Annals o/ the Roval College of Surgeons of England 1983) vol. 65

The Falkiands war: Army Field Surgical

experience

D. S. JACKSON FRCS Ed Major RAMC*.Senioi- Regitrar, Queen Elizabeth Au/i/au Hospital, IfoolrcichC G BATTYr MIBE %IBCHB Major RANICRegistrar, (Cambr/iige Militaoy Hospital, Aldershot

J .I RYAN FRCS Major RANICtSenior Regisitra, (Cambrioge MIilitar Hospital, .4ldershotWV S P MIcGREGOR OBI' FRCS Ed Lt. Col. RAMCCo(sultant Suigeon, Duchess of Kent .XIi/itary Hospital, Catterick

Key words: F IEL)SS RGI(:IIUl MR.\I)\VANC) SIRGIC.\L (EN FRE: HIGH \VILOCIT[Y MISSILES: WOUND EXCISION

SummaryIn the recent Falklands campaign four Army Field SurgicalTeams were deployed in the two phases of the war. Theyfunctioned as Adxanced Surgical Centres and operated on233 casualties. There were 3 deaths. The patterns of wound-ing and the methods of casualty management are discussedand compared with other recent campaigns.

IntroductionDuring the recent conflict a Naval task force which includeda land forces elemenit, consisting of 3 Commando Brigadeand 5 Infaintrv Brigade was dispatched to the South Atlantic.The initial landing of these units on East Falkland took placeon 21st May 1982. Support for the land forces provided bythe Armv Medical Services consisted of:(1) A Regimental Officer (RMO) assigned to each major

unit. At a later stage some units were assigned a secondMledical Officer.

(2) 16 Field Ambulance RAMC providing second linemedical support for the land force.

3) Surgical teams drawn from 16 Field Ambulance(Parachute Clearing Troop) and 2 Field HospitalRAMC.

Additional support was given by a Royal Navy Ship'sSurgical Team of the NMarine Commando Medical Squad-ron whose experience will be reported separately.A Task Force of this magnitude has not been deployed

since WNorld XVar II. The conflict took place at a distancefrom base of 8000 miles, and with such long lines ofcommunication and a relative lack of surface transport,obvious difficulties with re-supply of medical stores andrearward evacuation of casualties to base hospitals wasenvisaged. The medical support, therefore, had to be selfsufflcient to a degree not previously experienced.

Four Army surgical teams were deployed during thisperiod. They had to work under hostile conditions, often

Reprints and correspondeicc: Major D S Jackson, CambridgeMilitary Hospital, Aldershot, Haints.* Present appointment: Senior Registrar, Cambridge MIilitaryHospital, Aldershot.tPresent appointment: Consultant Surgeon, Cambridge NMilitaryHospital, Aldershot.

very close to the battlefield, and were bombed by theArgentinian Airforce onI a number of occasions.The lack of suitable buildings, the virtual absence of roads,

the often impassable terrain, and the appalling weatherconditions, all influenced the collection, treatment andevacuation of casualties. These features also influenced thesurgical management of the wounded.

The campaignFrom the surgical point of viewsN the campaign can beregarded as having occurred in two phases.

PHASE ONE

On the morning of 21st May 1982 a number of beach-headswere established on East Falkland in the area of Port SanCarlos, San Carlos and Ajax Bay (Fig. 2).

Mlarine Commandos and Paratroopers were landed,largely unopposed. Field Surgical support for these units wasprovided by the two Field Surgical Teams of the ParachuteClearing Troop of 16 Field Ambulance, and a Royal NavyShip's Surgical Team (SST) drawn from the CommandoNMedical Squadron.An Advanced Surgical Centre was established in a disused

refrigeration plant in Ajax Bay (Fig 1), and dealt withcasualties resulting from the landings and the subsequentbombings of ships in the Falkland Sound and San CarlosWater. In addition, the wounded, following the celebratedbattle for Darwin and Goose Green by the 2nd Battalion theParachute Regiment, were treated at this Centre during 28thand 29th May.

PHASE TWO

WNith the arrival and deployment of 5 Infantry Brigade overthe period 31st May-2nd June, preparations were made forthe next major land battles and the final assault on PortStanley. Two Army Field Surgical Teams designated FST 1and 2, and a Holding Section-vide infra drawn from theirparent unit 2 Field Hospital in Great Britain, in companywith 16 Field Ambulance, provided the Brigade medicalsupport and were to reinforce the Parachute Field SurgicalTeams designated FST 5 and 6, and the Royal NavySurgical Support Team on land.

