Page 61 - JSOM Summer 2018

board. 11,12 Triage protocols were not unknown to warships uses of tourniquets. First, he provided three easily identifiable
at this time; however, in the chaos of a major engagement, indications for appropriate tourniquet use: extremity arterial
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medical attention was frequently prioritized on a first-come, bleeding (“known by its flowing in jets”), severe open com-
first-served basis. Inevitably, many wounded died from mas- pound fractures, and traumatic amputation (“If the arm or the
sive hemorrhage before care could be given. Seaman William leg be knocked off by a cannon-shot . . .”). These are followed
Robinson (“Jack Nastyface”) of HMS Revenge described the by explicit examples of inappropriate use, with anecdotes that
consequences for crew wounded during the Battle of Trafalgar might seem faintly comic to modern readers:
in 1805:
In Her Majesty’s ship Rose, in 1836, on the East In-
For the rule is, as order is requisite, that every person dia station, a midshipman seeing a man wounded in the
shall be dressed in rotation as they are brought down neck, placed a tourniquet around it to the peril of the
wounded, and in many instances some have bled to sufferer; the fatal consequences, however, were averted
death. 13 by its timely withdrawal. At Balaclava, amongst the
medical news of the war, it has been reported, that a
Thus, if immediate treatment were required, it would have sailor observing a marine shot in the neck, at once ad-
to be performed by the men. The problem of reducing the justed a tourniquet, overlooking, until warned by urgent
numbers of “died of wounds” is essentially one of decreasing symptoms of suffocation, that his comrade would soon
evacuation time to definitive care; Caddy was prescient in be the victim of his well-intentioned services.
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recognizing that more inclusive training of all nonmedical per-
sonnel, officers and men, could substantially close this gap—a For respiratory compromise and penetrating wounds of the
responder-centric, rather than a surgeon-centric, approach. chest and abdomen, he provided simple instructions for pa-
tient positioning and use of occlusive dressings. Caddy gives
Caddy presented no new information regarding immediate clear directives for both for recognizing shock (the paleness
care priorities. Early and aggressive hemorrhage control was of the surface, the cold and clammy perspiration, faintness,
emphasized as early as 1798 by Blizard (but seemingly ig- trembling, imperceptible pulse, mental confusion and alarm)
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nored by later authorities such as Guthrie, who instead rec- and its treatment, involving application of some type of stim-
ommended bloodletting as treatment for simple gunshot ulant (generally medicinal wine or spirit), and active rewarm-
wounds ). Caddy reinforced Blizard’s original directive with ing by external heat applied to the upper abdomen and feet.
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a direct quote from Samuel Cooper’s then-definitive surgical Shock secondary to wounding was not understood in the
text: 17 Victorian era, although it was known to be a specific physi-
ological disruption related to extreme hemorrhage or blast,
In every wound, the bleeding demands the earliest at- and different in kind from the “shock” associated with emo-
tention because if loss of blood be not prevented with- tional trauma. 16,17,19 Medicinal wines and brandy were used for
out delay, the patient will frequently die in the course the treatment of shock well into modern times, with gradual
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of a few seconds or minutes. Every other consideration abandonment of their use only after the 1930s. However,
may be deferred; but when large vessels are injured, they guidelines for preventing hypothermia in combat casualties
must be immediately secured, or else the sudden death were not formally specified until World War I. Even today,
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of the patient will leave the surgeon no opportunity of shock-related hypothermia is a significant contributor to mor-
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exhibiting his skill and usefulness in other matters con- tality in both combat and civilian patients.
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nected with the treatment.
Although not novel in details, Caddy’s guidelines were inno-
Caddy then defined essential medical skills anticipated to cover vative in being both brief and systematic. In contrast to the
the most likely emergency scenarios, prioritized by urgency available written resources of the time, his two-page guidelines
and prevalence, and including descriptions of simple care pro- were a concise and commonsense distillation of general princi-
cedures. His numbered list of five categories of combat injury ples of combat injury management, summarized from surgical
correspond closely to modern TCCC care priorities —mas- textbooks and his own practical experience as a naval surgeon.
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sive hemorrhage, penetrating injury, traumatic amputation, However, his fundamental contribution was the recognition of
fractures, and shock (Table 1). Then, as now, treatment for the value of a systematized approach to combat casualty care:
massive bleeding was direct pressure and tourniquets. Di-
rect pressure was taught to soldiers and stretcher-bearers as A system, be it imperfect, is better than if none existed,
first-line treatment during the Crimean war. However, tour- or where each medical officer has to frame for himself
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niquets were the mainstay for control of massive extremity distinct rules.
bleeding. “Field” tourniquets, consisting of a wooden roller
and straps, were recommended for use by seamen ; however, The goal of this system was
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supplies could be limited, difficult to access in emergencies,
and unwieldy to use. Thus, tourniquet improvisation was an to furnish the officers and the men . . . with practical and
essential component of first response. Improvised tourniquets tangible rules, (which the author has never discovered,
were based on the principle of the Spanish windlass, with by conversation, to be in their possession,) methodically
sticks, pebbles, and even sword hilts used to apply tension arranged, and admitting a prompt application on urgent
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on the constriction band. Caddy himself did not provide much occasions.
in the way of specific details for tourniquet preparation as “[e]
very sailor has a tourniquet at hand in his clasp-knife and its To Caddy, a systematized method of care had two advantages.
laniard, and its application is easily to be learned.” However, First, it would directly benefit the wounded by reducing death
he was careful to itemize both appropriate and inappropriate and suffering:

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