The Progression of Trauma Care and Surgery after the Ring of Fire, Part 1


From Wiki: From Greek τρώυμα = “a wound,” compare verb τιτρώσκω (stem τρω-) = “I injure”

A number of stories in canon depict serious injuries and deaths resulting from trauma, but I don’t recall any specific articles, and few stories, covering the care of injuries either under austere conditions generally or in the New Time Line (NTL) specifically. In this article, I will include a number of references to stories in canon, to Wiki, and to professional articles and textbooks that cover some topics in more detail than practicality allows including here. I am also working on an addendum to be posted on the 1632.org site, with pictures and diagrams of various instruments as a resource for other authors.

I dedicate this series of articles to my first medical instructor: my mother, Darlene (a Diploma RN, 1951) who taught me how to give a bed bath and change the bed under the patient, even for patients in skeletal traction.

My thanks to Danita, Kerryn, Stanchem and Nimitz Lover for off bar advice, suggestions, and requests for clarification. Any errors of omission or commission remain mine.

The State of the Art in AD 2000

Here in the US, we've chosen to use a pyramid approach to treat trauma, where the doctors are usually centralized in hospitals, taking care of other patients when not working on a trauma patient. Other people, at various levels of training, occupy lower areas of the pyramid, seeing the cases earlier, usually in the field. Therefore, the first trained personnel to encounter most serious trauma patients in OTL are often among the lowest-paid and least-trained professionals (or volunteers) in the system, known as first responders. First responders open or maintain the trauma victim's airway so they can breathe adequately. If the victim is not breathing, they provide breaths through any one of various methods of artificial ventilation. If the victim's heart is not beating, first responders may perform compressions to promote circulation. They also control or stop bleeding and transport the patient to the hospital for definitive care. These steps are essential for the trauma victim's survival because they preserve brain and organ function before arrival at the hospital. While there has been much discussion in Old Time Line (OTL) about “the Golden Hour” and the “platinum ten minutes,” over the last thirty years, we’ve found that these are more guidelines for aggressive transportation, rather than hard limits on survivability. I will also point out that not all trauma requires an OR visit. For example, the casting of broken limbs, initial care of moderate or even some severe burn patients, and watchful waiting on many closed head injuries (CHI) all don't require immediate OR time. That being said, severe trauma is a condition that can only be treated in the operating room, and only temporarily handled in the field or even the Emergency Department (the ED, also known as Accident and Emergency—A&E—in the British system). Other countries, particularly France, Germany, and to a lesser extent Spain, have physicians and nurses responding directly to the accident site in the ambulance. This is practical in Europe because of the much smaller distances generally involved. I know of no study that shows an advantage either way.

Trauma—1 Team, 1 Goal

In the OTL, definitive treatment of trauma is a well-established surgical specialty. Most practitioners are true general surgeons, capable of both handling surgery in any major body cavity, including at least basic brain surgery, and of providing the intensive care needed in the vital hours, days, and weeks following that surgery. Most major trauma centers maintained at least one surgical team available on short notice—usually within minutes. The head of a team is an Attending Surgeon[i] or a Trauma Fellow[ii], and such a surgeon was expected to be “in-house” and available 24 hours a day, seven days a week, 52 weeks a year. Along with the surgeon leading the team, major centers generally keep multiple residents, fellows, and specialists of all types on staff, all available on short notice around the clock. Additionally, specialized equipment such as CT scanners, ultrasound scanners and “Cell Savers” (equipment to salvage blood that has been lost inside the body) are found in these major centers.

Ideally, critically injured patients barely stop in the ED on the way to the Operating Room (OR) or specialized care unit (e.g. the burn center), but this often isn’t done. Frequently, the surgery suite is in use or a needed subspecialist is not immediately available. Initial resuscitation has to take place, in such cases, in the ED’s trauma bay. Such first treatments might include putting tubes or probes in all natural and often several unnatural openings of the body, or even surgically opening the chest or abdomen in an effort to control severe bleeding. These trauma bays are stocked with the appropriate sizes of equipment most often needed—for example, some facilities specialized in pediatric trauma have a larger selection of the smaller instruments needed to handle children. The first mobile Computed Tomography (CT) scanners were appearing in 2000, allowing the machine to be brought to the patient, saving time and reducing problems moving the patient.

Hot and cold running residents are not always available.

Smaller trauma centers depend on surgeons who are on call but do not stay in the hospital. Those facilities utilize experienced physicians, usually certified in one of the general medical specialties (either Emergency Medicine or Family Medicine in the US, often Anesthesia in other areas of the world) to lead the center’s trauma team as part of their duties in the ED.

Depending on how badly a patient is injured, and what other specialty physicians are available at the facility, these centers may or may not transfer major trauma cases to larger facilities. Most of these facilities have fixed CT scanners in the ED, so that the patient does not have to leave the department to be scanned. Both critical trauma and medical patients could be treated in these centers’ emergency departments, which usually include at least one room with a cart with specialized pediatric equipment.

Rural and small town hospitals may not have a surgeon around all the time.

The smallest facilities may not have a surgeon on call on a regular basis, and will have to transport any major (and even some relatively minor) trauma patients to a larger facility for further care on an urgent basis. Recommendations for many smaller facilities included consideration for direct transfer, often by helicopter ambulance, for seriously injured patients, bypassing the smallest facilities and taking the patients directly to a large trauma center.

See One, Do One, Teach One

While learning the care of severe trauma is a years-, even life-long, process, there are courses available to introduce physicians, nurses and paramedics who are not trauma specialists to the systematic care of trauma patients. These include:

Advanced Trauma Life Support (ATLS)

Trauma Nurse Core Curriculum (TNCC)

Anesthesia Trauma and Critical Care (ATACC)

Basic Trauma Life Support (BTLS)

International Trauma Life Support (ITLS)

The US Department of Defense Combat Casualty Care Course (C4)

The C4 program includes ATLS for physicians (and physician extenders like Nurse Practitioners (NPs) and Physicians' Assistants (PAs) and TNCC for nurses. Please note that while NPs generally have collaborative but independent practices with physicians, they are still considered as physician extenders by the American College of Surgeons as far as the ATLS certification is concerned.[iii]

Any family medicine physician who wants to work in the ED or even to practice in a rural area will most likely have taken ATLS[iv]. Similarly, the TNCC course is recommended for any nurse wanting to work in an ED or a trauma ICU. Any physician, dentist or nurse with more than three years of (US) active duty military experience[v] will probably have taken the C4 course during that time. These courses, of themselves, do not qualify a physician or nurse to perform major surgeries, but instead gives them a good basis for starting treatment, and the knowledge to provide immediate life-saving care involving critical airway and chest injuries. I expect that Drs. Adams and Shipley will have taken ATLS in the years just before the Ring of Fire (RoF), Drs. Sims and McDonnell may have taken ATLS in the late 1970s or early 1980s, and that at least Mary Pat Flanagan may have been exposed to TNCC before the RoF. I have not found any evidence in canon that this was the case, but based on my experience in the ED during the 1990s, I believe it is likely.

Major surgeries associated with trauma care range from the short procedures best described as “damage control,” to hours-long reconstructive procedures. Aseptic (without infection) conditions are the norm in surgery and later care OTL. Frequently, further surgeries and treatments work together to help the patient heal fully or to address areas that could not be safely dealt with until the patient was more stable. These may range from an assortment of powerful antibiotics to high-technology instruments that monitor a patient’s condition. Life support can include everything from a ventilating machine that can breathe for a seriously injured patient to a specialized bed that helps prevent bedsores. Skin, bone, muscle and even digits can be re-implanted, transplanted, or grafted to repair or replace missing parts. Powerful anesthetic and analgesic drugs are available to allow the most seriously injured patients rest while intravenous or tube feedings prevent dehydration and malnutrition, provide routes to administer medications and allow healing to continue. This is the general pattern for trauma care in the US and Canada, and, with a few modifications, true in the rest of the developed world.

What can be done immediately after the Ring of Fire?