As plans were drawn up for battles to take the horse-shoe

282 D S Jackson, C G Batty, J M Ryan and W S P McGregor

i%m.:V0I

i.,. , 1FIG. 1 ASC in the disused refrigeration plant at Ajax Bay.

shaped perimeter of mountains surrounding Port Stanley,Field Surgical Teams 1 and 2, their Holding Sections and 16Field Ambulance less their advance party, were embarkedon Royal Fleet Auxillary Sir Galahad in company with theWelsh Guards.The object was to set-up a more proximal Advanced

Surgical Centre (ASC) at Fitzroy Settlement from which theenemy had withdrawn (Fig. 2). In addition, FST 5 wasmoved to Teal Inlet and FST 6 remained at Ajax Bay.However, events altered the planning. With only elements ofFST 1 ashore, Royal Fleet Auxillary Sir Galahad was bombedwith the loss of all surgical equipment. Both teams were re-supplied with a variety of medical equipment gathered fromthe supporting fleet. FST 1 was then sent back to Fitzroywith FST 6 forming a two table A.S.C. as originally planned.FST 2 having survived the bombing was established in therefrigeration plant at Ajax Bay, alongside the Royal NavySurgical Team which remained static.The final deployment of the Field Surgical Teams is

illustrated in Fig. 3.

Field Surgical TeamsField Surgical Teams (FSTs) are essentially highly mobileunits capable of working independently in small groups.They can be rapidly deployed and become operationalwithin 15 minutes of arriving at a location, subject to basicfacilities being available, e.g. buildings, tentage, water, heatand light.Each team consists of a surgeon, anaesthetist, resuscitation

officer, four operating theatre technicians, a blood trans-fusion technician and a clerk (1).The four Army Surgical Teams were organised as shown

in Table I.

HOLDING SECTION

Nursing and postoperative care were provided by holdingsections consisting of trained male nurses and medicalassistants, either from 16 Field Ambulance or 2 FieldHospital.

Pattern of woundingWe comment only on patients operated on land by ArmySurgical Teams. Two hundred and ten cases underwent

FIG. 2 Map of East Falkland.

FIG. 3 Deployment of Field Surgical Teams on East Falkland.

surgery by the four teams during the campaign. In additionFST 2 and FST 5 both utilised the civilian hospital in PortStanley after the ceasefire, and operated on a further 23cases. These included neglected war wounds, mainlyArgentinian, and sadly a considerable number of patients,Service and Civilian, injured by unstable ordnance, un-charted mines and booby-traps.

Several casualties were injured by the accidental dischargeof weapons which included the misfiring of a sidewinder air-to-air missile onto a group of soldiers on the airfield at Port

0

TABLE I Organisation of Army Surgical Teams

From PCT of16 FieldAmbulance

FST 5 Surgical registrar (CGB)Consultant anaesthetistGcneral duties medical officer

FST 6

FST I

From 2 FieldHospital

FST 2

Consultant surgeon (XVSP McG)Anaesthetic registrarGeneral duties medical officer

Senior surgical registrar (DSJ)Anaesthetic registrarDentist with resuscitation training

Senior surgical registrar (JR)Anaesthetic registrarDentist with resuscitation training

TABLE II Analysis of injuries treated by operation

Region Number of cases Percentage

Hcad and nieck 36 140'0Chlest 18 70(Abdomen and pelvis 30 11.5°,Upper limb 68 26.50Lower limb 106 41°,

TABLE III W4'ounding agents

MIissile N^umber of cases Percentage

Bullet 74 31.8%f'ragment 105 45°0Mine 25 10.80),Unclassified* 29 12.400* Uniclaissificd: includes secondary missiies, road traffic accidents, sidewindermissile.

Stanley on 13th July 1982. Table II gives a breakdown byregion of the surgical operations performed by the fourteams. The figures do not include the many patients whopassed through the units with a variety of conditions requir-ing treatment but no immediate surgery. These also includedseveral types of cold injury (immersion foot, trench foot, andfrost-bite), a variety of medical problems and more signifi-cantly numerous burns cases, resuscitated before evacuationto the Burns Unit on SS Uganda. FST 1 and 2 and 16 FieldAmbulance, as has already been mentioned, were involvedwith the immediate resuscitation of more than fifty burnscases resulting from the bombing at Bluff Cove.

