Falklands war 25TH anniversarY - Boekje Pienter

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From the group in which Kirschner wires were used, two remained hospital inpatients to allow their axial pattern flaps to mature. The other three were transferred, after grafting was complete, to the Joint Service Rehabilitation Unit at Chessington, for active full-time physiotherapy. At the end of 1982 one of these was back at work as a heavy goods vehicle driver and the other two were awaiting re-admission for further corrective surgery. None of the patients interviewed many months after the event admitted to any respiratory trouble either at the time of smoke inhalation or later, whether or not they had been treated with steroids. Continued use of pressure garments has been required to counteract hypertrophic scarring and web space contractures in 24 hands (15 patients). In this group only one pair of hands was treated conservatively. Hypertrophic scarring requiring similar treatment occurred in three other burnt areas, all treated conservatively. By the end of 1982 64 operations on 27 patients under general anaesthetic had been performed by the Unit. Discussion Distance: Casualty evacuation over a distance of 8,000 miles presents enormous problems administratively, logistically and for the patient. With many transfers from ship to ship, ship to aeroplane and hospital to hospital in the UK, the journey from the SS UGANDA to the Queen Elizabeth Military Hospital, Woolwich, took an average of six days. The nearest usable air base to the combat zone in the Falklands was 1,100 miles away at Montevideo. Patients stabilised on UGANDA were transferred to hospital transport vessels, which had been converted from survey ships, for the journey to Montevideo. From there they were flown to the United Kingdom via Ascension Island. This was a substantial achievement; the American forces in Vietnam used permanent air bases relatively close to the fighting and were able to use large jets, taking 20½ hours for a journey similar to that between the Falklands and the United Kingdom to evacuate patients in large numbers direct to the United States 6 . In the early stages of the Vietnam war most of the serious cases were evacuated rapidly, sometimes within 24 hours of wounding, but as larger more specialised medical facilities were established in the war zone, transfer of these patients was delayed and definitive treatment started immediately 7 . British soldiers arrived in England tired, confused and some in great pain. The length of the casualty evacuation chain precluded any reconstructive surgery in the South Atlantic for burn cases. Emergency surgery included amputations, escharotomies and tarsorrhaphies which were carried out as indicated, but no definitive grafting was started until arrival in the UK two weeks after injury. Early Treatment: In order to cope with a large number of casualties in a short period of time there needs to be an established well rehearsed regime for burns treatment on the battle field. Intravenous fluid replacement in the shock phase for large numbers can be adequately controlled by following Sorenson’s Dextran formula as adopted by the Army 8,9 . Experience on the hospital ship has demonstrated that large numbers of patients in the shock phase can be adequately monitored by hourly haematocrit levels using the ‘Uganda Rule’. Despite this, some will still be either under or over-resuscitated, but this is compensated for by the fitness, age and morale of professional soldiers in a regular army. Superficial burns of hands dressed conventionally with bulky bandages make otherwise fit patients dependant on others. However, plastic bag occlusion allows the patient a degree of mobility and self help, relieving overworked nursing and auxiliary staff for the more extensively injured 10 . The exposure treatment of burns is well documented 11 and this applies particularly to superficial burns of the face which require virtually no maintenance, a factor of importance when dealing with large numbers. Protective Clothing: To a limited degree clothing can give protection from burn injuries. The SIR GALAHAD victims were dressed for cold wet conditions with many layers of combat clothing, although the hands and head were uncovered. Two soldiers who were wearing gloves suffered only minor superficial blistering to the hands. Some wore plastic waterproof outer clothing with a hood, which was typically bunched up behind the head. This caused deep burns where it ignited and fused to the scalp. Others wore thick arctic parkas which gave a good degree of protection, particularly when the face was protected with the hood, as demonstrated by one quick-witted soldier who, although losing a leg, had no facial burns. Except for those close to the blast, multiple layers of clothing gave considerable protection. Analysis of this incident shows that despite the large numbers of casualties involved, many were of a relatively minor nature and might have been prevented. Flash protective clothing, as worn by the Royal Navy crews, could protect many hands and faces although both availability and troop compliance are likely to cause difficulties. Acknowledgements I wish to thank Col BC McDermott CBE FRCS L/RAMC for his encouragement and permission to report on his patients, and Col R Scott FRCS L/RAMC for his advice on preparation of this article. References 1. Chapman CW Burns and plastic surgery in the South Atlantic campaign. JR Nav Med Ser 1983; 69: 71-79. 2. Jackson DS 1983; Personal communication. 3. Jackson DS et al. The Falkland War arm field surgical experience. Ann R Coll Surg Engl 1983; 65: 281-285. 4. Williams JG, Riley TRD and Morley RA, Resuscitation experience in the Falkland Islands campaign. Br Med J 1983; 286: 775-777 5. McGregor IA and Jackson IT. The groin flap. Br J Plast Surg, 1972; 25: 3- 16. 6. Funsch HF Jet age evacuation of Vietnam casualties. Med Times 1966; 94: 1022-1029. 7. White MS et al. Results of early aeromedical evacuation of Vietnam casualties. Aerospace Med 1971; 42(7): 780-784. 8. Sorensen B, Seirsen P and Thomsen M. Dextran solutions in the treatment of burn shock. Scan J Plas Reconstr Surg 1967; 1: 68-73. 9. Kirby NG and Blackbury E. Field Surgery Pocket Book. London HMSO 1981. 10. Slater RM and Hughes NC. A simplified method of treating burns of the hands. Br J Plas Surg 1971; 24: 296-300. 11. Wallace AB. The exposure treatment of burns. Lancet 1951; 501-504. JR Army Med Corps 153(S1): 37-39 39
