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The origins of casualty evacuation and Echelons of care: Lessons learned from the American Civil War
The Origins of Casualty Evacuation and Echelons of Care: Lessons Learned from the American Civil War Major Joseph S. Blansfield, RN, MS The American Civil War produced many victims of battle who challenged the medical community. Not long after the war started the medical community was forced to make rapid, significant changes in how soldiers were evacuated, how they were cared for both immediately and long-term, and how the spread of fatal infectious diseases was controlled. This was the era in which nurses proved their importance and became a permanent segment of trauma care. (Int J Trauma Nurs 1999;5:5-9)
uch has been written about the great military campaigns of the American Civil War (1861 to 1865), or the "War of the Rebellion," as it was known at that time. The northern states formed the Union Army of the Potomac and the southern states fought as the Army of the Confederacy. The accounts of Union and Confederate battles that were won and lost have been documented in great detail, and monuments now stand where regiments, brigades, and armies met on famous battlefields. The contribution made by the medical departments of the armies of the north and south has been largely overlooked. This is unfortunate, because these medical departments consisted of dedicated professionals who were both willing and capable of caring for casualties--but who were faced with overwhelming numbers of victims and limited means to do their job. Throughout history, the medical care of trauma advanced significantly during military campaigns, and the American Civil War is a prime example of this. The medical failures early Major Joseph S. Blansfield, RN, MS, is with the Army Nurse Corps, 399th Combat Support Hospital, US Army Reserve, Taunton, and a Trauma Coordinator with the Boston Medical .Center. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US government. For reprints write Joseph S. Blansfield, RN, MS, 1835 Bay Rd, Sharon, MA 02067-3029. 6511195043
JANUARY-MARCH 1999
in the war were due in large part to circumstances beyond the control of medical personnel. These shortcomings are significant, and the attempts that were made to correct them during and after the war are far-reaching. Because strong leaders with good organizational skills were able to identify how to change the delivery of medical care, the military was able to provide more efficient trauma care. In the early 1860s, the discipline of nursing was in its infancy, and there was no Army Nurse Corps. There was not even a group of trained nurses anywhere in the country.
The First Battle of Bull Run In July 1861, before the first major battle of the war at Bull Run (Manassas, Va), no thought had been given to the handling of potential casualties. The north expected the battle to be "a glorious event" that would decide the war. The battle had been anticipated and spectators from Washington, DC, traveled south 27 miles for an outing to observe the battle. When events turned against the Union Army, the bewildered and confused forces dispersed in all directions. The Union Army suffered losses of 681 killed, 1011 wounded, and 1460 missing. 1 Medical treatment for the soldiers was nonexistent, and there was no organized means of evacuating the wounded from the battlefield. Many lay in misery for days where they had fallen on the battlefield. Those that were able to return to the capitol filled the streets, seeking treatment and shelter on their own. The public was outraged. The First Battle of Bull Run highlighted 2 significant INTERNATIONAL JOURNAL OFTRAUMA NORSING/Blansfield
5
Figure 1. Cared For. Wood engraving. Harper's Weekly, January 21, 1871 (National Library of Medicine, Bethesda, Md). deficiencies in how medical care was delivered at the time: there was a profound lack of integrated medical treatment for casualties and there was no evacuation system.
