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U.S. Armed Forces Medical Journal, Vol. 6, No. 5
U.S. ARMED FORCES MEDICAL JOURNAL, VOLUME VI, NO. 5 (MAY 1955)
HELICOPTER EVACUATION IN KOREA
SPURGEON H. NEEL, Jr., Lieutenant Colonel, MC, USA
Helicopter evacuation, as much as any other single factor, was responsible for the reduction of mortality among the wounded in Korea to the phenomenal figure of only 2.4 percent, the lowest of any major military campaign to date. Actually, the concept of utilizing rotary wing aircraft for the evacuation of seriously wounded casualties is not a new one. In 1936, at the Medical Field Service School, Carlisle Barracks, Pa., an autogyro was field-tested as an evacuation vehicle. The idea was discarded at that time for engineering and budgetary reasons more than any defect in the basic concept. During World War II the Air Force and Navy began to use helicopters for the rescue of pilots and other personnel lost at sea or in inaccessible terrain. This innovation was further developed during the interim period between World War II and the Korean incident.
It was in Korea, however, that helicopter evacuation became a reality. This final fulfillment of an old concept of the Army Medical Service had to wait for two developments. The first was the acceptance of the helicopter as an organic vehicle of the Army, and the second was the need for such an aircraft to surmount the many difficulties unique to the geography of Korea. The first problem was mastered by helicopter manufacturers and far-sighted logistical agencies in time to answer the requirements established in Korea.
It is advantageous to examine briefly the evolution of helicopter evacuation in Korea, with particular emphasis on medical lessons learned. Inasmuch as Korea represents the only large-scale, field test of helicopter evacuation under combat conditions, it should indicate trends of value to the Army Medical Service in the development of organization, doctrine and procedures for the future. The clinical aspects of helicopter evacuation have been presented in a previous report. 1
THE BEGINNING IN 1950
Helicopter evacuation in Korea was not the result of any preconceived plan; it was the result of expediency. In the early
From Headquarters, 30th Medical Group, APO 301, San Francisco, Calif. Col. Neel is now assigned to the Office of the Surgeon General, Department of the Army, Washington, D. C.
days of the Korean conflict, a helicopter detachment of the Third Air Rescue Squadron began to receive requests from ground elements for the evacuation of casualties from difficult terrain. Inasmuch as this detachment was not fully occupied with its primary mission of rescuing pilots downed over water or behind enemy lines, it responded to these calls. By August 1950, this United States Air Force unit was answering so many calls that it found itself in the medical evacuation business.
Quick to note the advantages of helicopter evacuation in terrain such as Korea, the Eighth Army developed an increased interest in the program. During a significant test conducted by Army and Air Force representatives on 3 August 1950 in the school yard of the Taegu Teachers College, Army helicopters were adopted for the evacuation of casualties and the first procedures were established. On 22 November 1950 the Second Helicopter Detachment arrived in Korea. This unit, equipped with four H-13 aircraft and initially assigned to the 47th Light Aviation Maintenance Company, spent the remainder of the year in an intensive training program.
DEVELOPMENTS IN 1951
Army helicopter evacuation was officially established on 1 January 1951 when the Second Helicopter Detachment became operational and was attached to the 8055th Mobile Army Surgical Hospital. In January 1951, two more helicopter detachments, the Third and Fourth, arrived in Korea with minimum operating personnel and four H-13 aircraft, followed in February by the First Helicopter Detachment. At this time all helicopter detachments used in medical evacuation were assigned to the 8085th Army Unit, Eighth Army Flight Detachment, and attached to forward surgical hospitals.
The early days of the helicopter evacuation detachments were very stormy, reflecting the chaos in Korea in the first part of 1951. The Fourth Helicopter Detachment, attached to the First MASH, suffered a complete breakdown of all its aircraft and had to be returned to a rear area for re-equipping. It did not become operational until 9 March 1951. The First Helicopter Detachment, which arrived in Korea in late February, was stripped of its four H-13 aircraft in March because of more critical operational requirements. Two weeks later it was given two replacement H-23 models, but the next day had to lend one to an engineer group. When this aircraft was returned in April, it was immediately sent to an ordnance aircraft maintenance battalion, and the second aircraft transferred to the Korean Military Advisory Group. This detachment, although operational under the Eighth Army Flight Detachment, had still flown no combat evacuation missions.