The complex and comprehensive care taken for granted in the developed world is not available in most of the world in OTL. This state of affairs will most likely be true in the NTL at least through the late 1640s or even the mid 1650s, due to the need to develop both the physical plants and the medical infrastructure out of the ruins left by the “Fifteen Years War.”

In OTL, outside of the U.S., Canada, Europe and other developed countries, complex and comprehensive care is usually limited to a few large hospitals in major metropolitan areas. People with major injuries in other areas of those countries, or even in metropolitan areas after a disaster, will receive care that is much more limited. As we shall see, “limited care” does not mean bad care, or even a bad result.

Canon shows that work on the Leahy Medical Center was the major construction project started in 1631 after the RoF, as Mike Stearns and company realized that the lack of an operational medical facility was a potentially disabling problem for the community. Leahy Medical Center (LMC) is in canon as operational by late 1632, when overtures were made to the medical faculty in Jena for a cooperative education effort. This leads in turn to the program now turning out advanced midwives, Bachelors of Science in Nursing (BSN)[vi]and Doctors of Osteopathic Medicine (DO) by sometime in 1634. Some of the equipment for Leahy’s operations and the Jena joint effort will be transferred from the physicians' offices, some from the veterinarian's offices, some from the nursing home, but many more instruments and devices will be made down-time, out of sheer necessity.

Trauma care in the NTL, before the establishment of the Leahy Medical Center, will be similar to that seen during the recent earthquake in Haiti or the floods in Pakistan—simple, even rough, and much more concerned with saving a life than saving a limb. Even after the establishment of LMC, only those patients fortunate enough to end up at LMC will benefit until other facilities open up.

The experience of Drs. Ellis, McDonnell and Sims during the middle years of the twentieth century will help the only fully trained surgeon, Dr. James Nichols, bring other physicians to the point of being able to handle all the surgery that is practical between the RoF and at least 1637. It should be recognized that all three of the older physicians will die by 1637, according to the Grid, which does put a premium on their remaining life spans.

By 1637, there will be New Model medical schools at Jena and Padua, as well as the New Model hospitals—at minimum in:

Grantville

Magdeburg

Bamberg

Essen

Jena

and probably in Padua and Venice, but in time, there will be others. These hospitals and medical schools will not only teach a fusion of up-time and down-time information, but will also start new medical research to further extend medical knowledge. It is in canon that by November 1634, the new hospital at Jena is capable of handling major trauma and burns.[vii]

An important point here: Dr. Nichols was trained during an era when a general surgeon was expected to be able to operate safely in any area of the body, at least enough to provide life-saving care in almost all conditions. The three older doctors, while not surgeons, were trained in an era when rural general practitioners were expected to handle basic surgeries and orthopedics as needed. I will explore many of these operations later in this series.

The initial limitations of surgical techniques will revolve around the lack of trained personnel, lack of instruments, lack of medications, (safe and titratable analgesics, muscle relaxants, and sedative agents) and lack of equipment (especially anesthesia equipment), but most importantly, the lack of a safe, clean place to operate. The older doctors probably remember the efforts of Josep Trueta i Raspall, MD—a Catalonian orthopedic surgeon who took the lessons from WWI and developed them into a consistent framework involving careful debridement, limited closure and long-term dressings with plaster cast immobilization of horrendous wounds during the Spanish Civil War. There is a fair chance that the older physicians had experience with these techniques during their training and practice in the late 1930s, 40s and 50s. There is also a good chance that Dr. Nichols will have learned some of those techniques while he was in surgical residency, since it is guaranteed that his older professors had experience with those techniques during WWII. Beulah McDonald should also be familiar with them, as these techniques were part of nursing training at the time and she would have used them in Korea.

These techniques are still used today by surgical teams from the International Committee of the Red Cross/Red Crescent and Doctors Without Borders who work in areas affected by major disasters. I have included links to PDFs available from the International Commission of the Red Cross/Red Crescent Societies covering much of this information.

Despite the Trueta method, the lack of vascular repair will increase the number of amputations markedly[viii]with up to half of the patients needing ligation of a major artery requiring eventual amputation. This is five to ten times the rate seen in OTL, especially as the art of trauma surgery has evolved with the current war on terror. We had recognized, after Operation Desert Shield/Desert Storm (1990-91), that limiting IV fluids and using tourniquets to stop severe bleeding was actually very effective at saving lives. However, direct pressure on the wound remained the quickest and safest method of bleeding control. Mary Pat Flanagan and David Dorrman would have been aware of these details, even if Dr. Nichols was not.

We already know that up-timers with varying degrees of training have overcome many of the obstacles to surgical training, since Dr. Nichols' daughter, Sharon, who was trained as an EMT with a BS in Biology (Magna Cum Laude, WVU 1999?) before the RoF, was able to master the techniques abdominal surgery well enough to save “Filthy” Sanchez after he was gut shot in 1634[ix]. Tom Stone was able to make it back from Padua to provide the open cone anesthesia, and provide Sharon with some light relief. Canon also mentions several industrial accidents, as well as combat injuries, that result in amputations[x], paralysis[xi], severe burns[xii]and other disabilities, where the patients probably would not have survived without the efforts of the up-time medical team. Beulah and Mary Pat saved the life of the young printer Veit when they first got to Jena, by inserting a chest tube to relieve a collapsed lung and tension pneumothorax.[xiii]As life-saving as this action was, it almost sank any chance to work with the Jena medical faculty, because of the embarrassment of the up-time, female nurses saving a patient that the down-time male doctors would have had to watch die.

Dr. Trueta's work, on the other hand, was more involved with salvaging horribly damaged limbs, and to this end, he developed a network of fixed, mobile and railroad hospitals during the Spanish Civil War of the late 1930s. His philosophy of debridement, loose closure, and sterile dressing followed by a long period of supportive plaster casting was responsible for a marked reduction in the infection and amputation rates for horrendously injured limbs. He was able to show, in an era before effective antibiotics, that it is often more important not to disturb the healing wound with dressing changes than it is to observe the healing wound for signs of infection. This technique was well-documented in the surgical textbooks written during and after WWII, and so should be available to Dr. Nichols even if he didn't learn about it during residency and the older doctors do not have direct experience with it.[xiv]This was something that was being gradually rediscovered in the 1990s, as more problems were being noted with infections resistant to standard antibiotics. I will discuss this more in Part 2.

Basics save Lives.

The basics of trauma care are surprisingly easy to teach: every US soldier and Marine has received this “buddy aid” teaching for years, culminating in the combat life saver course that was developed in the 1990s. The important steps are remembered with the mnemonic “ABBCDEE”: open the Airway [with cervical spine (neck) control], start the Breathing, stop the Bleeding, start the Circulation, evaluate for neurologic Damage, Expose the wound and Evacuate the patient. An experienced medic should be able to identify all of the immediate life threatening problems in a field situation in less than two minutes, given decent light. More importantly, this same experienced medic should be able to determine in less than one minute if the patient is treatable within the capabilities of the situation, or if the patient will die despite the medic's best efforts, a technique called “triage,” from the French word for “sorting.” It is important to note that children can be taught the basics of CPR and first aid, and babysitters often take a more advanced first aid training class, as do many lay people. Thus, there will be a fair number of people with that knowledge to spread.

Not every victim can be saved.

Based on my experience both doing and teaching triage, this is one place where the down-timers training as medics, nurses and physicians will have a definite advantage over their up-time counter parts, since most of the up-timers will have a desire to help no matter what the circumstances. That being said, just the use of paramedical personnel trained in the up-time methods will improve combat and field medicine. It is in canon that several groups of soldiers and sailors have taken the new EMT program, in addition to up-time trained EMTs who were first deployed by the NUS/USE government. These troops would have been trained not only in trauma stabilization but also in a broad base of core knowledge in the areas of medicine, pediatrics, obstetrics, sanitation and communications. Just having personnel on the battlefield who know the life-saving skills of stopping the bleeding, ensuring ventilation, splinting fractures and reducing infection will be a qualitative force multiplier. By reducing the troop losses from various infections, and by increasing the morale levels of the troops (since they know that one of their buddies is there to take care of them if they are wounded, and that they will not be left to die, alone, and in agony), [xv]the units will remain more cohesive and more effective. Canon shows that a number of the up-time EMTs died due to combat or disease by December 1635.

