MANUSCRIPT middle of the nineteenth century, we have the most severely ill patients being grouped together to ensure adequate observation and cared for by specially appointed nursing staff. Whether these
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staff underwent any specialist training is unclear and although there was, in these cases, closer
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observation than was standard, no advanced monitoring or therapeutic techniques were available.
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(Figure 3).
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The First World War
One of the great medical challenges of World War I was the understanding and management of
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shock brought on by traumatic wounds WB Cannon’s treatise on the subject detailed descriptions and discussed the pathophysiology of wound shock 5. Although not quite identifying wound
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shock with hemorrhage, Cannon (Figure 4) understood the significance of reduced blood
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volume.Tthe cornerstones of his recommendations for the treatment of shock were restoration of blood volume, warmth and rest. Hypovolemia was managed by oral or rectal fluid administration
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and by the intravenous transfusion of blood until urine output equaled water intake. Cannon
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recognized that casualties who had been in shock, resuscitated and operated upon remained “in a precarious state….and should be attentively watched for unfavorable developments, and if they arise should be promptly treated.”5
In the early phase of World War I, which included the First battle of Ypres (1914), the British Army medical services were overwhelmed and needed to clear the lines of the wounded en masse. Many casualties did not receive surgical care until back in England, several days after injury. Critically injured patients did not survive that journey. As the situation became more
ACCEPTED MANUSCRIPT static, Casualty Clearing Stations near the front lines were enhanced in size and capability to
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cope with the number of casualties and the severity of their injuries6.
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It was now appreciated that wards specializing in the treatment of shock should be established to facilitate the monitoring and prompt treatment of the most critically injured patients. Shock
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wards were staffed by specially trained shock teams consisting of a medical officer, a nurse and
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an orderly. The medical and nursing officers received training in the contemporaneous theories of shock, its manifestations, and the principles of treatment including the monitoring of blood
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pressure and the practicalities of blood transfusion. Surgical staff would visit the shock ward to decide when patients were adequately resuscitated to undergo surgery. As in modern intensive
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care units, it was appreciated that hopeless cases should not be admitted to the shock ward and
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use limited resources.
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Cannon also recommended that medical officers in the shock teams should be free of other duties
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that might distract them from their primary task and that “officers in charge of hospitals should understand that men badly wounded require special care and that medical officers who have been particularly trained to give that care should have, so far as possible, free rein in making proper arrangements.”5 Perhaps this was a herald of the “closed” intensive care units of the present day.
ACCEPTED MANUSCRIPT The Second World War Between the World Wars, with increasingly complex surgery being attempted, the requirement
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for specialist recovery units became more acute, and these units, such as the neurosurgical
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recovery room established at Johns Hopkins in 1923, became de facto surgical intensive care units albeit designed for a specific subset of patients. A more general unit was established by the
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German surgeon Martin Kirchner (1879-1942) at the University of Tuebingen, Tübingen,
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Germany. He recognized that increasingly complex techniques and the knowledge required to treat critically ill patients and those recovering from complicated surgeries demanded a
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specialization in its own right7. Advanced respiratory support was not a feature of these units.
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As is often the case, lessons learned during World War I had to be relearned during World War
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II, in particular the greater efficacy of blood transfusion compared to plasma alone in the treatment of shock. Casualty Clearing Stations were established to have the ability to separate the
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lightly wounded, who may be evacuated early, from the more severe cases that were treated in
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the operating rooms of the integrated Field Surgical Units. Severely ill patients were admitted to preoperative or resuscitation wards, analogous to the shock wards of World War I, run by transfusion officers who were internists or junior surgeons8. This concentration of the most severe cases facilitated the frequent visits by the senior surgeon to decide on priorities for surgical therapy.
One new concept that developed was the belief that surgery could, and in some cases should, be an integral part of resuscitation, particularly when internal hemorrhage made it inappropriate to postpone the operation until the vital signs were normalized. A similar policy of damage control
ACCEPTED MANUSCRIPT resuscitation and surgery has gained favor in recent years, especially in the presence of noncompressible hemorrhage9. After surgery, patients were moved to a post-operative ward reserved
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for the most severely injured who needed special attention.