The concept of medical command and control was lacking, or fragmented, at best. At the outset of the Civil War, the majority of medical officers in the field were regimental surgeons. They had been commissioned by their state governors and served with their state regiments under the command of a colonel. The chief medical officer of the Union Army had no authority over the "volunteers" (eg, soldiers who willingly enlisted for this cause) and had only a few regular army physicians in his command. The concept of medical command and control was lacking, or fragmented, at best. Some regimental surgeons refused to treat soldiers from other state regiments. As a result, some field facilities were overburdened with a large number of wounded, whereas others had no patients at all. 2 The evacuation of casualties 6
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Blansfield
from the battlefield was the responsibility of the regimental quartermaster. This officer controlled all of the wagons, horses, tents, and equipment. The rationale for the quartermaster to have this role was that the wagon teams bringing supplies to the front could also return wounded casualties to the rear. The principle may have appeared to be sound, but in practice it was not effective. Patient flow was not coordinated. The drivers had no experience in handling the wounded, would ignore their complaints, and often stole the alcohol from the medical supplies. The commanding general was reluctant to allocate sufficient manpower and equipment to the care of the wounded because it would detract from his potential combat power. The need for an ambulance corps was apparent to both the military and civilian health care providers. Medical care was very simply arranged into 2 levels or "echelons" of care at the beginning of the war. 3 The first echelon consisted of a field hospital located within a mile of the front line. Casualties would find their own way to the hospital or were assisted by fellow soldiers. Once at the hospital, initial definitive care was delivered. Amputation of a limb(s) was among the most common treatment performed. Because there was no ability to hold patients at the field hospital, they were evacuated VOLUME 5, NUMBER 1
Figure 2. Nurses Behind the Lines During the Civil War, c 1860. Wood engraving (National Library of Medicine, Bethesda, Md). by whatever means was available to Army general hospitals in major cities. At the general hospitals, patients would stay for long periods of convalescence. In most cases, regimental surgeons would send patients back to a general hospital without any idea of its availability of beds. After the first few battles of the war, the need for trained nurses became apparent. Although not all nurses had formal training, male and female nurses offered their services to the great numbers of sick and wounded from both armies. Many of the first "nurses" came from religious orders and had experience caring for large groups of patients during epidemics. They could work within an organized structure that required order and discipline (Figure 1). Many others who did not have formal training or prior experience simply appeared on the battlefields and in the camps (Figure 2). They did what they could to ease the suffering of the wounded and to comfort the dying.
A Change in Leadership Not long after the beginning of the war, a group of concerned northern citizens formed the United States Sanitary Commission. They were appalled at the disease and death rate that was rampant in all of the army camps. Twice as many soldiers were dying from diseases such as scurvy, dysentery, typhoid, diphtheria, and pneumonia than from wounds sustained in battle. Men were crowded together in filthy conditions, with little or no regard JANUARY-MARCH 1999
for field sanitation and public health. There were epidemics of measles, mumps, and other contagious diseases. The Sanitary Commission, described as "one of the great moral and physical forces of the war," 4 initially was met with resistance. The military perceived the Commission as a group of "sensationalists" and "meddlers.''5 The Commission insisted that camp sanitation be improved and that physicians who had been appointed because of politics be dismissed. Gradually, the Commission grew to the point that they were able to dictate events regarding the health and welfare of wounded soldiers. The Commission also raised hundreds of thousands of dollars for medicine, blmkkets, shoes, and food and ensured fair distribution of these resources. In July of 1862, Major Jonathan Letterman became the medical director of the Army of the Potomac (Union Army). Almost immediately, he initiated sweeping improvements. His predecessor, Major Charles Tripler, had recognized the problems but felt bound by Army regulations and was incapable of effecting meaningful changes. Seizing advantage of the climate created by the Sanitary Commission, Major Letterman crafted an ambitious plan to improve medical care for wounded soldiers on the battlefield and proposedan ambulance corps to be under the direction of the Medical Department. Letterman appreciated the need for fundamental organization, and he submitted detailed and complete plans INTERNATIONAL JOURNAL OF TRAUMA NURSING/Blansfield
7
Figure 3. Ambulance Train Returning from the Trenches With Wounded during the Campaign at Charleston Harbor. Engraving (Harper's Weekly, September 12, 1863). (National Library of Medicine, Bethesda, Md.)
to the Commanding General, Major General George McClellan. McClellan, a devotee of organization, was impressed and approved the plans. Creating an Ambulance Service. It is believed that Letterman's proposal was modeled after the very successful Legion des Ambulances Volantes developed by Barton Larres', who had been attached to Napoleon's Garde Imperiale. 6 The new ambulance corps, established in 1862, consisted of officers and men reassigned from "line" positions (eg, infantry, artillery, cavalry). These officers and men now served under a medical command.