For the want of a horseshoe nail

Of the 3500 folks transported to 1631 by the Ring of Fire, fewer than 100 had substantial and systematic medical training and education. A number of others had training as emergency first responders (police officers, firefighters, some of the mine employees) or in basic first aid (teachers, childcare workers). Active, up-time physicians included:

James Nichols, MD (born 1947, Surgeon, probable residency graduation 1979 to 1981 due to his time in the service)

Susanna Shipley, DO (born 1963, Family Medicine, probable residency graduation 1992)

Jeff Adams, MD (born 1962, Family Medicine probable residency graduation 1991).

As a baseline for comparison, despite being older than either Dr. Shipley or Dr. Adams, I would have been in medical school only a couple of years ahead of these two, because I spent four years in the Army as a medic between college and medical school.

Three older physicians:

Henry Moss McDonnell (1925-1636),

John Thompson Sims (1921-1637), and

Emery Ellis (1919-Dec 1634)

come out of retirement to help provide care for the community. There is also Mr. John Daoud, who has some training as a chiropractor. His background in manual therapy will prove particularly helpful to the rehabilitative medicine teams. Dr. Nichols was visiting for the Stearns wedding, so he does not have his personal library along, and no mention is made of him being enough of a technophile to own a PDA, much less have a substantial library hidden on one.

Dr. Sims' son is one of the two dentists, with the other being Jaroslav “Jerry” Elias. There are two veterinarians, Les Blocker DVM (1946) and Bentley Alexander DVM (1961), both of whom are in active practice; however, Dr. Alexander's office is a partnership left in up-time Fairmont.

Up-time educated nurses include:

Beulah McDonald, RN, BSN, US Army Nurse Corps veteran (Korea), now teaching midwifery and acting as the Dean of the College of Nursing and Associated Medical Arts— she is effectively in charge of the new medical curriculum. (B: 1930. Probably received her diploma in 1950. She had also started a nurse-midwife program but stopped as she was close to retirement and thought she was too old.

Garnet Szymanski, RN, BSN, now one of the Nursing Supervisors for Leahy Medical Center, as well as teaching LPN courses at the Vo-Tech. (B: 1947, date of graduation probably 1969)

Mary Pat Flanagan, RN, BSN, US Army veteran as an enlisted medic (with a tour in the Balkans and a Bronze Star for her actions under fire in Somalia[xvi]) and up-time trained as an LPN/91 C (advanced military medic). In her final year of a ROTC LPN to BSN bridge program when caught by the RoF, she is teaching the combat medics and acting as assistant to Dean McDonald. (B: 1971, graduated 1631 based on previous work)

Hendrickje “Henny” Kiers (De Vries), RN, has a substantial background in psychiatric nursing, and is a supervisor/instructor at Leahy Medical Center until her move to Copenhagen in 1635. (B: 1943, graduated in the early 1960s)[xvii]

Inez Wiley as a “Craft Midwife” and daughter and granddaughter of Craft Midwives.[xviii]

Darla (Wild) Bowers as an office trained practical nurse, also a Craft Midwife.[xix]

Kourtney Pence is shown as a Midwife in 1634[xx]

Anne Jefferson, RN, MSN, is setting up a de facto medical practice as a NP in Amsterdam. (B: 1972 Listed as having an MSN from Johns Hopkins, as well as course work toward a PA in critical care obstetrics.[xxi]Probable graduation around 1998)

Mary Pat had a fair part of her library with her, as she was going to do a rotation in Community Health after the wedding.

As another baseline for comparison, my mother, born 1931, graduated from her diploma nursing school in 1951, and my ex wife, born 1969, graduated from her LPN program in 1988.

There are a number of others with at least an up-time EMT certificate. Please see the Grid for other names.

Good Drugs always help!

Pharmacists and pharmaceutical chemists are also scarce, with just three pharmacies in Grantville.

Tom Stone is listed as having a Masters in Pharmacy, with work towards his PhD in that same field, as well as much practical experience. Bill Hudson, one of the up-time EMTs, goes to work with Tom Stone when the two of them return to Grantville.

Tino Nobili (1940) is the owner and pharmacist for Nobili's Pharmacy.

Trelli's Good Care Pharmacy went out of business and was absorbed by the Leahy Medical Center in 1635 when the owner and pharmacist, Lazare Trelli, had a stroke.

Raymond Little (1960), previously a partner in Moss & Little's Cut-Rate Drug Store, moves to Leahy Medical Center to run that department using equipment from Trelli's.

John Moss (1949) continues the Cut-Rate Drug Store, and agrees to take the apprentices from Trelli's into his teaching.

Up-time medications quickly run out. Trelli’s pharmacy had equipment for compounding and pill-forming, which can be used to supplement available down-time equipment in providing safe medications.

Senior Chief Hospital Corpsman David Dorrman is assigned as the NCOIC of the hospital at the Naval Yard. [xxii]He's also the closest thing available to a medical examiner, working with the Provost Marshal's Office, including NCIS, the Shore Patrol and the Marine MPs in Magdeburg.

Preventing the loss of the battle.

Despite the paucity of fully-trained up-time medical personnel at the time of the RoF, there are thousands of down-time medical workers, from classically-trained physicians to herb-wives, many of whom will be interested in learning the up-time methods. In turn, these down-timers will teach up-timers the effective points of down-time medicine.

Among the down-time physicians and surgeons already canonized are:

Scultetus—German, known as the surgeon at LMC to have work on you if Dr. Nichols was not available.

Balthazar Abrabanel—one of the first down-timers to meet the up-time people, and the first down-timer to be saved by up-time methods[xxiii]

Gerhard Eichhorn—German, a barber surgeon working with Essen Chemical and the Antonites and involved in development of penicillin.[xxiv]

The Reverend Bartholomew Wesley, MD and his wife, Anna, who is a midwife, move to Amsterdam just ahead of a King's Warrant, and participate in the defense of that city. [xxv]

There are some Jena-trained surgeons are in canon as of May 1634[xxvi]in Torstensson's army outside of Ahrensbök. These would have to be down-time personnel, either physicians or barber-surgeons, who have been “taught up to speed.” In particular, a Dr. Dietrich Weiss is mentioned as having saved Anse Hatfield's life, along with most of his left hand and arm.

Additionally, a Dr. Jensen complains that one of the field medics is being called “Doc” by the troops he is working with. While Dr. Jensen has spent six months working at LMC to learn the uptime techniques,[xxvii]he obviously had little experience with the military, and was quickly quashed by the field commander.

Nicolaes Tulp, a Dutch surgeon and politician, not yet in canon, could be interesting for the author who chooses to use him, as he was one of the Amsterdam city magistrates after 1622, and mayor of that city for four terms, beginning in 1654. In OTL, he was the subject of Rembrandt's 1632 painting, The Anatomy Lesson of Dr. Nicolaes Tulp, one of the works that was changed by the butterflies, as evidenced by the cover of Grantville Gazette IV.

Thomas Bartholin, one of several medical scions of the noted Danish surgeon and anatomist Caspar Bartholin, would be entering medical training in OTL in the mid 1630s. That would make him a natural to attend the up-time influenced program at either Jena or Padua. Other Bartholin family members also entered the profession. Other notable down-time physicians available include Peter Spina and his progeny. William Harvey is already in canon. There are many, many others.

Important predecessor physicians and surgeons to this era would include:

Caspar Bartholin the Elder, known in OTL both for a duct under the tongue, and a standard anatomy text of the time.

Abu Alī Sīnā (980-1037), more commonly known as Avicenna, and for the Canon of Medicine, one of the seminal works of medicine and surgery

Theophrastus Paracelsus (1493-1541), whose writings started to replace Galen as the ultimate source of medicine. He is the claimed ancestor of Herr Doktor Gribbleflotz.

Ambroise Paré, 1510-1590, a barber surgeon known for more humane battlefield medicine, ocular and orthopedic prosthesis

Hieronymus Fabricius (1533-1619), a gifted anatomist who first described the technique of tracheotomy, a life saving operation to open the airway when nothing else will work.