Korean War
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During the Korean War (1951-1953), there was a significant reduction in the percentage of
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casualties dying of wounds in hospital (2.5%) compared with World War II (4.5%). This has been in part attributed to the unlimited availability of whole blood, and the utilization of the
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helicopter in the evacuation of casualties between medical units10. Because helicopters were not used in the retrieval of casualties from the point of wounding, or “dust off” role, as in Vietnam,
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there were still delays in getting casualties from the battle field to the forward medical units due
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to the rugged terrain. Fewer mortally injured cases reaching the medical services.
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A major step forward in the care of the critically injured in Korea was the introduction of
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hemodialysis for acute renal insufficiency. This was not available during World War II in which the mortality for post-traumatic renal failure was 91%. At the start of the Korean War the mortality for this condition was 80-90%. With the establishment of the Renal Insufficiency Center at Wonju, South Korea, and the utilization of hemodialysis, the mortality of patients with post-traumatic acute renal failure decreased to 53%. The challenge for military medicine was moving from the initial treatment of shock to the management of complications that ensue when resuscitation has been adequate to preserve life but not organ function (Figures 5&6).
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Civilian Progress: The 1950s
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While military physicians were honing their skills in the treatment of the critically ill in Korea, a
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revolution was occurring in civilian practice. One stimulus for this revolution were the polio epidemics of the late 40s and early 50s. The epidemic of 1948-1949 in Los Angeles prompted
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the use of tank respirators and blood gas analysis that reduced in mortality from respiratory
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failure from 79% to 17% (Figure 7). During the epidemic in Denmark of 1952, Bjorn Ibsen (1915-2007), the senior anesthetist at Copenhagen’s communicable disease hospital ,was asked
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for advice concerning the imminent demise of yet another victim of respiratory paralysis. His advice was to insert an endotracheal tube, perform an elective tracheostomy and initiate manual
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positive pressure ventilation. This management was successful and was adopted as the standard
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of care for the rest of the epidemic, leading to a a reduction in mortality from 87% to 40%11.
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The lessons learntedfrom the polio experience were soon applied to other clinical specialties
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where patients, medical or surgical, had established or anticipated ventilatory deficiency and by 1958 respiratory care units were born12. Just as the effective treatment of shock in World War II and Korea had led to the appearance of post-traumatic renal failure as a problem, the near elimination of acute airway obstruction and ventilatory failure on the respiratory care units soon resulted in the appearance of multiple organ failure and sepsis as major problems encountered in critically ill patients. These respiratory units soon merged with recovery units to share equipment and expertise, the result being the modern intensive care unit. Holmdahl, in his 1962 description of the organization and functioning of respiratory care units, pointed out that what such units are called is not important; what is important, he writes, is “that patients needing a
ACCEPTED MANUSCRIPT particular kind of treatment, independent of the basic illness, should be concentrated in a unit, the staff and equipment of which are specially oriented to this kind of care…these units can be a
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meeting place for different medical disciplines…”12.
Vietnam
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The first major conflict after these significant developments in civilian critical care was Vietnam.
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This war, from the American perspective, was characterized by very rapid evacuation from point of wounding to definitive care in static hospitals. The high quality resuscitation initiated in the
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field by corpsmen and continued during evacuation by helicopter medics resulted in many severely injured casualties arriving alive, albeit sometimes barely, at the mobile army surgical
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hospital, field hospital or evacuation hospital. Here was an opportunity to improve not only the
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care of those who in a prior conflict might have died of wounds in hospital but also to make inroads into that large group of casualties previously destined to die on the battlefield prior to
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retrieval to the medical services. Success depended on effective initial resuscitation, surgery and
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postoperative care. In these severe cases, surgery, as had been recognized in World War II, was required to be part of the resuscitation process and also, in what was then a new concept, the anesthesiologist would continue resuscitative efforts throughout the case and into the recovery room.