Table III provides an analysis of the wounding agents andthe breakdown is as expected and correlates well with theresults from more recent conventional wars (2-6). Thisanalysis is quite unlike those reported from Northern Irelandwhere bullets cause a higher percentage of the wounds (7).

Casualty managementThe vast majority of casualties were received by helicopter asthe only effective method of transport (5-8). It is worthnoting, however, that particularly after the Bluff Covebombing, many casualties walked considerable distances.The mobility of Advanced Surgical Centres precludes a

large holding capacity. Thus to avoid being overwhelmedwith cases the ASC's in the Falklands dealt mainly with themost severely injured. These Priority One and Two Cases(Table IV) were immediately resuscitated, operated uponand quickly evacuated rearward, often within hours ofsurgery, by air onto the hospital ship SS Uganda whichfunctioned in this case as a General Hospital.

The Falklands War: Army Field Surgical Experience 283

TABLE IV Priority of treatment

Priority one Priority two Priority three

Require immediate Require resuscitation Require noresuscitation and/or and early surgery. resuscitation andimmcdiate surgery delayed surgery.

The majority of wounds were caused by high velocitymissiles. All wounds, therefore, were presumed to be heavilycontaminated as a result of the cavitation efflect of thewounding agent (9). Treatment was by accepted surgicaltechniques (1).On arrival at a centre patients were resuscitated using a

variety of intravenous fluids, Hartmann's, plasma expandersand whole blood. The airway was secured, endotrachealintubation being carried out if necessary. Tetanus toxoidbooster and benzyl penicillin were given to all exceptcases of known hypersensitivity to the penicillin group ofdrugs. In addition, head wounds received sulphadimidine,and patients with abdominal and pelvic wounds were givenmetronidazole and either ampicillin or a cephalosporin.An operating list was compiled by the resuscitation officer,

anaesthetist and surgeon working together, though each ofthe casualties was continuously reassessed in accordance withthe dynamic nature of the triage system, leading to frequentalterations of the list, depending on their changing clinicalconditions (1). The response of each casualty to resuscitationwas carefully monitored, and on occasions, in cases of severemultiple injury, immediate surgery was used as part of theresuscitative procedure.

In cases of limb injuries, entry and exit wounds wereincised along the axis of the limb. Wide fasciotomy waspractised, often including muscle compartments not seen tobe involved. Skin was preserved as far as possible butsubcutaneous tissues and dead muscle were widely excised,until the latter demonstrated healthy bleeding and con-tractility. Comminuted fractures were treated by lavage,removal of detached small fragments, approximate reduc-tion and maintenance of bone length, and external POPsplinting over well padded loose dressings.Damaged tendons and nerves were marked wherever

possible by silk sutures for secondary repair. Only importantarteries and veins were repaired or vein patched (femoral,popliteal, brachial). Limbs beyond salvage were immedi-ately amputated at the lowest possible level through healthyand uninjured tissues. Skin flaps were left long and bone endscovered by myoplastic flaps loosely approximated. A guil-lotine method was used when time was short. All woundswere loosely dressed and left open for delayed primaryclosure on the hospital ship (3,9).Abdominal and pelvic penetrating wounds were all

explored and presented major clinical problems; however, anumber of abdominal wounds were tangential and did notenter the abdominal cavity. These patients did not havelaparotomies at the advanced surgical cerntres, but wereevacuated rearward with the knowledge that some mightwell come to laparotomy by virtue of the indirect injury toabdominal contents which may be caused by high velocitymissiles (4).

At laparotomy a long mid-line incision was employed forwide access and arrest of haemorrhage was the immediatepriority. With injuries to the small bowel it was common tofind multiple perforations and lacerations caused by a singlemissile, in addition to severe mesenteric haemorrhage (4,9).Small bowel perforations were dealt with by marginalexcision and closure, or by segmental resection and end toend anastomosis. Colonic injuries which reached theAdvanced Surgical Centres were few in number. Those ofthe right colon were treated either by marginal excision withsimple closure or hemicolectomy and anastomosis. Wounds

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284 D S Jackson, C G Batty, J M Ryan and W S P McGregor

of the left colon usually involved bowel resection and acolostomy with mucus fistula, or repair with proximalcolostomy, combined with generous drainage, or exterior-ization of the injured segment.

