by Jon E. Lewis
Deep burns will be surrounded by very red skin and will be blistered and swollen. In the most serious instances the skin may be pale and waxy and even charred, and the casualty may not feel much pain due to destruction of the nerve ends.
Treatment
The first thing to do, as with any injury is to remove the casualty from the source of danger. Hopefully, someone else will extinguish the fire, while you deal with the casualty.
A burn is a wound like any other, and is treated in the same way – with a clean dressing. Cover the whole area to prevent infection getting in and more fluid leaking out. Burns can cause extensive fluid loss and this must be reduced as much as possible. Leave any blisters intact; they are performing a useful function in keeping fluid in. They may be removed later in hospital, but it’s not a first aid job. Also, do not attempt to remove any burnt skin.
Do not remove burnt or charred clothing unless it is continuing to be a source of heat. If clean water is available immerse the burn area to cool it. This reduces further heat damage and reduces the pain.
Even the smallest burn can be very painful. Paradoxically, some large deep burns can be surprisingly pain free because the nerve endings have been burnt away.
Splints and slings may help to keep the patient comfortable and will therefore reduce pain. Prepare them in the same way as for fractures.
FRACTURES
When you’ve dealt with the casualty’s breathing and bleeding, the third priority is broken bones. Fractured bones can cause serious injury or death, but can often be successfully treated and a complete recovery achieved. A great deal depends on the first aid you give the casualty before he is evacuated for treatment. Before he can be moved you must immobilize the fracture; the basic principle of splinting is to immobilize the joints above and below the break.
IMMOBILISING FRACTURES
You must keep the fracture still to prevent the sharp edges of the broken bone moving about. This achieves three things:
1 Stops further damage to tissue, muscle, blood vessels and nerves.
2 Reduces pain and shock
3 Stops a closed fracture becoming an open one because of bone fragments penetrating the skin.
Rules for splinting
1 Remove watches, rings and garments from the limb or these may reduce the flow of blood to the hand or foot when the injured part becomes swollen.
2 If the tactical situation allows it, splint the fractured part before moving the casualty and without any change in the position of the fractured part. If a bone is in an unnatural position or a joint is bent, leave it as it is.
If circumstances force you to move a casualty with fractures in his lower body before you can apply a splint, tie the injured leg to his other leg. Grasp the casualty beneath his armpits and pull him in a straight line. Do not roll him or move him sideways.
3 Apply the splint so that the joint above the fracture and the joint below the fracture are completely immobilized.
4 Place some padding between the splint and the injured area. This is especially important between the legs, in the armpits and in areas where the splint rests against the bony parts such as the wrist, knee or ankle joint.
5 Bind the splint with bandages in several places above and below the fracture but not so tightly that it interferes with the flow of blood. Do not bandage across the fracture. Tie bandages with a non-slip knot against the splint.
Signs and symptoms
Symptoms of a fracture include pain when slight pressure is applied to the injured area, and sharp pain when the casualty tries to move the area. Do not move him or encourage him to move in order to identify the fracture because the movement could cause further damage and lead to shock. Other signs are swelling, unnatural movement of the limb, bruising and crepitus (the distinctive sound of fractured bone ends grating together).
Types of fracture
1 Open fracture: An open fracture is a break in the bone and in the overlying skin and flesh. The broken bone may have punctured the skin or a bullet may have penetrated the skin and broken the bone.
2 Closed fracture: In a closed fracture the bone is broken but the skin remains intact. There may be tissue damage and the area is likely to swell and later bruise. It may only be a sprain, but you should assume the worst and treat it like a fracture.
If you have nothing with which to construct a splint, immobilize an injured arm by securing it to the casualty’s chest. Slings can be improvized from belts or bits of shirts or blankets. Remember to put some padding between the splint and the injured arm.
FIELD FIRST AID – IMPROVISATION
There might come a time when your oppo has been hit and you haven’t got the kit to help him. But most “official” first-aid kit is unnecessary, so you should not be tempted to burden yourself with a vast collection of equipment. Every soldier is trained in first aid. The only pieces of equipment he carries are dressings; everything else has got to be improvised.
DRESSINGS
A field dressing is a large pad of gauze with a bandage attached; ideally it should be in a sterile packet, and each soldier should carry at least three. A lot of dressings that are commercially available are frankly too small; a dressing cannot be too large. If you cannot find a proper dressing the next best thing is a suitable gauze pad held in place with a crepe bandage. Failing this, any clean material will do; clean cotton is best, so use handkerchiefs or shirts folded to make a pad or torn into strips to make a bandage. If you can’t find anything very clean, use the cleanest part up against the wound and the less clean further away. Remember, most gunshot wounds are highly contaminated anyway by the bullet; bits of cloth have been pushed into the wound and dirt sucked in as the temporary cavity caused by the wound repressurizes.