The requirement for postoperative intensive care was quickly appreciated by the clinicians involved but these facilities did not materialize overnight. Noble described in his account of a year’s tour of duty with an army evacuation hospital how two Bird Mark VIII respirators only arrived five months into the tour, after which the management of chest and abdominal patients
ACCEPTED MANUSCRIPT with pulmonary problems improved significantly13. In the year prior to December 1969, at the 24th Evacuation Hospital (US), a 300 bed unit with an average of 953 admissions and 385 major
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operations per month, 22% of post-operative deaths were due to pulmonary insufficiency and 16-
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25% were listed as seriously or very seriously ill at any given time.14 There was no surgical intensive care unit (SICU) and, on average, 9 patients were mechanically ventilated and were
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managed in various locations of the hospital. Initially requests for the creation of an SICU were
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met with a negative response on the basis that evacuation hospitals were not established for such an entity. Eventually the rules were circumnavigated by introducing a system of “graduated
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nursing”, whereby all the sickest patients were concentrated in one place and looked after by a consistent group of nursing staff; an SICU in all but name.15 Over the next six months the death
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rate due to pulmonary insufficiency decreased by 54%. Fleming et al14 reported this experience
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and wrote that “the advantages and feasibility of intensive care units in field combat hospitals have been demonstrated”14. In fact Lichtmann stated that “The recovery rooms of those large
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field hospitals did not differ greatly from the busy intensive care of a large urban hospital”16.
Once established, the intensive care unit were administered by the anesthesiology in terms of equipment and staff management, clinical policy was determined jointly by anesthesiology and surgery, and specific patient care remaining the surgeons responsibility. This is similar to “open” intensive care units in the United States. As well as mechanical ventilation of the lungs, the intensive care unit staff were now able to utilize central venous pressure monitoring by manometer and arterial blood gas analysis if required.
ACCEPTED MANUSCRIPT The experience of renal failure during the Vietnam War was different than that during Korea. The 629th Medical Renal Detachment (US) deployed to Saigon in 1966 in anticipation of a heavy
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workload. Although there were 24 admissions with renal failure occurring after trauma, renal
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failure presented several days after injury along with multiple complications. The acute renal failure occurring immediately after injury as seen in Korea and related to the delayed or
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inadequate treatment of shock had been eliminated in Vietnam10.
Just as shock had been the feared complication of trauma in World War 1 and World War II and
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renal failure had been a great concern in Korea, “wet lung” was a new and significant cause of mortality in Vietnam17. (It had, in fact, been described during World War II18). This condition
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was probably multifactorial in etiology, but two factors were probably significant. First, the rapid
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evacuation and initial survival of casualties with very serious injuries led to patients with a significant systemic inflammatory response resulting in what was later coined adult respiratory
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distress syndrome. Second, the liberal use of crystalloid fluids in the resuscitation of casualties
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likely contributed to the reduction in post-traumatic renal failure19. Yet again another conflict had presented military physicians with another challenge, one which was met effectively with the increasingly sophisticated standard of critical care medicine available. Hardaway estimated that if the standards of medical treatment characteristic of the conflict in Vietnam had been available in World War II, 117,748 additional American lives would have been saved20.
The satisfaction that might have been felt in military medical circles concerning the success of casualty care in Vietnam would need to be tempered by the understanding that in some important ways this had been a very atypical conflict. Complete air superiority allowed rapid evacuation by
ACCEPTED MANUSCRIPT helicopter directly to field hospitals which were static units, able to build capability to suit their requirements as the conflict progressed. The question as to whether intensive care units were a
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feasible component of the rapidly deployed field medical units of an unstable and fluid battle
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The Israel Defense Force Experience: 1973-1982
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space had not been answered.
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Another example of an atypical series of hostilities has been, and remains, the Arab-Israeli conflict. The relative proximity of major civilian medical centers in Israel to the various
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frontlines and the air superiority enjoyed by the Israel Defense Forces (IDF) allowed the Medical Corps of the IDF to adopt a policy whereby all surgery is, whenever possible, performed in well
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equipped, well-staffed rear hospitals. It was recognized, however, that when the lines of
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communications were longer, such as on the Sinai front in 1973, emergency lifesaving surgery may need to be undertaken in forward field units. Surgery at this level was only contemplated in
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cases in which the most critically injured would not survive further evacuation without
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intervention. These severely ill patients remained at risk post-operatively. Davidson and Cotev concluded from their experiences in the war of October 1973: “It is obvious from the nature of the injuries encountered in the field hospital that intensive care facilities, including a blood gas laboratory, should be available in such a hospital. Arterial blood oxygenation in particular would provide valuable aid in the assessment of a patient’s suitability for evacuation.”21 They also noted that the effective treatment in the forward units in addition to rapid evacuation to the major centers in the rear increased the numbers of severely injured servicemen arriving alive. They felt the rapid evacuation resulted in a requirement for intensive care in up to 10% of hospitalized casualties. Another recommendation was, therefore, that intensive care units in civilian hospitals
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expansion.