Liver wounds were inevitably low velocity (3,9). One caseof hepatic injury was treated by wound excision, lapar-otomy, marginal liver resection and haemostatic repair withdrainage. The biliary tree was repaired and ducts splintedwith drainage.

Chest injuries presented few problems. Patients with chestwounds were largely self selecting (4). No patients withmediastinal involvement reached surgical help alive in thisseries. Most of the wounds were peripheral or tangential, andbecause of the lungs peculiar resistance to the cavitationaleffect of high velocity missiles did not require formal thora-cotomy (3,9). Excision of the wounds along conventionallines, followed by tube drainage, was the standard treatment.Only 6 thoracotomies wtre carried out and these in cases ofpersistent haemorrhage and massive pulmonary injury. Also1 of our chest wounds had a large defect posteriorly resultingin a sucking wound. Here thoracotomy was followed byswinging a large muscle flap to cover the defect.

Casualties with serious wounds of the head and neck werefew among the survivors. Almost all high velocity penetrat-ing wounds are immediately fatal (9).Our cases on the whole suffered from low velocity injuries.

The small number of survivors from high velocity missileshad tangential wounds resulting in compound skull frac-tures, severe soft tissue loss and brain destruction. Unlikeother wounds, head wounds were closed, dural defects inparticular being covered, and in one case a rotation flap wasused.

Maxillo-facial wounds were only dealt with by theAdvanced Surgical Centre when they presented an airwayproblem. Tracheostomy was carried out with minimal fur-ther attempts to deal definitively with the wound in 3 cases.No attempts were made to remove the wounding fragments ifthey were not obvious or easily accessible.

It should be emphasized that only life and limb savingsurgery was carried out at this level, and thus our work in away was greatly simplified. The extensive problems that willfollow, such as those of reconstructive surgery were notconsidered and are beyond the scope of this report. Post-operatively casualties were held for as short a time as possiblecompatible with the nature of the surgical procedure and theavailability of helicopter transport. Rearward evacuationtook place from 1 to 36 hours after treatment and was to thehospital ship SS Uganda. The maximum flight time from themost forward surgical centre (Fitzroy) was approximately 40minutes, and our casualties tolerated this extremely well.

ResultsThere were 3 deaths and details of the cases are given inTable V. The figures only reflect the immediate mortality. Itis beyond our scope to deal with the long term results though

TABLE V Details of 3 deaths

Cause of Time ofAgent Site of injury death death

(1) Bomb blast Small intestine Haemorrhagic 14 Day post-opfragments Inferior vena pancreatitis on SS Uganda

cavaPancreas

(2) Gunshot Head Gross brain 24 Hourswound damage postopera-

tively onSS Uganda

(3) Anti-Tank Pelvis Uncontrollable Died onmine Perineum bleeding. operating

Both legs Massive table attissue loss Fitzroy

it is hoped to present these in a later study. We are, however,happy to record ihat no further deaths have occurred (to thisdate) following evacuation and repatriation.

DiscussionSited as they were on East Falkland, the four Army Teamsfunctioned as Advanced Surgical Centres& This was necess-ary because of the manner in which the battle was conductedand the difficult terrain. Surgical facilities further to the rearwould have posed insurmountable problems in casualtyevacuation as helicopters were in short supply, had a limitedload carrying capacity and many had no night flyingcapability.

Conventionally, casualties having been initially treated bytheir Regimental Medical Officer at the Regimental AidPost, are evacuated rearward by road or air to a FieldAmbulance. Here resuscitative measures are checked andcontinued and casualties sorted, such that the most seriouslyinjured are preferentially further evacuated by air, road orrail to a well equipped Field Hospital. Advanced SurgicalCentres short circuit the chain but are less than ideal inmany respects. The equipment is basic, though adequate,and is geared only to life or limb saving surgery.

It is tempting to draw comparisons with reports fromother Campaigns (2,5,7,10-14). However, there were as-pects of this war which makes direct comparison difficult. InVietnam the American Surgical Services were all permanentinstallations, on a grander scale with sophisticated labora-tory and diagnostic equipment available. Specialist teamswere on hand to deal with regional injuries. Thus headwounds were dealt with by neurosurgeons and chest woundsby thoracic surgeons (3).The reports from the Yom-Kippur War show that the

Israeli Armed Forces are provided with echelons of medicalcare similar to those planned by the British Army MedicalServices, with surgical facilities usually well back at the 3rdechelon (15).