A Cast of Thousands

If the up-timers are limited, and the traditional down-time MDs are relatively rare, often hazardous, and almost always expensive, the numbers of midwives, herb wives, barber surgeons, bone-setters and hedge—or horse—doctors were literally legion. We have some in canon already, including the midwife Greta in Magdeburg, who has taken up-time training, and is proving to be the bane of her less-scrubbed counterparts.

Herr Dr. Gribbleflotz has had a number of appearances reproducing up-time medical compounds for the benefit of his pocketbook and the community.

My shared characters in canon include:

Katharina Schrey is working with the Sanitation Commission as a quarantine house attendant while she is attending the BSN course[xxviii]. She expects to enter the DO program at Jena when she has her BSN.

George Lenkert, her husband, also works with the Sanitation Commission, and has completed EMT training.

Caspar Weybrecht has also completed EMT training, and will be starting in the Jena BSN/DO program in 1636.

Anna Krause is a couple of years behind him in school, but she is already in canon as the first geographic epidemiologist. She is also planning to attend the program at Jena.

Kerryn Offord and Danita Ewing were both kind enough to send me copies of information posted much earlier on the Bar from H.W. “Butch” Clor and Danita, laying out the expected progress of medical training down-time. Updating this material will become part 4 of this series.

Success has many fathers and mothers.

Medicine had many significant influences between 1632 and 2000, including many physicians, nurses, and educators, with various therapists and paramedical personnel coming in after 1970. Anatomists and surgeons in particular made major advances that paved the way for modern surgeons, starting with an increase in teaching human anatomy by direct dissection. There were two major problems with this: first, the lack of proper preservation of said bodies, which meant that there was only a short time each body could be used and second, the relative lack of usable bodies, since the only ones available were supposed to be those of executed felons. The change from execution to transportation as a sentence for many crimes lead to a marked decrease in the supply of bodies. This occurred even as the demand for fresh bodies went up. The increase in demand lead to the Burke and Hare murders[xxix] (to supply Dr. John Knox) and the only somewhat less unsavory activities of Dr. John Hunter in London as he “acquired” the bodies needed to support the anatomy classes he was teaching with his brother, Dr. William Hunter[xxx]. The outrage over the murders and body snatching lead to the Anatomy Act of 1832, which allowed the use of donated bodies in the teaching of medical anatomy.[xxxi]

An incomplete list of others would include Florence Nightingale, Baron Lister, and the aseptic surgeons Drs. Kocher, Crile, Halsted, Oschner, and the Mayo Brothers. Abraham Flexner, an educator and the physicians John Shaw Billings, William Osler, and William H. Welch systematized and revolutionized medical and surgical education in the OTL in many different ways, based on the program at Johns Hopkins University.

Nurses McDonald and Flanagan, and physicians Abrabanel, Nichols, Shipley and Adams will do much the same in the NTL.

Dr. Hugh Owen Thomas of Great Britain developed the first traction splints, along with many other orthopedic devices. He is considered the father of modern trauma orthopedics. His career was influenced by the problems that his father, Evan Thomas, had as a non-physician bone-setter in the early 1800s.

William T. G. Morton, a dentist, demonstrated the use of ether as a general anesthetic in 1846. Others, too numerous to list, will become more important as materials technologies develop to allow more advanced surgeries. Additionally, the use of assorted skeletal traction techniques is old and will make a comeback since it will be some time before the materials and techniques that allow up-time orthopedists to bypass the prolonged bed-rest needed by external traction.

I'll examine the problems of medical training in more depth in parts two and four of this series

If it's not written down, it wasn't done.

Most of the journals that I subscribed to and at least thumbed through every month were associated with various professional organizations. These included:

The American Family Physician (also available on CD ROM covering years 1990-1995, continuing medical education (CME) was a major feature of this magazine

The Journal of the American Medical Association JAMA

The Journal of the American Osteopathic Association JAOA

The Journal of the American Board of Family Practice JABFP

Family Practice Physician

The Southern Medical Journal.

Scientific American Medicine, considered one of the better textbooks of medicine and surgery, was in two large, loose-leaf binders, and updated monthly. A choice of hard copy or DOS (later ISO CD ROM) based CME programs was also included. Family Practice Management was dedicated to helping physicians manage their office, and offers more CME. The Clinics of North America series were slim hardbound volumes, issued quarterly, covering many different subjects. I personally subscribed to the Primary Care series, but also had access to the Surgical and Emergency Medicine series. Both Large Animal and Small Animal Veterinarian Clinics series were also available, and would probably be in the vet's office libraries.

Various other slick and pulp periodicals were also available, many of them in the category of “free to physicians.” The better ones I subscribed to included:

Emergency Medicine

Hospital Practice Physician

The Cortlandt Forum

Medical Economics (which had a fair number of articles that would be useful down-time on how to run a practice or hospital)

Emergency Medicine News

Nursing journals would include The American Journal of Nursing, Nursing (insert year here—my mother kept a subscription from at least 1970 to 1990), and professional journals for midwives and nurse practitioners. There was also a version of Clinics of North America, dating from at least 1995, directed towards the NPs

Most of these should be found when the libraries are consolidated, with enough overlap to cover the period 1950-1999 almost completely. Other articles would have been available with access to the National Library of Medicine through several different sources, most commonly, the local hospital. On-line searches (MEDLine/MEDLars) were available by 1994, and were even easy to use by 1998, replacing the hard copy Index Medicus for most purposes. Some of these articles were already available online, and my collection of hard and electronic copies easily numbered a thousand or more articles on various, and often odd, subjects by early 2000. In checking my personal library, and sorting out items that I acquired before January 2000, I have found a number of titles that would have been common enough that at least one of the five local doctors would have had a copy. I need to do an inventory and will post it as an addendum at 1632.org.

While I had a “typical small town/rural primary care practice” for the time, I will admit that I had a selection of medical books that were probably a bit wider than most physicians my age. This was due to my work in the US Army Medical Corps at various levels, as well as my interest in the fields of sports, emergency and field medicine. Additionally, I subscribed to the Classics of MedicineLibrary, a division of Gryphon Editions. Gryphon specializes in publishing high quality editions of classic literature, using leather covers, archival quality acid free paper, and fully sewn bindings—the kind of books that look good in a professional library, something that will attract most physicians at some stage of their career.

Stanchem reminded me that up until the late 1990s, it was common for drug companies to give assorted textbooks and other “giveaway goodies” to physicians. These would include everything from small monographs from Upjohn and Bacto covering office laboratory subjects, to more general textbooks in many specialties—I have a nice copy of Principles of Ambulatory Medicine that I received this way. It is hard to tell what Shipley and Adams might have received in this manner, much less the older physicians. While not directly related to trauma, these books would have been an important core for the medical library. Inexpensive but usable stethoscopes, assorted scissors and other medical equipment should be found amongst the detritus of the older offices.

Relevant surgical and medical textbooks from the period 1983-1999 include:

Various anatomy books

Grey's is still the classic, and widely available in the 1990s.

Grant's was commonly used in medical and nursing schools

The Ciba-Geigy Anatomy series, illustrated by the late, great Frank Netter, MD was one of the most colorful available.

The Color Atlas of Human Anatomy featured detailed photographs instead of drawings, and was popular with medical and nursing students.

Principles of Surgery (4thedition, Schwartz, 1984)

Advanced Trauma Life Support, 6th Edition

Modern Manual Therapy of the Vertebral Column (Greive, 1986)

Management of Wilderness and Environmental Emergencies (2ndedition, Auerbach & Geehr, 1989)

Sports Injury: Assessment and Rehabilitation (Reid, 1992).

Tintinalli's Emergency Medicine, 5thedition, was available in early 2000, but I'm not sure it would have been available by the time of the RoF. I would expect at least one copy of the earlier 4thedition to be available at the RoF.

I also had a selection of spiral bound “pocket textbooks” covering different subjects, mostly purchased as aide memoire items for student and resident rotations. Drs. Adams and Shipley will have done the same, as did virtually all medical students, interns and residents at the time. Many of these titles came out in formats compatible with PDAs, but that didn't really start until 1999, so the selection would have been limited, even if the doctors were technophiles.