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During the Lebanon war of 1982, the IDF took forward surgery and intensive care to another level of sophistication by deploying American made expandable iso-shelters that provided a
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controlled environment for an operating room and a 5-6 bed intensive care unit with
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sophisticated monitoring equipment22. These could be established ready for use within 8 hours of arrival in location. It was stressed that the temptation to undertake unnecessary surgery in well-
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appointed facilities in forward areas should be resisted in order to ensure availability for the most critical cases as they arose. It was also determined that with forward surgery and intensive care,
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which must coexist, the balance between maneuverability and medical capability was critical. It
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remained the policy of the IDF Surgeon General that the best procedure is one performed in an
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Israeli hospital.
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The United Kingdom Armed Forces Experience: 1972-1991 In the early 1970s, the UK government provided military assistance to the Sultan of Oman’s armed forces in the counterinsurgency operations in the Dofar, Oman, region. As part of this effort army and air force surgical teams provided medical support based at Salalah, Oman. This was in some ways similar to the Vietnam or Israeli model, although on a smaller scale, in that evacuation from wounding to the field surgical team was often achieved in less than one hour, and that the medical facility was static and its capabilities evolved over the course of the conflict. Again, rapid evacuation resulted in casualties reaching medical care who otherwise may not have survived to leave the battlefield. Dissimilarly, there were no intensive care facilities, no
ACCEPTED MANUSCRIPT capability for mechanical ventilation of the lungs post-operatively, and no measurement of blood gasses or electrolytes 23. The surgical team deployed between December 1972 and March 1973
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reported one case in which a patient died in part as a result of these deficiencies. Their
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recommendations for the equipping and staffing of an intensive care unit were heeded, and by 1975 Sharwood-Smith was able to report the use of one ward as an intensive care unit using
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positive pressure ventilation, blood gas analysis, and central venous pressure monitoring24. He
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commented that “The anaesthetist’s training in intensive care and the management of acute
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medical problems has a major part to play in a field hospital particularly in an isolated area.”24
The UK armed forces main efforts during the 1970s and 1980s were counterterrorism operations
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in Northern Ireland in which individual clinicians built considerable experience in the
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management of high velocity missile and blast injuries. In addition, the standoff in northern Europe with the Warsaw Pact countries involved the planning for a massive armored battle in
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which nothing less than national survival was at stake and the use of nuclear weapons was a real
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possibility. Overwhelming numbers of casualties were anticipated, and the medical plan would be to do the most good for as many as possible in the shortest time using overstretched facilities. With this approach of therapeutic minimalism, the very severely injured casualty, who in the Vietnam or Israeli wars reached the surgical team barelyalive but would have been resuscitated with the application of seemingly limitless resources, would not be saved. The British Army field hospital equipment scales and staff tables therefore did not provide for an intensive care unit. It was these field hospitals that would later deploy to the Persian Gulf for Operation Granby (Desert Storm).
ACCEPTED MANUSCRIPT In the meantime, a UK taskforce was deployed to liberate the Falklands Islands from Argentine occupation. This campaign was inevitably littoral in character, all the logistic support for the land
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battles came from naval vessels off shore, and the small medical units ashore were supported by
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the hospital ship SS UGANDA (UK) (Figure 8). The shore-based surgical teams were provided by the Royal Marines Surgical Support Team and the Parachute Clearing Troops of the Royal
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Army Medical Corps, both traditionally lightly scaled units intended to provide life and limb
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saving surgery before rapid evacuation to field hospitals in the rear. Equipment and staffing did not allow for the establishment of an intensive care unit. Post-operative patients requiring further
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resuscitation or more than minimal observation were returned to the resuscitation area until fit for the ward or evacuation offshore. Most of these patients were evacuated by helicopter within
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24 hours.
This conflict was more typical of conventional warfare. The UK did not rapidly command the
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skies and the conditions pertaining on land made evacuating or even finding casualties difficult.
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Jowitt reports that only 40% of casualties were operated on within 6 hours of wounding, and 43% waited 10 or more hours25. Inevitably this delay in evacuation resulted in casualties not making it off the battlefield who, with rapid evacuation, would have made it to surgery and been at risk of dying in the peri-operative period. Ironically, the lack of critical care facilities ashore would have seemed less of a hindrance to survival than it was in Salalah in 1973, where the severely injured rapidly reached the medical facility. Rapid evacuation of the wounded to medical facilities and the provision of intensive care in those facilities clearly need to go hand in hand to be effective.
