9. The Process of Managing Patients

Outerbridge described in detail the process of ingest and triage in one letter home.

"I can give you a little better idea of it by roughly outlining the general system by which the wounded or sick (for the latter are by no means negligible) are taken care of. Say a man is wounded during the ordinary day’s work in a trench, he is carried by stretcher bearers (or walks himself if able) to the first aid post, which is usually in the same sort of a dugout in the advanced trenches. Here he gets merely a first aid dressing of the simplest sort and is passed along to the field ambulance, or this latter may be the first place he strikes at all. At any rate, here is where he really meets the system, for here he is given his “field card” on which is recorded his number, rank, name, diagnosis, religion, length of service, and amount and date of tetanus antibiotics recorded, the latter being given here to every case.

This field card stays with him in all his further progress until finally discharged from the hospital, whether in France or England; all further notes in CCS (Casualty Cleaning Station) and Base Hospitals are made on it and to lose it is one of the most heinous crimes in military medicine! At the field ambulance, he gets his first dressing if none has been applied before or if it has it is looked at and changed as necessary and he goes right along, now probably by motor ambulance to the casualty cleaning station, always known as the CCS. This is the first hospital that he has reached. It is a group of tents capable of accommodating a large number of patients, with a staff of surgeons, full operating equipment, women nurses and orderlies. It is always situated at railhead, probably five to ten miles back of the front lines, at the nearest point reached by the railroad in that particular sector. Here the first attempt is made to do anything beyond what may be termed first aid. Here the man may stay a day or two or a couple of weeks or rarely even more; here any character of operations may be done, and usually the operating room is a busy place, half a dozen tables running constantly during a period of activity.

It was at one of the CCS’s that some of the men from this unit had such exciting experiences last summer; none of them have been farther forward than the CCS (i.e. none of the men regularly attached to the unit). They were sent up in “teams” consisting of an operator, anesthetist, nurse, and orderly. It was to a CCS that Dr. Hodge had expected to go, but did not. There are no teams away from here now. At the CCS our patient will be operated on if it appears necessary-i.e. emergency amputations will be done or dirty wounds will be cleaned up, abdominal injuries attended to, foreign bodies removed, etc. As soon as possible (in active periods), which means usually within 12 hours after even a major operation, he will be put on a stretcher and will stay on that stretcher until he is transferred from it to a bed in this or some similar hospital. The CCS as I said is at railhead, and the hospital train is loaded directly from it; a journey of a good many hours brings it to the station in the town at the foot of our cliff and there the stretchers are loaded into the motor ambulances and are brought up to us and other hospitals. This is what we call a “convoy”- i.e. an arrival of a trainload of patients. We always get word of several hours before the arrival of a convoy of the fact that it is coming, how many “cats”, and how many “sitters” it contains and the probable hour of its arrival, although the latter is by no means a certainty and it often doesn’t get in until long after expected. Somehow it seems as if the majority of convoys come at night, although there is no rule about it. It is really the best, as it doesn’t disturb the work of the wards so much and the patients have a chance to get bathed and rested somewhat before the “M.O.” (Medical Officer) comes around. If you see descriptions of surgeons rushing frantically around when patients are arriving, feeling their patients’ pulses, holding consultations, rushing into the x-ray room instantly, etc. don’t believe a word of it-some of that may go on up at CCS (though I doubt it) but not here. The arrival of a convoy interests just three persons aside from the chaufferines and orderlies - the chiefs of the surgical and medical divisions and the orderly officer. The former look after the cases going to their division and the latter all the sitters. The job of all three is to look at the diagnoses on the field card and assign cot cases to proper wards and very occasionally to see that an especially sick case receives immediate attention. When they reach the wards the cot cases are first to bed, leaving for the first time the shelter on which they left the CCS, bathed and let alone until they get a good sleep. Then they are examined and dressed at leisure the next day. The sitters are marched to a bath house, where their uniforms, often caked with mud and crawling, are removed and taken to the disinfector. The men get a thorough bath and receive the blue denim suits which they wear as long as they are in the hospital. When they go out they get a complete new outfit that has been through the disinfector, washed and pressed.

The minor cases are gathered in tents or huts and go to a dressing tent, in charge of Dr. Packa, for dressings and to a large living hall for meals. All others are treated in the wards. Our work consists in doing dressings chiefly, also in writing the records, which is no small part of it. We have a very busy x-ray plant in charge of Dr. Knowles, and a large number of the cases have to be sent there for examination for fractures, foreign bodies, etc. We usually get to the wards about 9:30 and do dressings all morning until lunch at 1. It is rarely that we won’t be finished with dressing by then. Many cases are dressed by the nurses or we may do them every second or third day and the nurses the other days. Operating is usually done in the afternoon, beginning around 2. As soon as minor cases are healed they are returned directly to the army, situated in the French cities behind the lines, or more frequently are sent to a large convalescent camp (Con Camp) adjacent to the hospital but a separate organization being fed from a number of different hospitals. They are here a couple of weeks, get drills and exercises, play football, and are then sent to their base and back to the line. More serious cases are sent to “Blighty” and hospitalized at a real base hospital in England. They may go out as “sitters” or “cob”, this being known as an evacuation. The hospital changes very quickly from great quiet to great activity and vice versa as we get good sized convoys or evacs. The condition of the hospital reflects the degree of activity along the British front, any considerable push out there means a big convoy here in about 48 hrs."