SPLINTS
Splints can be made from anything that is reasonably rigid, wooden planks, branches or metal sheeting. Items of military equipment might be suitable, but if you decide to use your rifle pay attention to the tactical situation first. Inflatable splints are carried by the combat medic.
Leg Splints
See illustration for how to apply improvized splints for a fracture of the lower limb or ankle. Note that the knots are against the splints, not the leg.
You can use the uninjured leg as a splint for the fracture; pad out the gaps between the legs before you start tying them together. Leave the boots on and tie them together firmly at the base and the top of the boot. There should be no shortage of things to use as strapping; the picture shows just a few ideas. They must be placed as shown and this is the minimum number that will be effective.
Arm splints
The aim of splinting is to immobilize the limb and prevent the break getting any worse. Both diagrams show methods of splinting a broken arm or elbow where the elbow is not bent. Try to pad the splint so that the casualty feels comfortable and immobilize the whole arrangement by strapping it down to the chest.
The binding or cravats should be firm enough to prevent movement but not so tight that they limit the blood flow. Use a piece of cloth or bandage so that it does not cut in. Remember to immobilize the joint above and below the fracture.
STRETCHERS
If you need to evacuate a casualty you will need a stretcher. Lightweight rope stretchers, as used in climbing, are ideal and can be carried, one per section. The new issue stretcher is collapsible and can be easily carried in a Bergen.
If you have to improvize, things such as doors and planks are obvious choices, but you may have to make do with branches or rifles. Obviously whatever you use must be as comfortable as possible for those who have to carry it. This becomes increasingly important the further the stretcher has to be carried.
If you do not have a stretcher and haven’t time to improvise, you may have to carry the casualty in, for instance, a fireman’s lift. There are several ways of making things easier for yourself, particularly in getting the casualty up on to your shoulder.
From the recovery position haul the casualty up onto your knee
and balance him there while you change grip to under his armpits. Then heave him on to his feet, leaning against you.
Hold out the casualty’s right arm and then duck under the arm. Put your head against his chest and your left arm between his legs, holding the right knee in the crook of your elbow and swing him up onto your shoulders. The higher up you carry him, the easier it is. Hold his right arm and leg together in your left hand and carry your rifle in your right hand.
CASUALTY CARRYING TECHNIQUES
“Stretcher bearers” always seem to be on hand in the movies, but the truth is that they will always be thin on the ground forward of the company aid post. In most cases you will have to move your own wounded back via platoon headquarters.
Wounded are usually controlled by the platoon sergeant. The lightly wounded should be given first aid and encouraged to fight on, and the walking wounded should move to the CAP under their own steam if possible.
The rest can roughly be divided into the conscious but immobile, and the completely out-of-it. There is a wide range of carrying techniques to deal with the different categories, so learn and practise them now. In any future European war there will not be sufficient helicopter assets for casualty evacuation.
TYPES OF CARRY
The drag
This is for conscious or unconscious casualties and requires a good deal of upper body strength. With the casualty on his back adopt an all-fours face to face position over him with his arms tied together and looped around your neck. Tie the arms of the casualty around your neck at the elbow to make the task easier. Then only his legs will drag in the dirt. This is a good technique if you are under fire.
The side drag
This, with its variations, is the method you will use when in close contact with the enemy and where cover is limited (when the rounds start flying you will pick it up naturally). With one hand grasp the casualty’s shoulder webbing and with your feet alongside him, lever yourself along on elbow and thigh. You can also try looping your foot through his webbing and dragging him on the end of your boot.
The fireman’s lift
This is comfortable to the carrier but hell for the patient. It does tend to make you a large target, and it is difficult to get the unconscious casualty onto your shoulders without help.
The piggy back
This is really only useful if the casualty is conscious and can use both his arms. It can be quite comfortable if you sit the casualty on your webbing, transferring his weight onto your shoulders.
Webbing carry
This method is best for short distances in place of the fireman’s lift for a casualty who can’t be doubled over. Hold the casualty on your back, his head next to yours and facing the same way, by grasping his shoulder, or webbing, with your hands close to your neck.
Webbing stretcher
Sit the casualty in his webbing the wrong way round with his feet through the shoulder straps to produce an improvised sit harness.
The seat
By crossing and linking your arms in this way, you can carry a casualty who is unable to walk. As a third soldier will be needed to carry the wounded man’s weapons and kit, it is easy to see how a couple of casualties can paralyse a unit.
The sit
This method provides back support but less of a seat. Two men hold hands so that one handgrip is below the casualty’s knees and the other behind his back with his arms grasping the carriers’ shoulders.
Extracting casualties from vehicles
You should be familiar with most Army MT and AFVs and know the positions of all the hatches, the fire extinguishers and the fuel cut-off.
Casualties in vehicles are often severely injured with multiple wounds, burns, etc so practise the techniques now.