ACCEPTED MANUSCRIPT The SS UGANDA did have an intensive care unit with 20 beds, 5 with ventilators. At one stage, when more than five patients required respiratory support, Royal Marine bandsmen were
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recruited to ventilate patients’ lungs manually26.
As alluded to above, the field hospitals that deployed to the Gulf for the 1991 war to liberate
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Kuwait were equipped and staffed to the same scale that had developed during cold war
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planning. The paper describing the experience of anesthetists with 32 Field Hospital (UK) remarked on how the absence of an intensive care unit or any capability for post-operative
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ventilation resulted in prolonged stays in the recovery ward which led to delays in the subsequent operations27. The hospital never worked to its full capacity, minimizing this effect, but these
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delays would have been a significant problem in a mass casualty situation. Another advantage of
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the deployment of critical care facilities in the field therefore is to maintain casualty flow
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through the resuscitation and operating theatre departments.
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The situation was slightly different At 33 General Hospital (UK). Although there was still no scale for an intensive care unit even in this static unit in the rear, the medical staff undertook to improvise (following in the footsteps of the 24 Evacuation Hospital in Vietnam in 1969) and created a rudimentary intensive care unit in terms of equipment, although it was effective in terms of concentrating the sickest patients and the most experienced staff in one area28.
The United Kingdom Armed Forces Experience: 1991-2000 Since the first Gulf War in 1991 the doctrine of the Army Medical Services (AMS) has had to adapt to the change from cold war planning to the support for military operations of a more
ACCEPTED MANUSCRIPT expeditionary nature, perhaps where the national interest was less clear. Hawley, in his 1996 paper on battlefield trauma management, discussed in detail how society’s expectations have
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increased in terms of the survival of military casualties; certainly it would be politically
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unacceptable for British servicemen to die “unnecessarily” as a result of inadequate medical support29. The most significant development has been the declaration by the defense chiefs that
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servicemen, ill or injured, should be offered medical care to a standard equal to that which they
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would receive in the United Kingdom in peacetime. To that end, there has been an increased willingness to expend significant resources on the management of critically ill and injured
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battlefields of North West Europe.
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patients who previously would have been treated offered little more than comfort care on the
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In the last few years of the 1990s, the UK Surgeon General’s Department undertook a major update in equipment allocation for medical units in the field, particularly fo r anesthesia and
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intensive care. The increasing recognition in civilian practice of intensive care medicine as a
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specialty in its own right prompted the UK armed forces to take the nursing staff and medical officers’ specialist qualifications and experience into account when planning deployments.
Another motivator for change was the perceptions in the late 1990s of an increasing threat in the Middle East, with particular concern about the potential use of chemical and biological weapons. The latter especially was seen as having the potential for generating many very sick patients who would have to be managed within the theater of operations to avoid spreading disease throughout the United Kingdom. To help counter this threat, a Biological Intensive Care Unit was developed and equipped to manage critically ill patients for an extended period. In doing so,
ACCEPTED MANUSCRIPT they had to manage the major complications of sepsis including septic shock, acute lung syndrome, renal and multiple organ failure. This unit was never deployed in anger and its
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conception may indeed have been flawed, but the concept of managing the critically ill in the
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field beyond the immediate post-operative period had been established.
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In the mid to late 1990s, there was much discussion within the UK Defense Medical Services of
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the requirement to provide resuscitative surgery in forward units including the Field Ambulances, soon to become Close Support Medical Regiments. The experience in Vietnam,
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Israel, Salalah and indeed the major civilian trauma centers of the United States dictated that where such heroic surgery is undertaken, post-operative intensive care is mandatory. The clinical
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experience developing in Bosnia during this time was based chiefly on small but static medical
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facilities, which gradually improved in sophistication over the years. This experience did not reflect the limitations of maneuver warfare, and the question remained as to the practicality of
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deploying a sophisticated level of critical care in small forward units that were required to
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remain as mobile as possible.