The success of the ambulance corps grew with each subsequent campaign. The medical officers were not able to provide supervision, especially during a battle, so they appointed their nonmedical counterparts to supervise the ambulances and to take charge of the wagons, horses, harnesses, and other equipment. Initially, the Army had no wagon specifically designed for casualty evacuation. Two-wheeled and 4-wheeled models were ultimately developed. The 2-wheeled ambulances broke down easily and were generally unreli8
INTERNATIONAL JOURNAL OF TRAUMA NURSlNG/Blansfield
able. Thus 4-wheeled ambulances, pulled by teams of 2 and 4 horses and with a dedicated driver, became the norm (Figure 3). The success of the ambulance corps grew with each subsequent campaign. At the Battle of Gettysburg (Pennsylvania), July 1 through 3, 1863, Major Letterman commanded more than 1000 ambulances that evacuated 14163 Union and 6802 Confederate casualties. After the battle had concluded on July 4, 1863, no casualties remained on the Union battlefield. 7 The advantages of using an organized ambulance service were readily recognized. Healthy soldiers, who previously had escorted wounded comrades to a field hospital, were now relieved of this responsibility and available to fight. Wounded soldiers received more timely care and thus were able to return to duty sooner, supporting the battlefield commander. Creating an Organized Medical Care System. Providing a systematic collection and evaluation of casualties by the ambulance corps was only part of the solution. The delivery of medical care needed to be structured and organized, and the placement, configuration, and usage of hospitals determined. In October 1862, immediately after the Battle of Antietam, Major Letterman used his authority to assume responsibility for revamping the entire hospital system. He eliminated the regimental field hospitals and established a new VOLUME 5, NUMBER 1
scheme in which a field hospital would be assigned to each division, with the necessary personnel and equipment for each. Aid stations were created to support field hospitals and were used to provide front line care. They were placed in protected or semiprotected locations on the edge of the battlefield and provided more immediate care. Regimental surgeons rotated in from various affiliated units to staff the stations, but were limited in their capabilities. They controlled bleeding, dressed wounds, and administered opiates or whisky for pain control. Patients were then sent by 4-wheeled ambulances to field hospitals. Field hospitals were organized and attached to maneuver units (units that engaged in battle) to receive casualties. They were located 1 or 2 miles behind the battlefield. The most skilled medical officers were assigned to deliver care to the most severely wounded; other surgeons and assistants helped or performed necessary paperwork. The wounded were often evaluated and treated on an operating table. Surgeons learned that amputations and other operations had the best outcomes if they occurred within 24 hours of injury. Although antisepsis and asepsis were not widely known or practiced at this time, early surgery helped to reduce the risk and magnitude of infection. After being cared for in a field hospital, patients were evacuated in the quartermaster's wagons, trains, or boats for definitive care in "general" hospitals (named so because they would take men from any fighting unit). The general hospitals were the next echelon of care. It is noteworthy that at the beginning of the war, general hospitals did not exist. A few army posts had hospitals; the largest, at Fort Leavenworth, Kansas, contained only 41 beds. By the end of war, general hospitals consisted of buildings that could accommodate hundreds and even thousands of patients. The general hospitals were built using the recommendations formulated by Florence Nightingale. They had high ceilings for good ventilation and pavilion-style build-
JANUARY-MARCH 1999
ings connected by corridors. By the conclusion of the war, nursing had grown considerably and had established itself as a necessary discipline with a strong foundation in caring for the sick and wounded.
SUMMARY The American Civil War provided valuable lessons concerning the organization of casualty evacuation and improved trauma care during military campaigns. 8 The lessons included the need for early care; using skilled care providers with reliable, safe vehicles; and preventing duplication and depletion of essential services. Although combat experience may be the best way to learn about strategy, tactics, and logistics, civilian trauma care can use these lessons to avoid making similar serious mistakes. The lessons learned on the Civil War battlefields have proven valuable in civilian trauma care management. REFERENCES 1. Barnes JK.The medical and surgical history of the war of the rebellion. Vols 1-4. Washington (DC): Office of the Surgeon General; 1870. 2. Blaisdell FW. Medical advances during the civil war. Arch Su rg 1988:123:1045-50. 3. Nolan DL, Pattillo DA.The Army Medical Department and the Civil War: historical lessons for current medical support. Military Medicine 1989:154;265-71. 4. Duncan LC. The medical department of the United States Army in the Civil War. Gaithersburg (MD): Old Soldiers Books; 1900. 5. Ward GC, Burns R, Burns K.The Civil War: an illustrated history. New York: Alfred C Knopf; 1990, 6. Ashbum PM. A history of the medical department of the United States Army. Cambridge (MA): The Riverside Press; 1929. 7. Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. New York: H Schuman; 1952. 8. Headquarters, Department of the Army: employment of field and general hospitals, FM 8-10-15. Washington (DC): United States Army; 1997.
