The Art of Battlefield Medicine

SPECIAL FRONTIER FORCE-OPERATION EAGLE-LIBERATION WAR OF BANGLADESH 1971-72:

Indian Prime Minister Mrs. Indira Gandhi initiated Liberation of Bangladesh during 1971 with military action in the Chittagong Hill Tracts. The battle plan of this military action is known as Operation Eagle. This post is related to that battlefield experience.

Army represents a large organized force armed and trained for War. The Primary Mission of Army is to wage a War or to defend itself in a War. The purpose of Army Medical Corps is to support the Army to accomplish its Primary Mission. AMC provides support during the Battle, while preparing for the Battle and to keep the Army Battle-Ready at all times. In a Combat, when a direct or indirect contact with an enemy is made, Casualties could occur. These Casualties could fall into three groups :

Group I : These are killed outright or severely wounded past any help. I encountered such Battle Casualties who died in my presence. However, it is important to identify them and document the nature of injuries with an aim to develop a strategy to use more effective Battle Plans and in evolving better personal protective clothing and devices.

Group II : These Casualties are severely wounded, they require continuous medical support and supervision and transportation to a Field Hospital for appropriate Life saving Surgery and further definitive treatment in a Base Hospital.

Group III : These Casualties are less critically injured persons who need minimal medical attention. When appropriately treated at the Battalion level, they could be immediately returned to the Combat Operations and very useful in sustaining the numbers of the fighting force.

Army Medical Corps acts to prevent the loss of life among the Group II and Group III casualties. In doing so, AMC provides a blanket of ‘Care’ and ‘Comfort’ to those injured and it acts to boost up the morale of the entire fighting Force. AMC personnel take part in military Operations as Combatants and are entitled to carry their personal weapons.

THE EFFECTS OF BATTLE INJURIES:

The battle wound is a ‘CONTINUING’ injury and its effects on the entire body are dynamic ones. If  left unattended, the physical condition of the Battle Casualty deteriorates. Hemorrhage or loss of blood from a blood vessel is a major contributing factor to Shock and death. Most of those patients with wounds of great vessels of the chest and abdomen bleed to death before getting medical help. Bleeding could be; (a) External or visible, or (b) Internal or invisible. Apart from loss of blood, injuries damage soft tissues, internal organs and structures like bones and nerves.

Resuscitation actually means the act of reviving or restoring the vital functions of a severely wounded person. Resuscitation involves those procedures which are carried out to counteract the effect of the wound. Since the wound is a ‘continuing’ injury and its effects on the entire body are ‘dynamic’ ones, the Resuscitation is a process of ‘continuing’ treatment. Since the effects of the wound start as soon as the man is injured, Resuscitation should start as soon as the wounded man is seen. Hence, ‘FORWARD’ Medical Care is essential for the survival of the wounded. Resuscitation must commence in the ‘Field’ where the Battle Casualty is found. The AMC personnel, Medical Officers, Nursing Assistants, and Ambulance Assistants are combatants and it is not unfair to send trained medical personnel to the Combat Zone. Use of a qualified doctor in the ‘Forward’ location is far more beneficial to the wounded soldier. During the India-Pakistan War of 1971, I was present in the Combat Zone and my services were immediately made available to the wounded soldiers. I witnessed the benefits of initiating early treatment of Battle casualties. The concept of ‘Combat Life Saver’ improves the chances of Casualty survival. Emergency life saving treatment must start as far ‘FORWARD’ as possible and it must continue as a Casualty is evacuated to the rear. It must be understood that swift medical treatment greatly enhances survival. AMC must plan to provide Emergency medical treatment of soldiers at or near a Combat Zone to increase the chances of survival. The next major problem which contributes to the death of Casualties is that of a faulty Evacuation Plan. Lack of transportation is often the primary cause of untimely Evacuation. I encountered this problem of lack of transportation during the initial phase of the India-Pakistan War of 1971 but I met this challenge with courage and had taken my patients in improvised stretchers on a memorable long march of about 40 miles and had them airlifted in a helicopter. All of my patients survived this ordeal. The initial treatment in the battle field is important to ensure that the Casualty will withstand the journey to the rear. The wounded patient must be able to survive the journey and should not arrive at the Field Hospital dead or dying.

THE PRIMARY AIMS OF TREATMENT AT BATTALION LEVEL:

1. If necessary, establish and maintain an adequate airway. The basic mechanisms of respiration should be intact. A ‘sucking’ wound of the chest must be immediately sealed.