In early 1999, a two-table field surgical team was deployed by 23 Parachute Field Ambulance (UK) (23PFA) to Macedonia to provide surgical support to troops on Operation AGRICOLA (prior to the entry into Kosovo) 30. The initial configuration included a four bay resuscitation department, a two table operating theater and a four bay post-operative department which included one intensive care bay (with available mechanical ventilation ), one high dependency bay (without available mechanical ventilation), X-ray, diagnostic ultrasound scan, and simple laboratory support, along with a telemedicine link to UK. Two six bed wards were added in due
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ninety minutes and taken down and ready to move in three hours (Figures 9 & 10).
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The equipment deployed was of a standard of sophistication that would have not been out of place in a civilian UK hospital; however, it had all been selected with simplicity of operation and
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versatility in terms of power supply in mind. Although not subjected to the caseload of a high
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intensity battle, this unit proved itself in terms of maneuverability and the level of critical care it
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provided to severely sick or injured servicemen.
The lead in time for Operation AGRICOLA allowed the 23 PFA to acquire the necessary
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equipment (on the shelves at the main medical supply depot and intended for the Biological
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Intensive Care Unit) in order to achieve this standard of care. This was not typical of other small scale deployments during this period.The 22 Field Hospital (UK) deployed a Medical Support
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Team to Kuwait in 1994 (Operation DRIVER), the 23 PFA deployed a Field Surgical Team to
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Brazzaville in the Congo in 1997 (Operation DETERMINANT), and 16 Close Support Medical Regiment (UK) deployed to Sierra Leone in 2000 (Operation PALLISER) – on none of these deployments provided anything other than a rudimentary, improvised “Cold War” level intensive care. Perhaps inevitably, the results of the Surgeon General’s equipment review were slow to arrive at field units.
Notwithstanding these delays, as the millennium drew to a close, both the political and military will and the capability to confront the challenge of providing a high standard of critical care on
ACCEPTED MANUSCRIPT military operations were in place. The conflicts in the 2000s and 2010s tested this capability was
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to the limit31, 32. The story of how this challenge was met is worthy of a further paper.
ACCEPTED MANUSCRIPT 1. Geoffrey of Monmouth. The History of the Kings of Britain (c1136). London; The Folio Society 1969
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2. Laffin J. Combat Surgeons. Stroud UK, Sutton Publishing, 1970
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3. Safar P, DeKornfeld TJ, Person JM: The intensive care unit. Anaesthesia 1961;16: 275 4. Nightingale F: Notes on Hospitals. 3rd Ed. Longman, Green, Longman, Roberts and Green, 1863,
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p.89.
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5. Canon WB: Wound Shock. In: The Medical Department of the United States Army in the World War. Vol 11. Washington, DC: Government Printing Office; 1927: Chap 7:185-213
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6. Bricknell MCM: The Evolution of Casualty Evacuation in the British Army 20th Century (Part 1) – Boer war to 1918. J R Army Med Corps 2002; 148:200-2007
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7. Hilberman M: The evolution of intensive care units. Critical Care Medicine 1975; 3: 159-165 8. Bricknell MCM: The Evolution of Casualty Evacuation in the British Army 20th Century (Part 2) –
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1918-1945. J R Army Med Corps 2002; 148:314-322
153:299-300
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9. Hodgetts TJ, Mahoney PF, Kirkman E: Damage Control Resuscitation. J R Army Med Corps 2007;
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10. Whelton A, Donadio JV: Post-Traumatic acute renal failure in Vietnam: A comparison with the Korean war experience. Johns Hopkins Medical Journal 1969; 124: 95-105 11. Anderson EW, Ibsen B: The anaesthetic management of patients with poliomyelitis and respiratory paralysis. British Medical Journal 1954; 1: 786-788 12. Holmdahl MH: The respiratory care unit. Anesthesiology 1962; 23:559-568 13. Noble MJ, Bryant T, Ing FY: Casualty anesthesia experiences in Vietnam. Anesthesia and Analgesia 1968; 47: 5-11 14. Fleming WH, Petty C, Gielchinsky I: Evolution of an intensive care unit in Vietnam. American Surgeon 1973; 39: 422- 423
ACCEPTED MANUSCRIPT 15. Petty C, Taylor W. Inhalation therapy: Experience in an Army Evacuation Hospital in Vietnam. Military Medicine 1971; 136: 891
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16. Lichtman MW. Vietnam. In: Military and battle anesthesia. In: Trauma anesthesia and critical
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care under conditions of environmental and circumstantial extremes. In: Grande CM, ed. Textbook of Trauma Anesthesia and Critical Care. St Louis, Mo: Mosby-Year Book; 1993: Part 13:
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Chap 107; Part 1: 1297-1306.