The three operational detachments, despite recurring maintenance problems involving faulty cooling fans, tail rotor cables, spark plugs, transmissions, and bearings; shortages of high octane fuel; and inadequacy of spare parts, performed their mission exceptionally well. With a total of only 11 aircraft they evacuated 1,985 patients during the first six months of 1951. These detachments contained only minimum pilots and supporting personnel, and there was wide variation in their organization. The impressive record of these detachments, despite their many difficulties, is a tribute to the officers and men who staffed them.
Figure 1. Genealogy of medical helicopter units in Korea.
On 14 May 1951, all helicopter detachments were redesignated as army units (AU). Figure 1 reflects the genealogy of medical helicopter units in Korea. The First Helicopter Detachment (or 8190th AU), which still had not flown a combat evacuation mission, became nonoperational on 14 May 1951, and its personnel and equipment were transferred to the three operational detachments. In the early months of 1951, the fluid main line of resistance (MLR) required frequent displacement of the mobile army surgical hospitals and their attached helicopter units. With the partial stabilization of the MLR in mid-1951, the hospitals with their helicopter units settled into more permanent positions. Despite all the difficulties encountered, the three operational detachments evacuated 5,040 casualties during the first 12 months of operation, logging a total of 4,421 hours of flying time.
Table 1 is a recapitulation of the evacuation record during 1951, by unit and by month.
ORGANIZATION DURING 1952
Tables of Organization and Equipment (T/O&E) 8-500, dated 25 August 1952, established the "helicopter ambulance unit." On 2 December 1952, the provisions of this new T/O&E were implemented within the Eighth Army. On that date the Army units representing helicopter evacuation detachments were inactivated, and from their personnel and equipment were established the 49th, 50th, and 52d Medical Detachments, Helicopter Ambulance. Until that date all helicopter evacuation units had been assigned to the 8085th AU, Eighth Army Flight Detachment, and attached to mobile army surgical hospitals. Subsequent to that date, helicopter evacuation elements were under the administrative as well as operational control of the Eighth Army surgeon. The medical helicopter ambulance detachments were recognized as medical units-a goal that had long been set by the Army Medical Service.
PROGRESS IN 1953
Since the outset of the Korean campaign, the inadequacy of the cellular organization of helicopter evacuation units has been recognized. Many of the early problems of these units can be traced to a lack of centralized control and unnecessary duplication of effort. On 3 February 1953, the First Helicopter Ambulance Company (Provisional) was organized, and the scattered, small, cellular detachments were welded into an integrated, smoothly functioning team. The company initially consisted of
the three operational detachments, plus the newly activated 37th Medical Detachment, Helicopter Ambulance.
On 1 June 1953, the First Helicopter Ambulance Company (Provisional) was assigned to the 30th Medical Group, the agency responsible for all evacuation within Eighth Army. Subsequent to this assignment, two additional helicopter ambulance detachments, the 54th and 56th, were organized. These latter two units were not operational during the period of hostilities. On 29 August 1953, the first five Medical Service Corps pilots reported in Korea and were assigned to the First Helicopter Ambulance Company. Prior to that time all medical helicopters had been flown by Armor Artillery, Infantry, Engineer, and Signal Corps officers. The capabilities of these line officers in their role as medical evacuation pilots is reflected in table 2 which recapitulates the evacuation record by month for 1952 and the first seven months of 1953. As more Medical Service Corps pilots became available, line officers were released to their parent branches of the service.
Though the combat evacuation mission was completed with the cessation of hostilities, emphasis was shifted to the evacuation of seriously ill and injured patients. During the peak of hemorrhagic fever incidence, the atraumatic nature of helicopter evacuation was clearly demonstrated. Casualties brought to the special treatment center by helicopter presented a greatly reduced morbidity and mortality rate. The ready availability of helicopter transportation permitted the economical storage of whole blood at the army medical depot and its forward medical supply points. When required, blood could be moved rapidly to forward treatment facilities. Both medical and transportation
helicopter units were used extensively during the exchange of prisoners of war, Medical helicopters proved very effective in the movement of patients between army medical installations and the U. S. Navy hospital ship offshore.
THE SITUATION IN 1954
The 56th Helicopter Ambulance Detachment was transferred to Japan on 1 February 1954. Only troop spaces needed for the establishment of a special aviation school were transferred; personnel and equipment were not moved from Korea. The 54th Helicopter Ambulance Detachment, based at Headquarters 30th Medical Group, provided the overhead for the provisional company organization. This unit also was responsible for air evacuation to the rear of the forward surgical hospitals, furnished the 30th Medical Group and Eighth Army medical section with aviation staff support, and field-tested certain items of auxiliary helicopter equipment. The remaining four helicopter ambulance detachments were located at the four operational surgical hospitals.