- However, their lines of communication were short withsome civil base hospitals close to the fighting. This is also trueof Northern Ireland. In the Falklands War the difficulties oflogistics, transport, communications, terrain and badweather necessitated the tactical advancement of the surgicalfacilities available, in order to provide adequate surgicaltreatment for the casualty as close as possible to the point ofwounding in both time and distance.Not since Anzio in 1944 have surgical teams worked in

isolated groups on a beach-head with small advanced sur-gical centres close to the fighting, with only basic equipmentand with ships functioning as base hospitals (16). Theconcept of the ASC is not new (13). It worked well. Itprovides surgical care, basic at best, at a forward level and isaimed at those patients who would have otherwise died if theconventional approach to surgical support had been adop-ted. It is worth commenting that no insurmountable clini-calproblems were encountered by the surgeons, most of whomwere of junior hospital doctor status. Only one consultantworked at an Advanced Surgical Centre (WSP McG). Thetraining of surgeons in the British Army includes time spentin all major surgical specialities in addition to the normaltraining in general surgery. Most of us approached theconflict with a certain amount of apprehension concerningour ability to deal with the widespread range of clinicalproblems we would encounter, though previous service inNorthern Ireland undoubtedly provided a framework ofexperience. In the event there were no particular difficulties.The thoracic problems we encountered should all be withinthe competence of a general surgeon, though neurosurgicalinjuries posed difficulties. However, we feel that a neuro-surgeon, whilst needed in a Field or Base Hospital has noplace with a Field Surgical Team in an Advanced SurgicalCentre.The extremely low mortality experienced by us deserves

comment. With very few exceptions our patients were

The Falklands War: Army Field Surgical Experience 285

evacuated from close to the point of wounding by helicopterand taken directly to resuscitation and subsequent surgery,either at an Advanced Surgical Centre or to the DressingStation of 16 Field Ambulance which had an advancedsurgical centre co-located with it (FST 1 and 6). TheDressing Station provided a useful filter, treating the minorwounded and passing on Priority I Casualties to the Surgicalfacility. Evacuation times, however, from wounding tosurgical care varied considerably from several minutes toseveral hours, and though most patients reached surgeryquickly, there are many reported instances of considerabledelay particularly following night battles because, as hasalready been mentioned, not all helicopters could fly atnight. On several occasions casualties were brought to uswho had been wounded at the start of the night battle, andhad waited all night on the mountains for evacuation at firstlight. It is likely, therefore, that some of the more seriouslyinjured died before evacuation was possible thus paradoxi-cally improving our survival figures at the surgical centres.However, in contra-distinction, a very short evacuation timepresented us with a live patient who had received woundswhich inevitably would and did prove fatal (Table V,patient 3).

Argentinian casualties presented a significant group and itis sad that we have no information on their fate. Most weretransferred to Argentinian Hospital Ships from SS Uganda.The final common pathway for all our cases was to the

hospital ship SS Uganda. We are very grateful to ourcolleagues of the Royal Navy who ran this floating hospital,and who absorbed casualties directly when the AdvancedSurgical Centres were overwhelmed, particularly forexample with the burns cases after the Bluff Cove bombing.Without them the Advanced Centres would have beenflooded and thus rendered relatively ineffective.

The authors would like to thank Colonel R. Scott M Ch FRCSProfessor of Military Surgery and Major General W. Pryn OBE

FRCS Director ofArmy Surgery for their help in the preparation ofthis article and Mrs D Brockley for the preparation of themanuscript.

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The Annals, November 1983, volume 65 No. 6Contents of the forthcoming issue will include papers on: Vaginal reconstruction using a pedicled graft of sigmoidcolon; reconstruction of the oesophagus; invasive breast cancer; a comparison of the experience of undergraduatestudents in peripheral and teaching hospitals; a study on the need for drainage following cholecystectomy; a hip cast-brace for hip prosthesis instability; a study, in an Indian general hospital, of the place of antibiotics in preventingwound infection after a clean operation.

In the historical section there will be articles on the history of scrotal cancer and on the life of Sir Benjamin Brodiewho was born 200 years ago in 1783.