Archives of Surgery 1971; 102: 400-405
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17. Gieger JP, Gielchinsky I: Acute pulmonary insufficiency; treatment in Vietnam casualties.
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18. Burford TH. Wet Lung. Surgery in WWII– Thoracic Surgery Vol II 1965; Chapter V p 207 19. Walker L, Eiseman B. The Changing Pattern of Respiratory Distress. Annals of Surgery 1975;181:
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693-697
20. Hardaway RM: Wartime Treatment of Shock. Military Medicine 1982; 147: 1011-1017
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21. Davidson JT, Cotev S: Anaesthesia in the Yom Kippur War. Annals of the Royal College of
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Surgeons of England 1975; 56: 304-311 22. Gasko OD: Surgery in the field during the Lebanon war, 1982: Doctrine, experience and
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prospects for future changes. Israeli Journal of Medical Sciences 1984; 20: 350-354 23. Melsom MA, Farrar MD, Volkers RC: Battle casualties. Annals of the Royal College of Surgeons of England 1975; 56: 289-303 24. Sharwood-Smith G: Anaesthetist in Salalah: Experience in a field surgical team. Anaesthesia 1976; 31: 1049-1053 25. Jowitt MD, Knight RJ: Anaesthesia during the Falklands campaign; the land battles. Anaesthesia 1983; 38: 776-783 26. Bull PT et al: Anaesthesia during the Falklands campaign; the experience of the Royal Navy. Anaesthesia 1983; 38: 770-775
ACCEPTED MANUSCRIPT 27. Adley R et al: The Gulf war: anaesthetic experience at 32 Field Hospital Department of Anaesthesia and Resuscitation. Anaesthesia 1992; 47: 996-999
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28. Ward P. Personal communication
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29. Hawley A: Trauma management on the battlefield: A modern approach. Journal of the Royal Army Medical Corps 1996; 142: 120-125
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30. Roberts MJ, Salmon JB, Sadler PJ: The provision of intensive care and high dependency care in
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the field. Journal of the Royal Army Medical Corps 2000; 146: 99-103 31. Roberts MJ, Fox MA, Hamilton-Davies C, Dowson S: The experience of the intensive care unit in
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a British army field hospital during the 2003 Gulf conflict. Journal of the Royal Army Medical Corps 2003; 149: 284-290
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32. Lockey D.J, Nordmann G.R, Field J.M, Clough D and Henning J.D.R. The deployment of an
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2004; 62: 261-265
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intensive care facility with a military field hospital to the 2003 conflict in Iraq. Resuscitation
ACCEPTED MANUSCRIPT Legends for Figures The Death of King Arthur. James Archer
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Machaon, son of Asclepius, treats Menelaos who has been struck by an arrow.
Figure 3
Florence Nightingale (1820-1910) with her candle making the night round of the wards at Scutari hospital. Florence Nightingale. Mezzotint by C.A. Tomkins, 1855, after J. Butterworth.
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Walter B Cannon (1871-1945)
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11 Evacuation Hospital, Wonju Korea, to which the Renal Insufficiency Unit was attached. US Army Medical Department, Office of Medical History
Figure 6
Artificial kidney (Kolff type) in operation at the Renal Insufficiency Center. US Army Medical Department, Office of Medical History
Figure 7
Iron lung ward filled with polio patients, Rancho Los Amigos Hospital, California 1953. Food and Drug Administration, US.
Figure 8
SS Uganda as a hospital ship during the 1982 Falkland Islands campaign.
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Mobile field surgical unit including intensive care, Operation Agricola, Macedonia 1999
Figure 10
Mobile intensive care. Operation Agricola, Macedonia 1999
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ACCEPTED MANUSCRIPT “The Development of Intensive Care in the Military Environment” Highlights
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1. Military intensive care has developed in parallel with the civilian specialty
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2. The military environment has presented additional challenges to intensivists
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3. As clinical challenges have been met, others are often revealed amongst survivors
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4. In recent years there has been a significant increase in expectations as to the level of care available to injured and sick servicemen