Helicopter ambulance detachments are Army Medical Service units, assigned to the 30th Medical Group, attached to the First Helicopter Ambulance Company, based on compounds of surgical hospitals and under the dispatch control of corps or senior area surgeons. While this organizational structure may appear complicated, it proved most effective in Korea. With one exception, all pilots in the First Helicopter Ambulance Company were Medical Service Corps officers. The exception, an artillery captain and the company commander, has been retained due to his experience and his value as a staff advisor in the tactical aspects of the helicopter evacuation program.
In the early months of 1954 the shortage of officers of the Medical Corps became acute in Eighth Army, requiring the closing of certain medical treatment facilities and consolidation of others. Increased emphasis was placed on bringing the patient to the doctor. Medical helicopters with qualified Medical Service Corps pilots again demonstrated their worth. Now it was practical to pick up injured personnel at the scene of accidents and bring them rapidly to the proper medical treatment facility. The medical training of the Medical Service Corps pilots, supplemented by additional instruction in Korea, enabled them to give effective first aid prior to evacuating patients to a facility staffed with a physician.
While it is accepted that forward helicopter evacuation is the mission of the Army Medical Service, the contribution of other aviation agencies cannot be over-emphasized. Auxiliary support
by the U. S. Air Force, Marines, and Army Transportation Corps, increased both the flexibility and over-all potential of helicopter evacuation. Helicopters organic to major tactical commands were also used from time to time for evacuation within division areas. Throughout the hostilities, and during the subsequent interim period, the Marine Corps maintained the capability of evacuating their own casualties to either a Navy hospital ship or supporting Army medical installations.
Specially equipped cargo helicopters of the Air Force proved invaluable in the pickup of patients from isolated areas, particularly when over-water flights were involved. Improved navigational instruments, flotation gear, and other impedimenta not available to the Army Medical Service enabled the Air Force to accomplish such missions with greater speed and a greater margin of safety. In each case evacuation requests were received and processed by the Army Medical Service, and those beyond the capability of currently available helicopters were referred to the appropriate supporting agency for execution. This helicopter evacuation team, under the guidance of the Army Medical Service, proved most effective and is a prime example of interservice co-operation.
Of particular value was the contribution of the Army Transportation Corps. While the mission of its helicopter elements is stated as ". . . to provide short-haul air transport to expedite tactical operations and logistical support in forward areas of combat zones," these units accomplished an additional air evacuation mission. In the closing five months of the war, one Transportation Corps helicopter company, equipped with H-19 aircraft, evacuated a total of 701 casualties. Another, in action only two months, evacuated a total of 1,547 patients. During one particularly heavy period of combat in an inaccessible area, this company evacuated 723 patients in one three-day period, moving 301 patients in a single day. The greater capacity of the H-19 aircraft make them particularly effective in convoy or mass evacuation. This auxiliary form of helicopter evacuation will prove invaluable in the future.
The experiences gained in Korea cannot be denied. It proved to be the testing ground of many new logistical concepts and procedures. One of the foremost was the evacuation of casualties from forward combat areas by helicopter. While the limitations imposed by the Korean conflict must be accepted, experiences documented here and in other articles must be critically reviewed with an eye to the future. The following lessons have been learned concerning helicopter evacuation
Organization. Observers in Korea were convinced that helicopter evacuation within the combat zone is the responsibility of the Army Medical Service. Supplemental evacuation by other aviation agencies should be provided as available and as required and requested by the Army Medical Service. One agency, within the Army, must be responsible for evacuation within the combat zone if confusion and duplication of effort is to be avoided.
The company-type organization for helicopter ambulance elements is superior to the small cellular detachments provided in T/O&E 8-500. Helicopter units, whether company or detachment size, should remain under the control of the field army or a centralized medical command should one be available. The inherent speed, range, and flexibility of ambulance helicopters dictate against their assignment to subordinate major commands.
Using the First Helicopter Ambulance Company as a prototype, a T/O&E for a helicopter ambulance company has been prepared, staffed, and submitted. This company, allocated to field army on a basis of one per corps, will consist of three forward evacuation platoons, each containing four reconnaissance helicopters of the H-13 type plus minimum operating and supporting personnel. A fourth, or support, platoon, equipped with utility helicopters of the H-19 type, will provide selective evacuation between forward medical installations and supporting special treatment facilities. Administrative and maintenance functions will be consolidated in the company headquarters. The proposed organization will improve both the efficiency and effectiveness of forward air evacuation.