INTERNATIONAL JOURNAL OF TRAUMA NURSlNG/Blansfield
9
uch has been written about the great military campaigns of the American Civil War (1861 to 1865), or the "War of the Rebellion," as it was known at that time. The northern states formed the Union Army of the Potomac and the southern states fought as the Army of the Confederacy. The accounts of Union and Confederate battles that were won and lost have been documented in great detail, and monuments now stand where regiments, brigades, and armies met on famous battlefields. The contribution made by the medical departments of the armies of the north and south has been largely overlooked. This is unfortunate, because these medical departments consisted of dedicated professionals who were both willing and capable of caring for casualties--but who were faced with overwhelming numbers of victims and limited means to do their job. Throughout history, the medical care of trauma advanced significantly during military campaigns, and the American Civil War is a prime example of this. The medical failures early Major Joseph S. Blansfield, RN, MS, is with the Army Nurse Corps, 399th Combat Support Hospital, US Army Reserve, Taunton, and a Trauma Coordinator with the Boston Medical .Center. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US government. For reprints write Joseph S. Blansfield, RN, MS, 1835 Bay Rd, Sharon, MA 02067-3029. 6511195043
JANUARY-MARCH 1999
in the war were due in large part to circumstances beyond the control of medical personnel. These shortcomings are significant, and the attempts that were made to correct them during and after the war are far-reaching. Because strong leaders with good organizational skills were able to identify how to change the delivery of medical care, the military was able to provide more efficient trauma care. In the early 1860s, the discipline of nursing was in its infancy, and there was no Army Nurse Corps. There was not even a group of trained nurses anywhere in the country.
The First Battle of Bull Run In July 1861, before the first major battle of the war at Bull Run (Manassas, Va), no thought had been given to the handling of potential casualties. The north expected the battle to be "a glorious event" that would decide the war. The battle had been anticipated and spectators from Washington, DC, traveled south 27 miles for an outing to observe the battle. When events turned against the Union Army, the bewildered and confused forces dispersed in all directions. The Union Army suffered losses of 681 killed, 1011 wounded, and 1460 missing. 1 Medical treatment for the soldiers was nonexistent, and there was no organized means of evacuating the wounded from the battlefield. Many lay in misery for days where they had fallen on the battlefield. Those that were able to return to the capitol filled the streets, seeking treatment and shelter on their own. The public was outraged. The First Battle of Bull Run highlighted 2 significant INTERNATIONAL JOURNAL OFTRAUMA NORSING/Blansfield
5
Figure 1. Cared For. Wood engraving. Harper's Weekly, January 21, 1871 (National Library of Medicine, Bethesda, Md). deficiencies in how medical care was delivered at the time: there was a profound lack of integrated medical treatment for casualties and there was no evacuation system.
The concept of medical command and control was lacking, or fragmented, at best. At the outset of the Civil War, the majority of medical officers in the field were regimental surgeons. They had been commissioned by their state governors and served with their state regiments under the command of a colonel. The chief medical officer of the Union Army had no authority over the "volunteers" (eg, soldiers who willingly enlisted for this cause) and had only a few regular army physicians in his command. The concept of medical command and control was lacking, or fragmented, at best. Some regimental surgeons refused to treat soldiers from other state regiments. As a result, some field facilities were overburdened with a large number of wounded, whereas others had no patients at all. 2 The evacuation of casualties 6
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Blansfield
from the battlefield was the responsibility of the regimental quartermaster. This officer controlled all of the wagons, horses, tents, and equipment. The rationale for the quartermaster to have this role was that the wagon teams bringing supplies to the front could also return wounded casualties to the rear. The principle may have appeared to be sound, but in practice it was not effective. Patient flow was not coordinated. The drivers had no experience in handling the wounded, would ignore their complaints, and often stole the alcohol from the medical supplies. The commanding general was reluctant to allocate sufficient manpower and equipment to the care of the wounded because it would detract from his potential combat power. The need for an ambulance corps was apparent to both the military and civilian health care providers. Medical care was very simply arranged into 2 levels or "echelons" of care at the beginning of the war. 3 The first echelon consisted of a field hospital located within a mile of the front line. Casualties would find their own way to the hospital or were assisted by fellow soldiers. Once at the hospital, initial definitive care was delivered. Amputation of a limb(s) was among the most common treatment performed. Because there was no ability to hold patients at the field hospital, they were evacuated VOLUME 5, NUMBER 1
Figure 2. Nurses Behind the Lines During the Civil War, c 1860. Wood engraving (National Library of Medicine, Bethesda, Md). by whatever means was available to Army general hospitals in major cities. At the general hospitals, patients would stay for long periods of convalescence. In most cases, regimental surgeons would send patients back to a general hospital without any idea of its availability of beds. After the first few battles of the war, the need for trained nurses became apparent. Although not all nurses had formal training, male and female nurses offered their services to the great numbers of sick and wounded from both armies. Many of the first "nurses" came from religious orders and had experience caring for large groups of patients during epidemics. They could work within an organized structure that required order and discipline (Figure 1). Many others who did not have formal training or prior experience simply appeared on the battlefields and in the camps (Figure 2). They did what they could to ease the suffering of the wounded and to comfort the dying.
