What World War I and medical history brought to our game
Authenticity matters in media, and it matters in games too. Titles like Call of Duty, Medal of Honor and many others employ military advisors to improve the authenticity, and hence the sense of realism, for the player. Any game, even one set within a fantasy world, can benefit from this, which is why it was key to us in the making of Call of Cthulhu: The Wasted Land. Although the game is partly based on works of horror and science fiction we wanted to make the World War I setting as authentic as possible.
The Wasted Land is a strategy RPG. You command a team of investigators to uncover a deadly inhuman conspiracy underlying the Great War, during which your units can and do get wounded. Of course, your team recovers from wounds faster than in reality, but we took pains to make the nature of the equipment and process used as authentic as possible. And because there was little out there to inform us, we’re grateful to a small grant from the Wellcome Trust, which allowed us to research the historical medical information we would use in the game.
Our Army Medical Services Museum Trip
As part of our research we went to visit the Army Medical Services Museum in Aldershot, outside London. Its Director, Captain Pete Starling, was incredibly helpful in talking to us about the topic and giving us a tour of the fascinating museum.
Upon the outbreak of World War I (1914-1918), the medical services of the British Army were not really prepared for the type of war they were about to become bogged down in. In 1914, the last major war had been the Boer War in South Africa and while this did feature rifles, artillery and machine guns, it was a hot and dry environment. By contrast, the waterlogged trenches built upon manure-ploughed fields of Europe were infection prone environments adding the additional dangers of tetanus and gangrene to the immediate danger of the high velocity rifle.
Face with this, the British army adapted fast with new technologies, processes and ideas that rapidly filtered into the medical services. For example, if you were unlucky enough to have been shot in the femur in 1914, you had about an 80 per cent chance of death. This was in part because, as your well-meaning comrades moved you away from the front line, the broken bones inside the leg would be tearing and ripping the muscles inside the leg, possibly hitting an artery. This could result in wound-shock (the huge and rapid loss of blood), which would probably finish off what the rile shot started. However the invention and deployment of the Thomas Splint – a metal frame to hold and protect the wounded leg – meant that by 1917 your chances would have completely flipped to an 82 per cent chance of survival.
The evolution of the treatment of other wounds was similar; at the start of the war a chest shot or headshot would merely have been bound and the soldier left on his own healing. As the war progressed, new ideas about neurosurgery coupled with the use of technologies such as X-ray, meant that by the end of the war surgeons were able to locate, identify and remove bullet and shell fragments from such wounds (previously, this was not considered worthwhile). The overall preparedness also advanced with the army stocking up on vitals such as blood prior to a big battle, ready to help the wounded.
Upgrading the game kit
There are 3 levels of medical equipment available to the solider in the field during World War I, which we had (unintentionally) replicated in The Wasted Land. With the support of the Wellcome Trust grant and our subsequent research, we were able to update the text and images in the game from generic medical sounding/looking things to objects that are realistic representations of the period equipment.
The generic ‘Small First Aid Kit’ became Basic Field Dressing. This is what the normal soldier would have carried in a special pocket in his uniform jacket. It was a sealed waterproof package with two identical gauze dressings inside. If a soldier were shot, an assisting colleague would pull the package from the soldier’s own pocket and apply it – the idea being your own dressing was used on you if you were unlucky enough to need it. The two identical parts were used to dress the entrance wound and the exit wound of a rifle shot.
The next level up, the ‘Medium First Aid Kit’ is the equivalent of the Stretcher-bearer’s haversack. Stretcher-bearers were soldiers whose job was to follow behind the advance and bring the wounded back into their home trenches and into an aid station. This was a dangerous job requiring repeated sorties into no-man’s land even after the battle was over. A Stretcher-bearer was not armed, so sometimes people with religious/moral objections to killing would be given this role. Their haversacks would consist of more types of dressings including a larger gauze shell dressing – a bigger item that was used to cover a shrapnel wound. The medical training a Stretcher-bearer had varied considerably and was often dependent on what the Regimental Medical Officer (see below) may have given them. There would be 18 Stretcher-bearers per battalion of about 700 men.
Finally, we come to the top first aid kit, that of the Regimental Medical Officer (RMO). This was a qualified doctor who oversaw the care of a battalion. The officer was exposed to shellfire and other hazards on the frontline and some 740 British RMOs were killed during the 1914-1918 war. Like the Stretcher-bearers, an RMO was unarmed. They were equipped with a wicker pannier that contained a much larger range of medical equipment including splints, syringes (with ampoules of morphine). In battle, his job was to stabilise the casualties ready for transport back to the rear lines. But while the RMO was a qualified doctor, few had much prior experience with the wounds they would have to deal with in war. Most had been general practitioners and so spent much of their time dealing with coughs and sneezes rather than machine gun wounds.