I lost the copy of the DePuy instrument catalog that I acquired in or about 1995, when I was helping select new instruments for the local ED, but it had good drawings and photographs of many of the instruments. I've included a link to a similar on line catalog as a simple reference to the instruments[xxxii]

Among the Classics of Medicine Library editions that would have been available in 1999 would be:

The Expert Midwife (Rueff, 1637, 1997),

Classic Descriptions of Disease (Major, 1932, 1994).

There were also books by or about Percival Potts, Osler, Lister, the Mayos, Crile, Halsted, and many others, covering much of the development of medicine and surgery from the 1630s to the 1940s.

Thanks to the assistance of my antique-hunting aunt, I was also able to acquire books from several different rural Kansas physicians, including Modern Medical Therapy in General Practice (3 volumes, Barr, 1940), which was one of the premier texts of its day. While not covering surgeries directly, these tomes cover physiotherapy of the day in detail, as well as “low tech” diagnostic techniques for some of the more operable cancers. This is the sort of book I would expect in the libraries of the older physicians. They also would have various surgical textbooks dating back to their student and internship days.

A number of textbooks were available from the International Commission for the Red Cross/Red Crescent Societies in Geneva, Switzerland. Among those that were current in 1999 were Surgery for Victims of War (1999)[xxxiii]and Amputation for War Wounds (1992)[xxxiv].

One or more of the ICRC books might have found their way home with one of the folks who had been on a mission trip, or could have been in Mary Pat's traveling library. At least one copy of any of several editions of NATO War Surgery will probably be in the doctors' personal libraries. I owned the 2ndUS (1988) edition of the NATO book, and had access to Amputations through my local hospital, so I'll have to defer to the Editorial Board the chances that one of them might have come back.

“Modern” nursing textbooks available would have included:

Mosby's Textbook of Nursing,

Brady's Textbook of Medical-Surgical Nursing

Taber's or Dorland’s medical dictionary,

The Anatomy Coloring Book (which many medical students also used!)

The Lippencott Manual of Nursing Practice

The older nurses might have had copies of Cunningham's Anatomy, DeLee's Obstetrics and one of the older editions of The Merck Manual. This is based on the books that my mother still had in her library well into the 1990s, when my sister (a high risk OB doc) received them for her library.

Mary Pat is almost certain to have had an up-to-date Merck Manual, probably Stanhope & Lancaster's textbook[xxxv] on public health, and her NCLEX (the US national nursing exam) review book. She'll also probably have the current version of The Control of Communicable Diseases in Man, a publication of the US Centers of Disease Control. She's interested in emergency nursing, so she may also have a copy of the Trauma Nurse Core Curriculum course with her. She may have had a number of other textbooks (including various military manuals) with her, but none have made it into canon yet.

The paramedics, basic emergency medical technicians, and anyone who took a medical course in the military should have a variety of medical resources in their libraries. In addition to the medical and nursing textbooks already mentioned:

Nancy Caroline's Emergency Care in the Streets,

The American Academy of Orthopedic Surgeons' EMT book, (The Orange Book),

Paramedic Emergency Care (Bryan Bledsoe, DO; Brady)

will all be popular. In addition to these, the military medics should have copies of

FM 8-230, Basic Nursing Care

FM 21-10, Field Hygiene

FM 21-11 First Aid for Soldiers

FM 8-36 The Aidman's Handbook

and various others. The military manuals will have great (if not yet canonized) importance, as they will provide much information directly related to field medical care under austere circumstances. David Dorrman probably has copies of the USN versions of some of these books in his library.

Besides Chief Dorrman, we do have more up-time military medics[xxxvi] in canon, but few with recent experience. It was a very common secondary MOS in infantry units, and especially in the Special Forces. I'll have to research to find which of the Combat Lifesaver programs was in effect between 1993 and 1999, as there were several changes in that time, but that will wait until Part 4.

Nimitz Lover also pointed out that there would have been other resources in the libraries of various fire fighters, including at least Hazardous Material Emergency Response Guides, and Civil Defense First Aid manuals, as well as more copies of books such as TheMerck Manual and various editions of Grey's Anatomy. It is also probable that the safety office at the mine will have a library covering occupational health and advanced first aid, as well as equipment that will prove valuable to the rescue teams. She also pointed out that the families of chronically ill folks would likely have acquired a variety of useful popular medical books (ranging from Grey's Anatomy to TheMerck Manual and on to herbal and other alternative therapies) before the RoF.

By 1999, a wide variety of medical resources and continuing medical education material were available in downloadable and CD-ROM formats. In addition to the previously mentioned Scientific American Medicine program, Novartis (a large pharmaceutical corporation) was a leader in this field, and I have several different items from them that were distributed by 1999. Most of mine covered drug therapies, but there were others aimed at surgeons (to get them to use the expensive drugs as an adjunct to the operations), that might prove valuable as materials technology catches up with the needs of the surgeons.

There were a few textbooks on CD available by 1999, and I would expect that Drs. Shipley and Adams would have owned them. Two that I can lay my hands on right now are:

The Color Atlas and Synopsis of Clinical Dermatology (a companion CD to the book Clinical Dermatology by Fitzgerald, and was available in 1997).

The Interactive Atlas of Human Anatomy, (Ciba-Geigy 1995), featured the brilliant works of Frank Netter. The etchings and drawings of Grey's Anatomy pale by comparison. This one contains a feature that the instructors will love even more: the ability to create test material based on the illustrations. This CD was based on the hard back version noted above.

Some things will last . . .

Durable medical equipment available after the RoF will include items from the professional offices, ambulances, and mine safety group, as well as items that are out in the community for home health care. These will include respiratory equipment such as demand valves, Intermittent Positive Pressure Breathing (IPPB) treatment machines and Continuous Positive Airway Pressure (CPAP) equipment, and home nebulizer sets with associated air pumps. Other pieces of equipment will include laryngoscopes, a flexible endoscope or two, one to three electric cast-cutters, several portable electronic monitors and simple electric coagulation devices. As will be noted repeatedly, at least some of this equipment may come from the veterinarian's office, as this office is likely to have been equipped for animal surgery, which does translate well to the capabilities down-time. A consideration is that many of the items that we currently take for granted as “single patient use/disposable,” can be cleaned, re-sterilized and then reused for other patients. We will examine the needs of sterilization in Part 2 of this article.

Considerations for how long the up-time equipment will last will be mostly due to battery life or the need for small, high intensity lamps. Any flexible, fiber optic endoscopes[xxxvii] would also have a life limitation due to breakages in the fiber optic bundles, although with care, those should last long enough for the technology to catch up with the need for a high intensity lamp for the light source. Drs. Adams and Shipley may have one flexible sigmoidoscope in their office; the veterinarians may have a flexible colonoscope or long gastroscope, and possibly the equivalent of a flexible bronchoscope to facilitate the intubation of large animals.

Rigid endoscopes, including bronchoscopes, gastroscopes, proctoscopes, and laryngoscopes will remain useful after their bulbs burn out. These instruments can be used with a coaxial mirror (that's the one that fits over the doctor's eye in many Norman Rockwell paintings) and an acetylene or “town gas” mantle (Coleman or Aladdin style) lamp as a light source. The rigid versions of the instruments are also within the capabilities of down-time technology to reproduce.

Women will not be neglected. Their special examination needs are relatively easy to manage, as the appropriate specula will be readily duplicated down-time by journeyman whitesmiths, using up-time recipes for pewter for the metal, to reduce the lead content, and make the equipment stronger. Again, the coaxial mirror will provide decent lighting into the recesses of the body.

Drs. Adams and Shipley should have been familiar with a couple of low technology tricks to help identify women at high risk for problems[xxxviii], and one of them might have even owned a culposcope[xxxix], which can double as an operating microscope in Dr. Nichols' hands. These were techniques that I picked up in my residency and an item that I owned and used in private practice.

“Pap” smears won't be a high priority for various reasons, but will be readily reproduced as the first down-time pathologists and pathology technicians come out of the system.

