At this moment military commanders are putting into motion their grim responsibility to both engage in battles and win them, although doing so means the potential sacrifice of many young soldiers. The military medical officer, on the other hand -- sequestered within the subordinate framework of "logistics" -- exercises no comparable command authority. His obligation is "merely" to rescue, and repair the damage sustained by, those who have been offered up into harm's way.
The daily saving of lives in close support of combat troops is by no means an insignificant contribution to the military effectiveness of an army recruited from the population of a democracy. Much to the consternation of some combat commanders, however, preserving the personal dignity and integrity of the individual adds untold complexity to the organization of services on the battlefield. Nevertheless, without this consideration, a sustained military effort would be impossible to achieve.
No military surgeon can work for long in a combat setting without becoming aware of an important conflict of values and philosophies that affects his treatment of the combat-injured. This pertains to the unique goals and objectives of the military casualty management system. On the one hand, the purely "military view" is primarily concerned with the recuperation of the greatest number of wounded soldiers and their restoration to their units in the shortest time. This has been effectively memorialized by the motto of the Army Medical Corps, "To Conserve the Fighting Strength." The purely medical, or human point of view, however, is concerned with providing maximum medical and surgical aid at the earliest possible moment to those most gravely wounded.
Under the enormous pressure of casualty care in forward combat areas during major military engagements, it becomes impossible to satisfy both philosophies. With large numbers of casualties coming in all at once, while the number of wounded yet to arrive is as yet indeterminate, where should the greatest effort and expenditure of resources be directed? Should it be to the gravely injured, or to those with minimal wounds who can be more surely returned to the pursuit of war?
Generally, the implementation of treatment philosophy does not pass down from higher command authority. Nevertheless, the words of Gen. George Patton in 1943, during a visit to medical officers in Casablanca, are starkly illustrative of command expectations -- "If you have two wounded soldiers -- one with a gunshot wound of the lung, and the other with an arm or leg blown off, you save the s.o.b. with the lung wound, and let the g.d.s.o.b. with the amputated arm or leg go to hell. He is no g.d. use to us anymore!"
During civilian training, physicians are taught never to sacrifice or compromise the welfare of any individual patient. They are imbued with the belief that nothing but excellence in care is to be tolerated. A noted combat surgeon once related his observations of the inevitable reactions of idealistic, inexperienced physicians when placed within the combat environment of an earlier major national conflict. He described outrage, frustration and resentment among them. Such need to effect compromises with their ideals became even more poignant when it affected the care of critically injured young soldiers where the margin for error, and the difference between life and death, were both infinitesimally narrow.
Yes, many young surgeons may soon assume the mantle of "coming of age" in the Arabian desert, and the values of their culture, as well as their consciences, will be their only guide. The writer is a professor of surgery at the Medical College of Georgia and a captain in the Navy Reserve.