Page 63 - JSOM Summer 2018

TABLE 1 Cont.
Tourniquet use
Caddy 1855 . . . ‘Every sailor has a tourniquet at hand in his clasp- TCCC 2014 ‘. . . tourniquets are the best option for temporary
knife and its laniard, and its application is easily to be learned.’ control of life-threatening extremity hemorrhage during Care Under
Appropriate tourniquet use: ‘If the arm or the leg be knocked Fire’.
off by a cannon-shot, &c., or the bones be fractured, with much
laceration of soft parts . . . a tourniquet should be placed to control
the main artery The tourniquet to control arterial bleeding of a
limb is always placed above the wound.’
‘Bleeding from an artery is known by its flowing in jets, and by the
florid red colour of the blood.’
‘. . . if the fracture be compound, and there is any bleeding
vessel within reach, it should be secured; or by compresses and a
handkerchief properly applied, an extempore tourniquet may be
made.’
Inappropriate tourniquet use: ‘The temporary tourniquets in
ships and vessels of war, as put on by the man-of-war’s man, are
frequently placed as the hangman’s rope adjusts itself around the
criminal’s neck - to strangulation of the superficial and deep parts;
and this, too, where the tourniquet is not always called for. . . . ’
Moving casualties
Caddy 1855 ‘A litter carried by men is the easiest conveyance, and TCCC 2014 After the scene is secured and casualty disarmed, the
the least likely to inflict any additional injury to the limb; if one casualty may be moved by a one or two–person carry, or conventional
cannot be procured, any other mode of conveyance at hand must or improvised litter.
be employed, and the surgeon must seat himself so as to be able to
support and steady the fractured limb. . . .’
Bellamy, 1984; Butler et al., 1996 ; Maughon, 1970 ; Savage et al., 2011; TCCC ; and
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http://www.naemt.org/education/TCCC/guidelines_curriculum
If general instructions were given to the officers and the of relevance. In his focus on trauma care, Caddy was out of
men, and to orderlies for hospital service, many valu- step with his time. Care and treatment of epidemic, diarrheal,
able lives would be saved, and the convalescence from and sexually transmitted diseases were the chief professional
many a severe injury would be agreeably shortened. preoccupations for most naval surgeons. The high mortal-
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ity of naval personnel from disease, once thought inevitable,
Second, the responders themselves would benefit; confidence was becoming less acceptable, and improvements in standards
obtained from learning a basic skill set would be the most ef- of naval health were receiving more attention. Caddy’s own
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fective tool for boosting morale and managing fear and stress: service records do not mention any specific war-related ser-
vice, and his medical logs 29,30 and occasional references in the
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In fact, to inspire men with confidence in their own re- medical news outlets of the day refer to tropical diseases,
sources is to do much to mitigate the anticipated horrors cholera, syphilis, and civilian-type accidents. Finally, lack of
of gun-shot injuries. If men know not their worst, their professional credibility among the medical establishment may
most helpless state, at the least teach them when and have played a role. Naval surgeons were often of relatively
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where their own personal exertions will avail for their low social status (“not gentlemen”), poorly paid, and denied
comrades, themselves, and their officers. professional respect from their non-naval peers and were con-
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sidered to be greatly inferior professionally to physicians. 10
However, more than 120 years later at the CINPAC Third
Conference on War Surgery in 1969, we find Maughon com- The deterioration and loss of professional knowledge, experi-
plaining that representatives from all branches of the armed ence, and skills over time are referred to as organizational for-
services “seemed uncertain regarding the best method to im- getting. The progress of military medicine has been described
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plement factual knowledge [of first aid] to the man most in as fragile in that lessons learned during periods of conflict
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need, the frontline trooper.” It took another thirty years to tend to be forgotten or regress until rediscovered in the next
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produce TCCC and a truly systematized and service-wide ap- crisis. Resistance to change and inability to learn from past
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proach to self-aid/buddy aid combat casualty care. experience contribute to this forgetting. However, the com-
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plete invisibility of Caddy’s insight is another issue altogether.
Why did Caddy’s ideas failed to gain traction? The primary Caddy’s innovation was not a single identifiable or fashionable
drivers of idea spread and cultural change are communication intervention, but a re-organization of the thinking surround-
and influence; barriers to change are usually a function of ing already-known and commonly performed procedures. It is
complex social, organizational, and cultural forces. Caddy profoundly disturbing to consider how many lives might have
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no doubt hoped for rapid and widespread dissemination of been saved if the significance of Caddy’s ideas had been rec-
his ideas by publishing in The Lancet; it was inexpensive and ognized earlier.
up-to-date, and its “crusading, controversial, and combative”
style ensured a large readership. It was also becoming in- Acknowledgments
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creasingly identified as a mouthpiece of surgeon-apothecaries I thank Christopher Josef (Retired, Capt USMC) and J. Las-
such as Caddy in their efforts to improve pay and professional karis (University of Richmond) for thoughtful and construc-
standing. However, The Lancet was not a specialty jour- tive suggestions and the editors for suggesting Table 1. The
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nal, and may not have been read by a critical mass of mili- opinions expressed are my own, and do not necessarily reflect
tary doctors. A second barrier may have been a perceived lack those of the US Department of Defense.
John Caddy and the Victorian Origins of TCCC | 61