A Change in Leadership Not long after the beginning of the war, a group of concerned northern citizens formed the United States Sanitary Commission. They were appalled at the disease and death rate that was rampant in all of the army camps. Twice as many soldiers were dying from diseases such as scurvy, dysentery, typhoid, diphtheria, and pneumonia than from wounds sustained in battle. Men were crowded together in filthy conditions, with little or no regard JANUARY-MARCH 1999
for field sanitation and public health. There were epidemics of measles, mumps, and other contagious diseases. The Sanitary Commission, described as "one of the great moral and physical forces of the war," 4 initially was met with resistance. The military perceived the Commission as a group of "sensationalists" and "meddlers.''5 The Commission insisted that camp sanitation be improved and that physicians who had been appointed because of politics be dismissed. Gradually, the Commission grew to the point that they were able to dictate events regarding the health and welfare of wounded soldiers. The Commission also raised hundreds of thousands of dollars for medicine, blmkkets, shoes, and food and ensured fair distribution of these resources. In July of 1862, Major Jonathan Letterman became the medical director of the Army of the Potomac (Union Army). Almost immediately, he initiated sweeping improvements. His predecessor, Major Charles Tripler, had recognized the problems but felt bound by Army regulations and was incapable of effecting meaningful changes. Seizing advantage of the climate created by the Sanitary Commission, Major Letterman crafted an ambitious plan to improve medical care for wounded soldiers on the battlefield and proposedan ambulance corps to be under the direction of the Medical Department. Letterman appreciated the need for fundamental organization, and he submitted detailed and complete plans INTERNATIONAL JOURNAL OF TRAUMA NURSING/Blansfield
7
Figure 3. Ambulance Train Returning from the Trenches With Wounded during the Campaign at Charleston Harbor. Engraving (Harper's Weekly, September 12, 1863). (National Library of Medicine, Bethesda, Md.)
to the Commanding General, Major General George McClellan. McClellan, a devotee of organization, was impressed and approved the plans. Creating an Ambulance Service. It is believed that Letterman's proposal was modeled after the very successful Legion des Ambulances Volantes developed by Barton Larres', who had been attached to Napoleon's Garde Imperiale. 6 The new ambulance corps, established in 1862, consisted of officers and men reassigned from "line" positions (eg, infantry, artillery, cavalry). These officers and men now served under a medical command.
