Birmingham, UK (Spring 2016)
|Archibald McIndoe and the staff of Ward III enjoys a song with a number of Guinea Pigs, also present is actor Edward Chapman.|
The Second World War marked the beginning of a new generation of aerial warfare. The slow wooden bi-planes of the First World War were replaced by swift aerodynamic fighters, such as the Spitfire and Hurricane, and a new type of aircraft entirely: the heavy bombers of RAF Bomber Command. However, the increased mobility and speed of these new aircraft came at a cost. The change from two engines to just one required a large fuel tank to be fitted in front of the cockpit. Consequently, if the fuel tank was hit it could, and often did, result in burning fuel being funneled directly into the cockpit. These flames were intensified by the descent of the plane until they became blue-hot, and pilots who lived to tell the tale described the experience as akin to sitting in the center of a ‘blowtorch.’1 This produced a very similar pattern of burns on the affected pilots, and the phrase ‘Airman’s Burn’ was coined. These injuries were characterized by severe burns to the exposed skin of the face and hands, usually accompanied by contact burns from touching scalding fragments of the plane’s chassis.2 These dreadful and sadly common occurrences, coupled with improved treatment for patients with burn shock, lead to a whole new population of patients who were alive but suffered terrible disfigurement. It was Archibald McIndoe, the civilian consultant to the RAF at the time,3 in the quiet Sussex town of East Grinstead who took charge of them and engineered a program to treat and rehabilitate these brave servicemen. His efforts would not only prove to innovate, but also refine the techniques and skills learned in the First World War by his distant cousin, Sir Harold Gillies,4 whom many consider being the ‘father’ of modern-day plastic surgery.5
The war started quietly for the staff of Ward III at the Queen Victoria Hospital, the first severe burn victim arriving seven months after the onset of war— a pilot who had crashed his training aircraft.3 It was not until Dunkirk and the Battle of Britain that beds began to fill. It was at this point that McIndoe was forced to consider how to manage these patients who had survived against all odds but had lost so much. Russell Davies, an anesthetist who worked alongside McIndoe, described the surgeon’s ethos in the following way: ‘continuous care should be extended from the moment of injury to the point at which the injured person re-entered society and beyond.’6 Likewise, John Barron, another plastic surgeon at the time,7 summed up McIndoe’s philosophy of care using two phrases: ‘Total patient care’ and ‘It takes a team to treat a patient.’8 It is this early example of the true understanding of a multidisciplinary team approach to complete holistic care that I will discuss in this essay.
McIndoe saw the importance of immediately creating good relationships with his patients to gain their confidence and alleviate their anxieties. This relationship was needed as they were often under his care for a long time and would frequently need as many as 10-50 operations each.2 Initially he would make sure the patient was aware of their care plan6 and the dates each operation would occur.2 Next he would make sure that they understood the procedure, and he would even invite them into theatre to watch him operate on their peers. It was through this process that they would become ‘the most well-informed and critical patients of their day’.6McIndoe’s patients, in my eyes, became the equivalent of our modern day ‘expert patients’9 and helped new arrivals come to terms with their injuries and with the road ahead of them. This camaraderie was an aspect of the care at East Grinstead, which whilst not created by the staff, was encouraged and supported. These patients formed the famous Guinea Pig Club; an embodiment of the bond shared through mutual experiences and the esteem for the hospital staff. This respect was gained through simple adjustments to the hospital norm. For instance, McIndoe removed the ‘hospital blues’, the uniform of the convalescent, and instead let his patients wear full battledress, transforming them from injured helpless invalids into war heroes whom could wear their uniform and scars with pride.3 Other adjustments included bringing men of all rank, commissioned and non-commissioned, together onto the same ward, along with the introduction of a barrel of watered down beer, which was a clever ploy to keep his patients hydrated and their morale high.3
The other doctors who worked at East Grinstead also tried their hardest to raise the men’s morale, and in no other specialty could it be more apparent than in the anesthetists who worked with McIndoe, and in whom the airmen placed their trust every time they went into theatre. Due to this trust, and the number of operations that most required, strong bonds between anesthetist and patient often developed. John Hunter, the chief anaesthetist, made a bet with the Guinea Pigs that if he made them sick after surgery he would buy them a drink3 and it was simple actions such as this that bridged the gap between patient and doctor. Another anesthetist working at East Grinstead was Russell Davies who was an innovator himself and pioneered the development of a recovery unit in East Grinstead.10,11
In the substantial program which McIndoe would prescribe his patients, the backbone of the ‘multidisciplinary team’ were the nurses and the orderlies. East Grinstead had one of the highest levels of nursing staff of any British hospital and a large proportion of those nurses were Red Cross Nurses.3 These ‘Voluntary Aid Detachments’, or VADs as they were known, while not as experienced as professional civilian or military nurses, were vital in sharing the massive workload present in military hospitals.12 Nurses were selected to work at East Grinstead not for their status or age, but for their ability to cope, emotionally and practically, with the unique situation of normality found there.3 The devotion of these nurses to their patients lead to incredibly intense, and sometimes romantic relationships forming. Former patients and nurses have recalled the blurred-line of their patient-nurse relationship which was so often crossed and have spoken fondly of the friendships that formed, the dates they used to have3 and for some the ‘clandestine sex at night on the trolleys in theatre’.13 Sometimes these relationships developed further and it was not uncommon for marriage to occur.12 While not strictly speaking professional, this behaviour does highlight McIndoe’s insistence on normality and his stance against the clinical hospital archetype.
