Treating Critical Illness: The Importance of First Doing No Harm

0497 T he Battle of Trafalgar was a short-lasting but bloody affair. By the end of the afternoon of 21 October 1805, the French/ Spanish fl eet had lost 4,408 men, and a further 2,545 were wounded while the victorious British force suffered 455 dead and 1,242 wounded [1]. The British fl agship HMS Victory, where Admiral Horatio Nelson lost his life to a sniper's bullet, sustained 56 other deaths. The surgeon on board, Dr. William Beatty, also listed 102 wounded sailors who survived the battle or its immediate aftermath [2]. He needed to perform ten amputations, mainly involving the leg, and reported instances of death from gangrene and tetanus. Yet only six of the 102 wounded sailors subsequently died. This remarkably low mortality rate was mirrored by that sustained by the 13th Light Dragoons during the Battle of Waterloo in 1815. Of 52 privates reported as wounded, only three later died of their wounds [3]. The United States Civil War fi ve decades later was a more protracted but equally bitter confl ict, with over 550,000 deaths in the four years of battle [4]. Of note, twice as many troops died from disease, privation, and accidents than died of injuries sustained on the battlefi eld. Typhus, typhoid fever, mumps, and measles were rife in army camps where poor sanitation, hygiene, and an inadequate diet were the norm. The surgeons in these camps often held their instruments between their teeth, and these tools were only cleaned at the end of the day's operating. At the Battle of Antietam, maize husks were used as bandages. Yet despite the prevailing conditions and lack of aseptic technique, mortality rates were remarkably good. The Union forces kept detailed records and reported a directly attributable mortality rate from battlefi eld injuries of 14%. The overall mortality rate following amputation was only about 25%, (Table 1) with some patients even surviving hindquarter amputation [5]. These survival rates do appear impressive, especially when one considers that they were obtained without antisepsis, antibiotics, blood transfusion, oxygen, and the other paraphernalia of modern medicine, and that the surgeons relied upon rudimentary surgical techniques performed without the assistance or comforts of sophisticated anaesthesia or mechanical ventilation. Clearly, a direct analogy should not be made to the mortality rates for today's battlefi eld injuries, which involve far more destructive weaponry, or to those of modern hospital populations, where many patients are …