BATTLE CASUALTY EVACUATION
The first man in the casualty evacuation system is the soldier who has been wounded. The first thing he has to do is to stabilize his injury – in other words, stop the flow of blood, move into a position that prevents his lungs flooding or throat clogging, or simply keep broken limbs supported so that simple fractures don’t become compound. Your buddy may also assist if he is nearer than the section medic.
BATTLE CASUALTY MARKING
When treating a casualty you can make the medic’s job a great deal easier and prevent complications further down the line of casualty evacuation by marking the casualty’s forehead with the relevant information. The section medic will label the casualty when preparing him for casevac, but labels can be lost; information on the forehead cannot. The symbols are:
X
Emergency evacuation necessary
T
Tourniquet applied with the date, time group written underneath
H
Haemorrhaging
M
Morphine with the date and time of the injection written underneath
C
Gas – contaminated chemical casualty
XX
Nerve agent poisoning
R
Radiation sickness
P
Phosphorous burns
The section medic will then check the casualty on orders from the section commander – remember that in contact with the enemy the medic may himself become a target. Next, the platoon medic will be brought in to prepare the casualty for evacuation, and, while this is happening, platoon HQ will contact company HQ with a request for a casualty evacuation.
The company stretcher bearers then evacuate the casualty to the Company Aid Post. The stretcher bearers will be moving backwards and forwards between the platoons in contact and the company and, as long as they are not badged up with red crosses, can also be used to move up ammunition. They can’t do this if they are protected by the red cross, because they are engaged in humanitarian work and cannot give material support to the battle – a convention normally respected by both sides. In an infantry battalion medics are normally members of the band (or buglers or pipers) who combine their skills as musicians with first aid training.
The company medic ensures not only that the casualty goes on his way to the Regimental Aid Post (RAP) in a stable condition but also that medical supplies are fed back down to the section from the RAP.
Out of the battle
In transit, you must protect casualties from the weather, chemical agents and enemy weapons. Shock can kill, and it can be accelerated by wet and cold. Casualty bags have been produced for work in an NBC environment, but it may be necessary to make repairs to the casualty’s NBC suit as an expedient.
The casualty will retain his weapon while he is evacuated though the section medic will probably have removed and redistributed ammunition and grenades. The weapon will need to be made safe, and you should search for other weapons at an early stage.
Enemy casualties are evacuated in the same way, but they are disarmed when they are captured. Security is the unit responsibility, though a wounded PoW is unlikely to wish to escape or cause trouble.
The Regimental Aid Post varies in size depending on the type of battalion, but a typical team comprises a Regimental Medical Officer (RMO) and eight assistants. They will document casualties and dead – the dead are brought in, in the same way as casualties. The usual daily work of the RMO is to treat the battalion sick.
From the RAP, the casualty will be evacuated by ambulance to the Dressing Station in the divisional administrative area, where he is treated for further evacuation, or return to his unit. He will not receive any surgery here.
Field surgery
Surgery in the field can be brought forward to the casualty, rather than the man having to make a long journey to the rear. Helicopters have made evacuation fast and reliable, but the turn-around time can be critical. Battle injuries have some uniquely unpleasant features – blast and fragments can produce extensive damage. Though a gunshot wound may be precise, the track of the round after it has entered the body can be unpredictable, and the exit hole can be larger than the entry hole. Dirt, clothing and fragments enter the body w
ith the round, and tissue is damaged by the passage of the round through the body.
The only advantage that the field hospital surgeon has is that the casualty is basically a fit man. There is no danger of heart attack, respiratory collapse, or thick layers of subcutaneous fat to be penetrated. Recovery can be fast, with sleep and proper nursing, since a man in his late teens or early twenties is the “ideal” patient. The problems lie in psychological adjustment to permanent disablement or the death of close friends.
Triage and survival
A uniquely grim feature of battlefield surgery is the triage system. Developed by the French in World War I, triage is the classification of incoming casualties by types. T1 can have his life saved by emergency surgery, T2 can await treatment, T3 has relatively minor injuries and can look after himself: finally T4 has serious multiple injuries. In surgical terms T4 may not be worth working on. He may die after surgery and, meanwhile, a T1 may slip into a T4 while this operation is under way. A US army surgeon recalled his first encounter with T4 in Vietnam, when he saw an unconscious casualty apparently neglected in the corner of the ward. When he started to work, a colleague told him not to bother. Raising the soldier’s head, he showed the young surgeon that half the man’s brain was spilling out of his smashed skull.
CASUALTY EVACUATION
In battle, the most important priority after achieving the unit mission is the successful management of combat casualties.
Educational role
Despite this, it is vital that men should know that when they are asked to put their life on the line, they are backed by an efficient evacuation and treatment system. They will fight more effectively. The RMO has an important “educational” role within a battalion explaining the system and ensuring that everyone understands basic first aid. The panic and terror that can ensue after a man has been hit will be reduced if he knows what to do and what will be happening to him now that he has become a casualty.