Otoscopes (ears) and opthalmascopes (eyes) will also be limited to the useful lives of their bulbs, but this will be measured in years for the wall mounted, line powered versions, due to the habit of most physicians of stocking a dozen or more bulbs for each type of instrument. The portable versions of these instruments usually had rechargeable batteries, which also last a long time. Again, coaxial mirrors will make a comeback for the examination of various cavities of the body, where the portable units are no longer usable due to battery or lamp failure.

Electric cast-cutters are heavy-duty vibrating saws, used to trim, modify or remove heavy plaster or plastic casts. We can expect at least two, possibly four, of these in Grantville. I'm sure that one will be turned over to the medical school or the medical examiner's office, as they are also used to remove the top of the skull during an autopsy (or in the teaching of head and neck anatomy). Duplicating these items will be within the capabilities of any facility able to make fractional horsepower electric motors.

A few electric coagulation devices, such as Bovie[xl]and Hyfrecator[xli] devices, will also be available after the RoF, again, mostly in the veterinarian's office. There will most likely be at least one Hyfrecator in each of the doctors' offices, as those are cheaper, lower power and simpler than the Bovie devices, and don't require the expensive grounding pads needed to use the more comprehensive devices safely. Bovie devices do have the advantage of being able to cut flesh and coagulate the minuscule blood vessels that otherwise make for a messy operating field. Hyfrecators provide point coagulation of bleeding vessels, and can be used to treat skin lesions by electrically desiccating them. Both devices use radiofrequency electric currents instead of heat to do the job, allowing the surgeon better control over the amount of damage that is caused. As more down-time electronics engineers are trained, these devices will be as simple to make as the first low-powered transmitters.

These should not be confused with the diathermy machines used in physical therapy to provide local heating with the use of microwaves to relieve sore muscles[xlii]. I would expect that at least one of the three older physicians would have a diathermy machine in his office, as the method was commonly used in office practice in the 1950s and 60s. Again, I inherited such a machine (operating at 1250 megacycles per the nameplate, and with two extra final power tubes still in the box) from one of our older doctors when I started my office practice in 1993, and he would have been a younger contemporary of Dr. McDonnell. It will take a bit longer for the diathermy machines to be replicated, so the hot wet packs and paraffin baths will have to do for a long time.

Most of the electrocardiographic monitors will be in the ambulances, with possibly one in each of the physicians' and veterinarians' offices, one at the mine and at least one at the nursing home. From the same sources, perhaps a dozen vital sign monitors will also be transported in the RoF. The state of the art of monitors at the time is such that the batteries will wear out long before the monitors break from other reasons, given a modicum of care, and the presence of stable AC line power. Between the time the batteries wear out, and the time the electronics and chemical industries can reproduce the monitors and batteries, it is probable that those monitors will still be able to work on AC line power in the operating theater and intensive care units, providing valuable information in critical situations.

At least two x-ray machines should be available, along with the film cassettes from before the RoF. One of those machines should be in the vet’s office. At least one more will be found in the physician's offices (forty miles is a long way to go to get basic radiographs—we had a decent, if elderly, set in our office and we were only three miles from the hospital), and maybe even a mobile machine at the nursing home (for the same reason). A fourth machine may be mothballed at the mine. The film is simple fine-grained monochrome, and glass plates can be used if needed. Once roll film is again available in 1635[xliii], I would expect 17×20 films to be within reach. Basic x-ray units, gently cared for, are mature enough technology that I’d expect many thousands of uses before failure, and a portable unit could be converted to stationary unit with the addition of a (large, oil bath) capacitor when the batteries wear out. The developing and fixing solutions are well within Dr. Gribbleflotz' capacity (or that of any other reasonably competent alchemist) and the folks over in the electro-refining operation should reclaim over 99% of the silver in the used solutions. We know that black and white film photography is widely practical by 1636, and I would expect that a critical application such as radiographs would have been available at least a year earlier.[xliv]

Some things won't . . .

There is a significant amount of disposable medical equipment that must be saved as future reference, since having these items on hand will make reproducing them easier as down-time materials science benefits from up-time knowledge. These items include almost everything made of flexible polymers, such as endotracheal tubes, urinary catheters, chest tubes, IV catheters and assorted drains. Many of these can be made from latex, but most work better with clear, stiffer, polymers such as PVC. Bag-Valve-Mask breathing assistance systems are reproducible with a formed, flexible latex membrane for the valve, machined brass or pressed glass for the valve body, and firm rubber for the mask. Making the bag is trickier, but can be done with a flexible rubber bag and a bit of spring steel, but better ones will come along as soon as PVC is available. I have included some illustrative diagrams adapted from the World Health Organization's book, Anesthesia in the District Hospital, kindly provided to me by Stanchem, in the supplemental information to be posted on 1632.org.

Boys (and girls) and their toys.

Most of the basic surgical instruments[xlv] we use today date back hundreds of years, and many have roots in the Roman era. They fall into several broad classes, including cutting instruments, hemostatic clamps and holding instruments. While most instruments in 2000 were made of stainless steel with some inserts made of tungsten carbide, there were a few being made of the lighter titanium. We can expect a few odds and ends of instruments to have been in the nursing homes and more from the younger doctors' offices[xlvi], but many, if not most of them, will be low quality “single use/disposable” instruments.

Drs. McDonnell and Simms probably had a better selection of instruments stashed, and Dr. Ellis might have some made out of mild carbon steel as well. While carbon steels rust under adverse conditions, this is not a problem if the instruments are properly cleaned, lubricated, sterilized, dried and stored between cases[xlvii].

Almost all of the instruments needed before 1640 can be reproduced from examples found in Grantville or from the illustrations and descriptions that can be found in some of the catalogs and books found in the doctors' libraries, or in the State Library. Instrument makers working with the doctors will redevelop the ones that cannot be directly duplicated, through trial and error. Each hospital will probably have at least a journeyman instrument maker working as part of the central supply department as a matter of course, since carbon steel instruments need far more care than stainless steel. This is especially true of scissors and needle drivers, both of which have the harder carbide inserts in OTL, but which will need regular adjustment, sharpening or re-facing in the NTL.

I would expect a master instrument maker to be on the staff of the Department of Surgery of any medical school that adopts the up-time techniques, to work with the surgeons and operating technicians to produce new instruments at need. Uberzeit Metall Werks[xlviii], established in September 1633, was planning to offer “medical instruments, and different types of shears or scissors,” along with the Ka-Bar and Swiss Army style knives. Mr. Farha reportedly had a number of type patterns available for his smiths to work from. One nice item in canon already is the development of replaceable razor blades[xlix]as this is the same technology needed to make replaceable scalpel blades. While fixed blade scalpels are still occasionally used even as late as 2000, they require regular and careful sharpening, while the replaceable blades are changed with each case.

The scalpel handles will come in about five different styles, depending on where and how they are being used, and there will initially be about five different styles of blades compared to the many currently in the inventory. Wiki[l]gives a decent rundown on the various handle and blade combinations available in OTL. Handles type 1, 2, 3, 4 and 7 are the most common, with the #2 and #4 being heavy-duty models. Type #7 is a longer, slimmer handle that is often used for delicate work such as plastic surgery. Blades 10, 11, 12, 15 and 22 will probably be the first ones made using disposable technology, but others will be made as the need occurs.[li]

Scissors cover several different, sometimes overlapping areas. It is possible to use them “across” the categories, but this may damage the scissors or the tissue. Paramedics and nurses carry some form of Lister or bandage scissors, which have a blunt lip (shovel tip) on the bottom blade and a rounded tip on the top blade. They also have an angle at the pivot, so that the bottom blade can be held flat against the skin, sliding under the bandages so that the bandages can be cut and removed without having to try to unwrap the dressing. The heavier forms usually carried by the paramedics, known as trauma or combat shears, have slightly serrated blades to prevent slippage and were developed in OTL to cut through a soldier's heavy web gear on the battlefield. These shears will cut soft metal the thickness of up-time pennies easily, so will also handle the heavy leather jacks and buff coats common to downtime soldiers.