2. Bleeding should be stopped or arrested. Severe blood loss may not be evident immediately after injury. After wounding, a blood-volume deficiency will always occur. As opposed to internal bleeding, bleeding from blood vessels in extremities can be controlled more easily. The pressure dressing used must be tight enough to control bleeding. If applied properly, pressure dressings will often control major hemorrhage than the use of a tourniquet. The aim is to prevent the onset of Shock, delay its progression and to stabilize patient’s condition to prepare him for transportation.

3. Relief of Pain : Pain induces and aggravates stress. Prompt relief of pain provides an enormous sense of Comfort. Pain aggravates the casualty’s poor condition. Fractures apart from causing pain, also increase damage to muscles and thereby promote further blood loss. Fractures must be adequately splinted. Patient must be properly immobilized to withstand Evacuation. The pain associated with most soft tissue injuries could be easily relieved by the use of Morphine. I had very effectively used Injection Tubonic Morphia/ Morphia syrettes 0.25 or 1/4 grain.

4. Prevention of Wound Infection : Wounds break the barriers against bacteria. Bandages should not be applied carelessly. When applied properly, bandages arrest bleeding, prevent disturbance of the wound by foreign objects and prevents further contamination. Battle wounds get easily contaminated. Before clinical evidence of infection, early administration of antibiotics is useful. I had orally administered Tetracycline tablets, a broad-spectrum antibiotic with very good results.

5. DO NOT LAY TOO MUCH EMPHASIS ON TRANSPORTATION : Hurried Evacuation leads to undue deterioration during transportation.  The transportation should not be at the expense of proper treatment. The Medical Officer at the Battalion in a Combat Zone is not merely a First-Aid provider. He is the most important member of the Resuscitation Team. He must take time to institute initial procedures which will best prepare the wounded soldier for transportation. At all times, the Medical Officer must aim to put a Casualty in the best possible condition for transportation in the shortest period of time.

THE CONCEPT OF CARE AND COMFORT:

Army Medical Corps accomplishes its mission of providing ‘CARE’ by making an effort and actually by reaching the Battle Casualty as early as possible. The presence and the physical contact with a person providing medical aid gives the feeling of being cared for. The Battle Casualty should not struggle to find his way to reach the Regimental Aid Post. A Battle Casualty feels reassured if the medical care provider demonstrates a sense of resolve, determination, and purpose in reaching out to the wounded person in the Field. An early and effective medical intervention is the key to deliver ‘Care’ and ‘Comfort’. The human body experiences a sense of improvement when the bleeding is stopped, when the pain is relieved and when you are placed in a position that physiologically contributes to the sense of ‘Comfort’. I also speak about the role of compassionate care in the relief of pain and in the management of pain. Compassion acts like a Force/Power/Energy. It has an uplifting power. Compassion provides both a physical and mental experience to the person providing the care and on the person receiving the care. The caregiver experiences less physical and mental fatigue and would be able to accomplish a physically and mentally challenging task with ease and a sense of joy or happiness. The person receiving the care experiences a sense of calm and reassurance, his pain tolerance improves, he becomes pain resistant and wold require less effort in his pain management both in terms of the dose and the frequency of his pain relief medication. The psychological and physical stress caused by the battle injuries is reduced as the wounded person experiences a sense of joy or happiness for getting compassionate attention. Human touch is a powerful tool in the arena of Battlefield Medicine. 

THE GREATEST CHALLENGE FOR ARMY MEDICAL CORPS:

The lives of the seriously wounded soldiers depend upon the professional skills of the Medical Officer and other medical personnel deployed at the Battalion level. I served as a Medical Officer at a Battalion level during the India-Pakistan War of 1971, and later served in a Field Hospital providing support to an Infantry Division, and in a Medical Battalion providing medical support to an Armoured Division. I had also used this experience in serving the Land Forces of the Sultanate of Oman. The need for the best trained men in the most ‘FORWARD’ location where the greatest test of ability is made remains the greatest challenge for the Army Medical Corps. AMC must orient its policy and training to achieve this end. AMC must apportion training time of the Medical Officer so that a maximum training occurs in acquiring the skills to provide initial care to the battle casualty in the combat zone. To supervise the training of the medical care support personnel, the Medical Officer should also be trained to acquire the professional skills that are used by a Nursing Assistant and an Ambulance Assistant. In the Art of Battle-Field Medicine, no job is a small job.

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Dr. R. Rudra Narasimham, B.Sc., M.B.B.S.,  

Service Number: MS-8466; MR-03277K; Rank: Major; Branch: Army Medical Corps( Direct Permanent Commission)   Designation: Medical Officer, Unit: South Column, Operation Eagle(1971-72) 

Organization: Headquarters Establishment No. 22  C/O  56  APO; Vikas Regiment, Special Frontier Force/Directorate General of Security.