War wound excision Modern aids to clinical decision making in the acute abdomen
Sir
Fackler's contribution to the understanding of wound ballistics is acknowledged. He has shown that modern rifles do not always cause dramatic wounds. Like many military authors he thinks that rifle wounds are the only wounds worth discussion. In an International Committee of the Red Cross (ICRC) hospital the 'great majority' of war wound are not 'punctate through-and-through rifle wounds of the extremity with minimal tissue disruption'. His response (Br J Surg 1989; 76: 1217 (letter)) to the advice on war wound management from the ICRC'.' is unacceptable because:
(1) He chooses to ignore the enormous experience of the authors in the continued care of war injured. The 'thorough review of historical war surgery experience' clearly missed the reports of others who had responsibility to the patient beyond initial surgery. Davis3 witnessed the evacuation of wounded from Vietnam onto a hospital ship and concluded: 'the mechanism for every failure lay in inadequate debridement of a given wound'. Likewise Latta4 managing wounded from Korea stated: 'It was abundantly evident that nothing yet can take the place of the efficiently planned surgical toilet of the wound'. The mainstay of Trueta's' closed plaster technique for limb fractures was careful wound excision. It is clear that those concerned with the continued care of the patients rapidly recognize the value of correct wound surgery. A modern army wishing to evacuate the patient rapidly may find it acceptable to teach their forward surgeons time saving but suboptimal wound surgery. In this situation the surgeon cannot gain the valuable feedback necessary to learn wound excision. In an ICRC hospital, surgeons new to war surgery sometimes choose to ignore advice from those with more experience. There is an immediate increase in bed occupancy and number of reoperations. It is incomplete wound excision that, 'imposes an unnecessary drain on surgical resource and inflicts a higher than needed complication and morbidity rate upon the patient'.
(2) The experimental work that Fackler et al. use to support their argument6 is not applicable. It is only by a long stretch of the imagination that the shooting of ten anaesthetized pigs through the muscular part of their thighs, 'conform as closely as possible to the real-life combat situation'. The fact that this has influenced the rewriting of the NATO handbook' is very distressing.
(3) Fackler takes exception to the excision of wounds that present late. What does he advise for large volumes of dead tissue rendering the patient toxic and anaemic? Loose bone fragments (sometimes from other people), clothing, mud, stones, grass and pieces of shoe cannot be left to discharge themselves from the wound. The increased