Surgical scissors commonly used in the ED and the OR fall into two basic types: tissue scissors and suture scissors. A surgeon who cuts too many sutures with his tissue scissors will set himself up for a rap on the knuckles by the operating assistant who is responsible for the instruments, as that tends to dull the relatively delicate tissue scissors rapidly. The tissue scissors come in four basic forms, most of which are made in OTL in both straight and curved versions, with the curved versions allowing for cutting closer to the body. The Metzenbaum scissors most often seen in the curved form, and the iris scissors most often seen in the straight.

Mayo scissors are blunt tipped, symmetrical scissors that are used for heavy work such as cutting the thick connective tissue around muscle bundles. The handles of a pair of Mayo scissors are only about twice as long as the length of the blade. Metzenbaum scissors are lighter scissors, again with blunt tips, where the handles are often more than twice as long as the blades. While they are used for cutting, one of the more important uses is to insert the tip of the closed Metzenbaum scissors into tissues and then spread the tips. This splits the tissues along the natural planes without cutting blood vessels or nerves in a technique known as blunt dissection.

Iris scissors are very finely pointed scissors initially developed for eye surgery, but this instrument has also found favor in plastic and hand surgery.

Lastly, there are so called “sharp and blunt” scissors that are midway between the Mayo and Metzenbaum scissors in weight, and have one sharp point and one rounded point on straight blades. These are often used as suture scissors in the OR, but can also be used to trim ragged tissue edges.

Suture scissors tend to have shorter, heavier blades than most tissue scissors, and often have a “hook” on the bottom blade and sometimes, fine serrations to prevent the slick suture material from slipping out. Wire-cutting scissors have even shorter blades, often as short as 15mm, with comparatively long handles to provide the extra advantage needed to cut stainless steel wire. They also frequently have a notch in both the top and bottom blades near the pivot point, which provides even more security to cut heavier wires.

Bone saws are already common in the 1600s, because amputations were the last chance to save someone's life when gangrene threatened. The big improvement in the saws will be using first metals and later autoclavable plastics for the handles of the instruments, rather than the bone or wood, which was common up to the 1880s in OTL. A smaller, but significant improvement will be the Gigli style wire saw, which will make some types of brain surgery possible down-time, and does an amazingly fast job of cutting through a femur, when used by an experienced surgeon. Interestingly, one of the major uses of Gigli saws started in WWII, when the saws were inserted into bootlaces worn by aviators for use during escape attempts. Similar saws are included into tactical survival kits to this day in OTL.

There are a number of other cutting implements in use, primarily in orthopedics. Bone cutters (rongeurs) have sharp edges on scoop shaped mating jaws, allowing the surgeon to nibble the harsh edges of cut or broken bone to allow for the closure of an amputated stump. Several types of diagonal cutters are available for trimming wires and pins after they have been inserted into bone. Simple hand drills, again made with metal instead of wood grips, are used to place pins to align bone, or to start holes in the skull to pass the Gigli saws so that a flap of skull can be removed. Manual cast-cutters may bear a distinct resemblance to compound metal snips or to an arboralist's tree limb lopper, save for having a blunt shovel tip like bandage scissors.

There are a wide variety of different types of “clamps,” so called because they generally have a ratcheting locking mechanism, which allows a variable amount of pressure to be maintained by the clamp after the surgeon has released the handles.

Hemostatic clamps or forceps fall into two classes: crushing and vascular (atraumatic) clamps. The difference is simple: the vascular clamps are used when the surgeon wishes to preserve that blood vessel for later reattachment, while the more common crushing clamps are used when the surgeon plans to ligate (tie off) the blood vessel.

These hemostats are also used for blunt dissection, where their smaller tips may be more effective in delicate dissections. Most of the crushing clamps were devised between 1880 and 1940, with the rise of the vascular clamps after 1940 as vascular repair became practical, and intricate cardio-thoracic surgery became possible. Because of the worldwide progress of medicine, it is not unusual to find similar clamps named after widely separated surgeons, doing the same function. For example, there are the Crile and Halsted mosquito clamps, invented by G. W. Crile and W. S. Halsted respectively, which differ only in how far along the jaws the serrations are carried.

Before the development of electrocautery (actually, an offshoot of radio experimentation) in the 1930s in OTL, much time had to be spent providing a “dry” operating field by individually ligating (tying) all of the little bleeders in the skin, subcutaneous fat and the muscles of the abdominal wall before an abdominal operation could proceed. This was done in OTL with the use of upwards of twenty mosquito hemostats being placed along the length of the incision, and then lengths of suture material being used to ligate those small bleeders. Silk and cotton threads were most commonly used, and were tied using one or two-handed “free tie” techniques most commonly associated with Dr. Halsted. A well-coordinated surgeon and first assistant can ligate all of those little blood vessels and remove those hemostats in a remarkably short length of time, but this is far longer than the same team can affect the same process using an electric cautery.

Fortunately for Sharon Nichols, Sanchez was both slender and probably in early shock, both of which tend to reduce the amount of bleeding she had to deal with during his operation.

Small vessels are tied off with fine thread, usually of silk or cotton in the early part of the twentieth century, replaced for hemostasis with either electric cautery or synthetic absorbable sutures after the 1980s. Larger vessels are secured with wide tape, which may be held in place with one of the hemostats, or with one of the vascular clamps if available. This helps prevent excessive damage to the lining of the blood vessel, reducing the formation of blood clots inside the vessel lumen.

True vascular surgery will have to wait for several milestones:

the (re)development of polymers strong and flexible enough to be pulled as hair fine monofilaments for sutures

the (re)development of “swaged on” suture and needle combinations and

the (re)development of polyester and PTFE (Teflon® and Gortex ®) for large diameter grafts (because veins are only suitable for small diameter arterial grafting).

Until those milestones are reached, ligation rather than repair will be the rule for vascular injuries.

An interesting hemostatic device, called a “bulldog clamp,” is very useful for surgery of the head and neck, particularly of the scalp. These areas are so richly supplied with blood vessels that achieving a bloodless field is difficult, and the surgeon often finds the need to tie blind. These clamps resemble small binder clips, with the folding handles being replaced by a tong shaped applicator. Once a ring of these clamps stop the bleeding of the scalp edges, the surgery can be completed easily. As the clamps are removed for wound closure, individual bleeding vessels can be tied off as needed, with the final closure and a firm dressing providing a final stop to the bleeding.

Another group of clamps is used to close off various types of hollow organs such as the bowel or the bile duct, preventing the contents of that organ from contaminating the abdominal cavity. As with the vascular clamps, there are a number of different but similar clamps, invented by widely separated surgeons, which do the same job. For example, Drs. Emil Kocher (Switzerland) and Alton Oschner (USA) invented similar clamps used in the removal of the gall bladder.

Other locking clamps are designed to hold tissue gently but securely so that the surgeon can reattach edges together. The jaws of these clamps may be smooth, have grooves along or across their width, and may or may not have teeth at the tips.

The last general type of clamp is a simple long, locking clamp with looped ends. Called sponge forceps, these are used by placing a folded square of gauze in the looped ends of the clamp. The gauze “sponge” is used to swab on fluids or medications or to swab blood from the depths of a wound (or occasionally, sweat from the surgeon's nose).

Thumb forceps, by contrast, are tweezers, often writ large, ranging from 6 to 12 inches (15 to 30 cm) in length. The tips of the thumb forceps will usually have grooves across the width of the tips, and most forceps used to manipulate tissue have some type of interlocking teeth at the ends. Dressing forceps, on the other hand, have relatively smooth tips to avoid snagging on the loosely-woven fabric. Two special kinds of thumb forceps that have proven very handy to me in the past include the Brown-Adson tissue forceps and the Russian or “bear paw” forceps. The Brown-Adson forceps have two rows of a half dozen teeth on each tip, which interlock to hold tissue over a wider area than other tissue forceps, allowing for a firm grasp with less pressure, and therefore less damage to the tissue. The Russian forceps have circular tips with interlocking teeth, allowing the surgeon to easily manipulate a suture needle deep in a body cavity. This both reduces the size of the cavity needed, and reduces the chance that the surgeon (or the assistant) will end up stuck with the bloody needle.