The journey of the wounded
Stretcher-bearers would gather the wounded from no-mans land and take them to the Regimental Medical Post, where the RMO would stabilise the wounded as best he could. Stretcher-bearers would then take the casualties to a Field Ambulance (not a vehicle but a unit). This could be a journey of 1000 yards or more over rough ground and as such there would be relays of stretcher-bearers every 100 yards at least to the nearest road, where a horse-drawn ambulance might be available to carry them to the nearest clearing station. These tents tended to hold about 200 beds and were staffed with surgeons able to perform much-needed operations.
Post-operation, the wounded could then be moved by rail to hospitals in the major port cities (incidentally, the first point at which they might encounter female medical staff). The aim was to get the wounded fit for active service as soon as possible. If the injury were really serious there’d be no choice but to head home to Britain (hence the nickname ‘Blighty wound’ on a hospital ship.
In The Wasted Land, we replicated this journey, to an extent, using the Regimental Aid Posts found dotted around the trenches. When a unit is placed within the area of influence of one, they can recover some life each turn. This represents the greater access to medical equipment and the RMO and makes these points valuable positions to use in the game.
Gas! Gas! Masks On!
World War I saw the invention of a number of new weapons such as the tank, however it was the deployment of chemical warfare that was to cause the front-line solider a whole new dimension of horror. The first use of such weapons was chlorine gas in April 1915. This attacked the respiratory system, causing the larynx and bronchial passages to swell-up, choking the victim. Initially, there was little treatment or protection for the soldiers but advances were rapidly undertaken. Victims could be treated by thinning the blood and by stopping them panicking (if they did it further depleted the oxygen in the blood).
The medical services also contributed to the development of protection from this form of warfare too. Initially it was just a pad hung over the mouth dipped in a mixture of sodium thiosulphate, washing soda, glycerine and water. Then came a smoke-hood type mask until the development of the small box respirator, which had a flutter valve and a charcoal filter to remove impurities from the air breathed in.
But as the treatments evolved, so did the weapons. Phosgene was another respiratory irritant like chlorine but far more aggressive. Mustard gas followed, which damaged any exposed skin and had to be treated by immersing the victim in a saline bath to ease the suffering.
We have replicated some of these dangers within the game. Clouds of a greenish gas can be found around the battlefield (visually tweaked to look more like mustard gas). Standing in these or moving through them causes damage to a unit within. And the more you move within the cloud, the more damage you take. These effects can be mitigated by equipping your units with gas masks, but the level of protection from this varies depending on the training your units have received in their use.
In a modern war, such as the current Afghanistan conflict, the dangers to the solider are not that dissimilar to that faced by a British ‘Tommy’ in World War I – bullets and shrapnel. However if a soldier is unlucky enough to have been wounded, it is here that one would see huge differences. In modern Afghanistan, a Chinook helicopter may well arrive to evacuate the casualty with a Medical Emergency Response Team on-board. This means that the Accident and Emergency doctor, nurse and medical technicians will be working on the wounded from that moment to stabilise the wound for all of the 40 or so minute journey back to hospital.
It was a different story in 1914. There was no concept of A&E doctors or many of the familiar techniques used as routine today. However, the First World War did focus minds, ideas and technologies and is part of the evolving story of trauma medical care that has resulted in benefits not just in war but for a whole range of civilian injuries such as industrial accidents. We can see this, for example in medical journals such as The Lancet who from 1919 saw a huge numbers of papers written by doctors exploring their wartime experiences and what they meant for future medical care.
The First World War was arguably the first truly ‘modern’ war and this was as true of the healing methods as much as the weapons used. Both advanced rapidly over the course of the four-year hostilities. At the outbreak of war, the common view was for a short sharp conflict with glorious cavalry charges. However barbed wire, mud, high explosives and machine guns soon turned it into a battle of attrition. Such was the loss of life and the horrific injuries that those who saw this war vowed it would be ‘the war to end all wars’, that following the slaughter, the great nations of the earth would never again resort to such methods. They were sadly wrong, but we hope that by better replicating some of the medical challenges they faced in our game, we can bring something of that message to our players.