The success of the ambulance corps grew with each subsequent campaign. The medical officers were not able to provide supervision, especially during a battle, so they appointed their nonmedical counterparts to supervise the ambulances and to take charge of the wagons, horses, harnesses, and other equipment. Initially, the Army had no wagon specifically designed for casualty evacuation. Two-wheeled and 4-wheeled models were ultimately developed. The 2-wheeled ambulances broke down easily and were generally unreli8
INTERNATIONAL JOURNAL OF TRAUMA NURSlNG/Blansfield
able. Thus 4-wheeled ambulances, pulled by teams of 2 and 4 horses and with a dedicated driver, became the norm (Figure 3). The success of the ambulance corps grew with each subsequent campaign. At the Battle of Gettysburg (Pennsylvania), July 1 through 3, 1863, Major Letterman commanded more than 1000 ambulances that evacuated 14163 Union and 6802 Confederate casualties. After the battle had concluded on July 4, 1863, no casualties remained on the Union battlefield. 7 The advantages of using an organized ambulance service were readily recognized. Healthy soldiers, who previously had escorted wounded comrades to a field hospital, were now relieved of this responsibility and available to fight. Wounded soldiers received more timely care and thus were able to return to duty sooner, supporting the battlefield commander. Creating an Organized Medical Care System. Providing a systematic collection and evaluation of casualties by the ambulance corps was only part of the solution. The delivery of medical care needed to be structured and organized, and the placement, configuration, and usage of hospitals determined. In October 1862, immediately after the Battle of Antietam, Major Letterman used his authority to assume responsibility for revamping the entire hospital system. He eliminated the regimental field hospitals and established a new VOLUME 5, NUMBER 1
scheme in which a field hospital would be assigned to each division, with the necessary personnel and equipment for each. Aid stations were created to support field hospitals and were used to provide front line care. They were placed in protected or semiprotected locations on the edge of the battlefield and provided more immediate care. Regimental surgeons rotated in from various affiliated units to staff the stations, but were limited in their capabilities. They controlled bleeding, dressed wounds, and administered opiates or whisky for pain control. Patients were then sent by 4-wheeled ambulances to field hospitals. Field hospitals were organized and attached to maneuver units (units that engaged in battle) to receive casualties. They were located 1 or 2 miles behind the battlefield. The most skilled medical officers were assigned to deliver care to the most severely wounded; other surgeons and assistants helped or performed necessary paperwork. The wounded were often evaluated and treated on an operating table. Surgeons learned that amputations and other operations had the best outcomes if they occurred within 24 hours of injury. Although antisepsis and asepsis were not widely known or practiced at this time, early surgery helped to reduce the risk and magnitude of infection. After being cared for in a field hospital, patients were evacuated in the quartermaster's wagons, trains, or boats for definitive care in "general" hospitals (named so because they would take men from any fighting unit). The general hospitals were the next echelon of care. It is noteworthy that at the beginning of the war, general hospitals did not exist. A few army posts had hospitals; the largest, at Fort Leavenworth, Kansas, contained only 41 beds. By the end of war, general hospitals consisted of buildings that could accommodate hundreds and even thousands of patients. The general hospitals were built using the recommendations formulated by Florence Nightingale. They had high ceilings for good ventilation and pavilion-style build-
JANUARY-MARCH 1999
ings connected by corridors. By the conclusion of the war, nursing had grown considerably and had established itself as a necessary discipline with a strong foundation in caring for the sick and wounded.
SUMMARY The American Civil War provided valuable lessons concerning the organization of casualty evacuation and improved trauma care during military campaigns. 8 The lessons included the need for early care; using skilled care providers with reliable, safe vehicles; and preventing duplication and depletion of essential services. Although combat experience may be the best way to learn about strategy, tactics, and logistics, civilian trauma care can use these lessons to avoid making similar serious mistakes. The lessons learned on the Civil War battlefields have proven valuable in civilian trauma care management. REFERENCES 1. Barnes JK.The medical and surgical history of the war of the rebellion. Vols 1-4. Washington (DC): Office of the Surgeon General; 1870. 2. Blaisdell FW. Medical advances during the civil war. Arch Su rg 1988:123:1045-50. 3. Nolan DL, Pattillo DA.The Army Medical Department and the Civil War: historical lessons for current medical support. Military Medicine 1989:154;265-71. 4. Duncan LC. The medical department of the United States Army in the Civil War. Gaithersburg (MD): Old Soldiers Books; 1900. 5. Ward GC, Burns R, Burns K.The Civil War: an illustrated history. New York: Alfred C Knopf; 1990, 6. Ashbum PM. A history of the medical department of the United States Army. Cambridge (MA): The Riverside Press; 1929. 7. Adams GW. Doctors in blue: the medical history of the Union Army in the Civil War. New York: H Schuman; 1952. 8. Headquarters, Department of the Army: employment of field and general hospitals, FM 8-10-15. Washington (DC): United States Army; 1997.
INTERNATIONAL JOURNAL OF TRAUMA NURSlNG/Blansfield
9