The nursing orderlies of the Queen Victoria were just as much of a vital asset. They needed to learn the complexities of the saline bath treatment McIndoe arranged for his patients almost daily, while also being strong and caring enough to gently move them given their serious burns.3 The time these orderlies spent with these patients often lead to strong bonds forming between them. Leo Tremblay, a member of the Guinea Pig Club, wrote about the caring nature of these staff, and reported how he was often taken into town by one particularly devoted orderly.3
It was in the town of East Grinstead that the final part of the ‘team’ was found. The people became an indispensable part of the treatment of McIndoe’s patients. The staff of East Grinstead educated the community about burns and prepared them for the sight of these severely disfigured men by arranging concerts in the hospital and having local residents come to the hospital to arrange flowers.3 Once the people of East Grinstead had become accustomed to their new guests they were more than happy to welcome them to their community, and they truly became ‘the town that didn’t stare.’13 Burnt servicemen became an ordinary sight at local restaurants, pubs and dance halls, where they were treated not only like the war heroes but also as normal young men out to enjoy themselves. One such place, the Whitehall Restaurant, became an ‘unofficial social club’ for the Guinea Pigs.3 One former patient has recounted how the manager, Bill Gardener, was there for them when they were feeling self-conscious, and how he would always look out for them, especially the ones ‘who tended to drink too much’.14 Such actions, however small, affected the patients deeply and enabled them to progress along the road to recovery.
McIndoe was a truly talented surgeon, but what makes him so significant is his emphasis on the importance of the pre- and post-operative periods and his willingness to contest the views of those in charge. His determination to do everything in his power for the men under his care was reflected in the staff working with him, and also by the people of East Grinstead.Together these dedicated people helped to give back these injured men their confidence, and the willpower to make something of the life that had been handed back to them.
- Gleave T. I Had a Row with a German. London: MacMillan & Company; 1943
- Mclndoe AH. Total reconstruction of the burned face. The Bradshaw Lecture 1958. Br J Plast Surg. 1985;36(4): 410-20
- Mayhew ER. The reconstruction of warriors: Archibald McIndoe, the Royal Air Force and the Guinea Pig Club. United Kingdom: Greenhill Books; 2004
- Ellis H. The Cambridge illustrated history of surgery. 2nd ed. Cambridge: Cambridge University Press; 2009
- Neil Shastri-Hurst. Sir Harold Gillies CBE, FRCS: The father of modern plastic surgery. Trauma. 2011; 14(2): 179–87
- Davies RM. McIndoe Lecture, 1976. Relationships. Archibald McIndoe, his times, society, and hospital. Ann R CollSurg Engl. 1977 Sep; 59(5): 359-67
- Rogers BO. British Plastic Surgeons Who Contributed to the Revue de ChirurgiePlastique and the Revue de ChirurgieStructive (1931–1938): “The Big Four’’ in Their Speciality. Aesthetic Plast Surg. 2001; 25(3): 213–40
- Barron JN. McIndoe the gentle giant. Ann R CollSurg Engl. 1985 May; 67(3): 203–6
- Tidy C. Expert Patients. Revised May 8 2015. http://www.patient.co.uk/doctor/expert-patients. Accessed March 25, 2016
- Davies RM, Hunter J. A Recovery Ward Its Planning and Use. Lancet. 1952; 259(6713): 865–8
- Zuck D. Anaesthetic and postoperative recovery rooms. Some notes on their early history. Anaesthesia. 1995; 50(5): 435-8
- Harrison M. Medicine and Victory: British Military Medicine in the
- Second World War. New York: Oxford University Press; 2004
- Byrski L. In Love and War. Fremantle: Fremantle Press; 2015
- Simpson W. The Way of Recovery. London: Hamilton; 1944
ALEXANDER BALDWIN is a medical student studying at the University of Birmingham. He has an interest in the history of medicine.