FALKLANDS WAR 25th ANNIVERSARY Commentary on Operation Corporate – The Sir Galahad Bombings Woolwich Burns Unit Experience Lt Col Alan Kay FRCS FRCS(Plast) RAMC Consultant Adviser to DGAMS, Burns & Plastic Surgery 16 Close Support Medical Regiment The Falklands Conflict produced some iconic images of burn injury in modern warfare; the skin hanging off the burnt sailors getting off helicopters, the rescue attempts around the blazing Sir Galahad, the smiling burnt faces of the casualties on SS UGANDA lying on the floor in their makeshift ward with their hands in plastic bags, the scarred Simon Weston. This paper should be part of the iconography of medical planners as it is a clear condensation of the issues around several key aspects of military burn injury. Much of the information presented in this paper confirms what was already known. Ships engaged in war fighting are a significant potential source of mass burn casualties, most casualties will have small burns, some will have other non-burn injuries, burn casualties (even small burns) place a huge strain on logistic support, burn casualties can do well in extended evacuation chains if moved early and initial management is good. These headline messages are still valid. That said, some things would have been done differently today. There has been a shift in what is considered “best practice” in burn care. Early excision (certainly within 48 hrs) of a burn wound is now seen as a life saving measure in large burns. As in 1982, it is still considered impractical to perform such surgery forward of Role 4. Only four burns greater than 20% entered the evacuation chain after this incident and more recent conflicts have also yielded very small numbers of large burns. It is, therefore, difficult to test statistically whether our doctrine of not excising large burns prior to evacuation is an unacceptable compromise of care. Repeated anecdotal evidence from UK forces and observation of the larger US figures has so far produced no evidence to suggest we may be getting it wrong. Aspects of the initial management highlighted in this paper would be criticised now but we should not view matters outside of the context of what was seen as best practice then. Most of burn care has evolved through personal anecdote and prejudice rather than being evidence based. There would have been no “National standard” for a burn fluid resuscitation regime. The exposure method of burn management would be deemed negligent by many Burn Surgeons today. Here we must put ourselves in the shoes of those who, adapting the knowledge of best practice at the time, produced pragmatic solutions to a resource limited environment. Adaptive thinking produces concepts such as “The Uganda Rule”. Does this ‘making it up as you go along’ lead to outcomes that are any worse than rigid pre-planned protocols The patients who are seen during the learning phase of adaptive thinking may well be in receipt of sub-optimal treatment. Again, though, we cannot answer the question “did they get it right”. A simple glance at the reported end-points does not inform the debate about whether outcomes improved or worsened by what was done or not done. The liberal use of steroids for inhalation injury in the Falklands Conflict is a clear example on non-scientific medicine; there being then, as now, no evidence of benefit. The mechanism of injury on the Sir Galahad should have produced casualties with inhalation injury. The fact that none of the casualties required intubation nor had long term respiratory sequelae was, particularly within Naval circles, the evidence used to advocate prophylactic steroids as an essential intervention for several years. I cannot help but feel that one or two of the casualties would today have been intubated and ventilated. One of the casualties with 48% burns arrived in the Burn Unit a month after injury and this would now be regarded at unacceptable. We should be asking ourselves the awkward question that, did these casualties do so well because of the omission of early aggressive treatment For example, it is now well recognised that the pulmonary insult of ventilation in inhalation injury is in itself harmful. The complexity of the evacuation chain from point of wounding to definitive care is clearly highlighted. Without more detail it is difficult to know, in retrospect, if any part of that chain could have been improved on. In particular, the delayed arrival of the most severely burnt casualty because of septicaemia is not expanded on. Where in the chain was he held Leading up to 1982, it was considered inconceivable that the UK would embark on such a mission. There is nothing today that should allow our strategists to be allowed to think that a similarly complex scenario could not again be a reality. We must have in our system the ability to evacuate severely injured casualties from all environments. The four larger burns from this incident would in itself generate a very heavy workload in any modern Burn Unit. Added to this was the greater number of smaller but functionally significant burns. Surgery to heal and reconstruct hand burns is demanding and time consuming. The on-going rehabilitation and scar management even more so. This total workload would today, I am certain, have such an effect on any single unit that the patients would be distributed to a number of burn services. This would have been an excellent cohort to follow up and report on the long term outcomes of hand function as they would represent about a decades worth of experience for the average UK Burn Surgeon. Personal protective equipment (PPE) issues are still with us. The wearing of body armour to protect against chest penetration is almost universal. Anti-primary blast wave technology is available but, for conventional explosives, of uncertain value. Anti-burn PPE has been around for decades but is not popular with dismounted infantry. The time of maximum danger for burns is when such troops use ships, aircraft and armoured vehicles for mobility. Finding appropriate anti-burn protection for the infantry is an area of on-going research. This paper adds to our collective anecdote about military burn injury. Its descriptive style makes it difficult to extract useful data for analysis and it would certainly have been inappropriate to base any doctrinal change in clinical practice on what it presents. It does provide a good overview of the scale of the problem and gives an insight into the pragmatic approaches adopted. It is a “must read” for medical planners. 40 JR Army Med Corps 153(S1): 40
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