The most important device that prevents the surgeon from being stuck is the needle driver. Using a similar locking ratchet mechanism to the hemostatic clamps, the jaws of the needle driver are shorter and stouter, with a definite crosshatch pattern, rather than the simple unidirectional ribbing of the clamps. The drivers range from 4 inches (10 cm) to 12 inches (30 cm) long, but the jaws remain constant at about 10-15 mm long. Someone skilled in the “instrument technique” of suturing can place neat stitches deep in the belly or another body cavity through a surprisingly small incision.

One major problem with surgery in the early 1630s will be the strictly limited supply of up-time suture material, something that will take years to replace. Fortunately, there are some old-fashioned and down-time alternatives that will suffice for most uses until materials science in general and polymer technology in particular catches up with the needs of surgery.

One last piece of equipment that the field medics and many of the ED nurses will carry will be a leather holster that has slots for two hemostats, a regular pair of Lister bandage scissors, a pair of trauma shears, and a lock-back folding knife. A loop for a pen light will be included, but not filled until the battery and bulb technologies get to the point of providing the small lights again. The floor and ICU nurses will carry a lighter version, with room for only one pair of scissors, one or two clamps, a penlight and a pen.

In Part 2, I'll discuss the basics of aseptic surgery and anesthesia.

[i] The Trauma Attending is a board certified General Surgeon with extensive experience in trauma and critical care.

[ii] A Trauma Fellow is a surgeon who has completed a seven to ten year residency, and who is now acquiring extra experience in trauma and critical care prior to taking the general surgery boards.

[iii] Personal communication with the ATLS coordinator at the American College of Surgeons.

[iv] Some of us go so far as to become ATLS instructors, but there is nothing in canon to indicate that any of the physicians have done that.

[v] The C4 program is open to any nurse, dentist, PA, or NP who has completed their training, and to any physician who has completed at least their first year of postgraduate training (the internship year). Reserve and Guard members can use the program to fill all or most of their Annual Training requirement. I took mine during an elective block in my second post graduate year, as soon as I was eligible. Mary Pat would not yet have been eligible, and Beulah McDonald and the older physicians would have completed their service before the program was in place. CW3 John Sullivan (MOS 18D- see below) might have taken the course as part of his military training,

[vi] In a communication from Danita, she indicated that the nursing degree would be a BSN rather than the BN that has occasionally appeared in Bar discussions.

[vii] Grantville Gazette Volume 16: “The Galloping Goose”

[viii] In 1946, DeBakey and Simeone wrote a landmark paper entitled “Battle Injuries of the Arteries in World War II; An Analysis of 20,471 Cases”. This paper, published in the Annals of Surgery, looked at two distinct groups. In the larger group, soldiers underwent ligation of their injured arteries, and 49% of those individuals who survived went on to amputation. In a much smaller group of 81 patients, primary suture repair of the injured vessel was performed, and the amputation rate in this group was 35%, and was “deemed significantly better” by the authors. With the institution of “routine” primary vascular repair by Spencer and colleagues during the Korean conflict, and the progressive decrease in times from injury to definitive care in Korea and Vietnam, amputation rates dropped to around 10%, and the current civilian experience with isolated arterial injuries now has documented an amputation rate of less than 5%.

Quoted in a Trauma-L correspondence with Ron Gross, MD, FACS, COL, MC (ret)

[ix] 1634: The Galileo Affair Chapter 43

[x] Grantville Gazette, Volume 9: “Tool or Die” Feb 1632

[xi] Grantville Gazette, Volume 4: “‘Til We Meet Again” January 1634

[xii] Grantville Gazette, Volume 14: “The Galloping Goose” November 1634

[xiii] “An Invisible War” ibid

[xiv] Trueta, Joseph, TREATMENT OF WAR WOUNDS AND FRACTURES WITH SPECIAL REFERENCE TO THE CLOSED METHOD AS USED IN THE WAR IN SPAIN. London 1940, PRINCIPLES AND PRACTICE OF WAR SURGERY WITH REFERENCE TO THE BIOLOGICAL METHOD OF THE TREATMENT OF WAR WOUNDS AND FRACTURES. St. Louis 1943

[xv] Grantville Gazette, Volume 14 “Doc”

[xvi] From communications with Jose Clavell and Danita

[xvii] Grantville Gazette, Volume III “If the Demons Will Sleep”

[xviii] Ibid

[xix] Ibid

[xx] Grantville Gazette Volume 26: “Advice and Counsel”

[xxi] I've never understood this one. Why didn't Jefferson get her MSN as a Midwife or a Nurse Practitioner? “A Matter of Consultation, Ring of Fire

[xxii] Grantville Gazette, Volume 29: “NCIS: No Greater Love”

[xxiii] 1632

[xxiv] Grantville Gazette, Volume 10: “The Prepared Mind”

[xxv] Grantville Gazette, Volume 23: “Loose Canon”

[xxvi] Grantville Gazette, Volume 15: “The Whippoorwill” I base this statement on the salvage of Hatfield's arm, rather than an amputation, which I would have expected most down-time surgeons to do because of the damage. This goes along with the statements in “Doc.”

[xxvii] “Doc” ibid

[xxviii] Grantville Gazette, Volume 11: “A Gift of Blankets” Spring 1632

[xxix] http://en.wikipedia.org/wiki/Burke_and_Hare

[xxx] Moore, Wendy The Knife Man (Broadway Books, 2005)

[xxxi] http://en.wikipedia.org/wiki/Anatomy_Act_1832

[xxxii] http://www.teleflexmedicaloem.com/pdf/KMAD-4_General.pdf

[xxxiii] http://www.icrc.org/Web/Eng/siteeng0.nsf/htmlall/p0446/$File/ICRC_002_0446.PDF

[xxxiv] http://www.icrc.org/Web/Eng/siteeng0.nsf/html/p0516

[xxxv] Suggested by Danita

[xxxvi] Including at least one Special Forces (18D) medic and another 91C LPN (John and Anamarie Sullivan), pointed out to me by Caper2. They are currently claimed by Kerryn, and he has slushed a story where they are now a BSN (John) and a DO (Anamarie) respectively.

[xxxvii] Endoscopes are used to “look inside” the body. These include devices to peer into the throat and voice box (laryngoscope), the lungs (bronchoscopes), the stomach and upper part of the small intestine (gastroscope) and the large intestine (proctoscopes (very short), sigmoidoscope (longer) or colonoscope (very long)). http://en.wikipedia.org/wiki/Endoscope

[xxxviii] A mild acetic acid (vinegar) wash is used to turn precancerous cells white, and is followed by an iodine wash which turns normal cells a mahogany brown, making the white cells stand out.

[xxxix] The culposcope is used to examine the back of the vagina and cervix for cancerous changes.

[xl] http://en.wikipedia.org/wiki/Electrosurgery

[xli] http://en.wikipedia.org/wiki/Hyfrecator

[xlii] Oddly enough, finding a diathermy machine hiding in one of the older doctor's attics would go a long way to helping redevelop the microwave oven, as the older machines would be easier to copy than the more compact kitchen microwave units.

[xliii] Grantville Gazette, Volume 28, “On His Majesty's Secret Service” the first down-time produced movie

[xliv] Grantville Gazette, Volume 17, “Feng Shui for the Soul” HDG has developed film sensitive enough for Kirlian photography by the end of 1634. HDG is producing commercial quantities of the developing chemicals by this time.

[xlv] http://www.teleflexmedicaloem.com/pdf/KMAD-4_General.pdf

[xlvi] Again, I was a bit atypical. I purchased a small steam sterilizer and four decent suturing sets, including high quality carbide insert scissors and needle holders when I first started in practice in 1990.

[xlvii] Personal experience as a sterile instrument technician

[xlviii] Grantville Gazette, Volume 31: “Me fecit Solingen Nicht”

[xlix] Grantville Gazette, Volume 5: “Burmashave”

[l] http://en.wikipedia.org/wiki/Scalpel

[li] Insert link here to supplemental material posted on 1632.org. These will include both regular and macro jpgs of various instruments.

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