Control. Long a basic principle of medical service, control is particularly important in helicopter evacuation. Integration of the evacuation and treatment components of the field army's medical service is essential. Helicopter evacuation units should remain assigned to field army or an appropriate central medical command headquarters. In the "type" situation, the dispatch of individual helicopter evacuation sorties should be the responsibility and function of the corps surgeon who is at a sufficiently high level to determine realistic priorities, yet close enough to the scene of action to keep abreast of the immediate situation. In unusual situations, helicopter evacuation elements may be decentralized to the control of subordinate surgeons as any other form of logistical support is decentralized. As soon as possible, however, control should be regained by the highest command level capable of accomplishing the evacuation mission.
Only Army Medical Service agencies should accept evacuation requests. Command surgeons alone know the status of medical treatment facilities, such as surgical lags, location of special treatment teams, and projected displacements of medical installations. Requests which exceed the capabilities of the medical service can then be referred to the appropriate supporting helicopter element for execution. This system, proved in Korea, ensures integration of evacuation and treatment elements and eliminates the confusion which accompanies division of responsibility.
Communications. No separate communications net is required to control helicopter evacuation. It is feasible and desirable to process evacuation request through medical channels over "common user" facilities to that surgeon possessing dispatch control over supporting helicopter evacuation units. The present system is economical, and ensures integration of helicopter evacuation with tactical operations in forward areas. Air-ground radio communications between medical helicopters and forward medical installations were never used in Korea. Reliance was placed on accurate reporting of pickup locations, and visual air-ground communications of panels and smoke. This procedure is sound. The large area over which helicopter units are capable of operating, and mechanical limitations in available radios, make it undesirable to depend on air-ground electronic communications. Weight limitations dictate against providing several types of radio equipment in the evacuation helicopter. Airborne radio sets should be netted with appropriate Air Force agencies and fire support coordinating centers to provide control of aircraft in flight.
Personnel. Helicopter pilots, particularly those flying reconnaissance type helicopters engaged in battle field pickups, should be officers of the Medical Service. On occasion, they will be required to administer first aid at the site of pickup prior to movement of the patient. In all cases, though they are incapable of administering treatment in flight, they must possess sufficient medical training and experience to make sudden decisions regarding the destination of patients. Medical Service pilots should receive greater consideration in the development of career patterns. Assignments are presently limited, and no progression is ensured.
Greater emphasis should be placed in integrating medical service pilots into the over-all effort of the Army Medical Service. There has been a tendency to feel allegiance to the nonexistent "Corps of Army Aviation" rather than to the Army Medical Service. Pilots must be provided with an opportunity to
develop in the normal functions of their corps and to assume normal medical service responsibilities. Recently, several experienced pilots were given full responsibility for staff positions in hospitals and various medical command headquarters. The importance of this program cannot be overly emphasized and must be continued. If these principles of personnel management are ignored, the Army Medical Service will, in effect, lose some of its most capable junior officers.
Aircraft. The most maligned evacuation vehicle in the Army Medical Service is the H-13 aircraft. There is a great discrepancy between the opinions of those at research and development level and those at the operating field level. Those responsible for the development of evacuation aircraft believe that all such aircraft should be capable of transporting patients internally. Observers in the field are convinced of the superiority of the present reconnaissance helicopter with patients transported externally on litter racks. Actually, both are required.* The larger aircraft of the H-19 and H-25 type will never replace the smaller H-13 for forward "battlefield" pickups. Their greater cost, larger silhouette, increased loading and unloading times, all dictate against their utilization in the division area. Tactical commanders, responsible for their mission as well as for the lives of many men will be hesitant to clear the landing of a larger helicopter in their area when they would permit the landing of the small reconnaissance type.
It is uneconomical and unnecessary to provide the Army Medical Service with enough aircraft of the various types to accomplish the entire medical evacuation mission on a unilateral basis. Situations requiring mass evacuation (i. e., to empty a hospital for displacement or in connection with area damage control operations) can be met by requesting supplemental evacuation support from the Transportation Corps or other available aviation agency. The Medical Service has long depended upon the Transportation Corps to operate its ambulance trains and the Air Force to provide high-performance, long-range aircraft. This concept is also valid in helicopter evacuation operations.
Many observers in Korea have expressed the belief that there is no requirement at the present for incorporating fixed-wing aircraft in Army Medical Service air evacuation units.** The advantages of the greater speed, longer range, and lowered main-
*Current developments envision that a two-litter, internal-carry, utility helicopter, of no greater over-all size than the present reconnaissance helicopter will soon be produced. The present H-19 is only an interim utility helicopter and the H-25 is only a training helicopter.-Editor
**The Surgeon General, Department of the Army, is conducting testing to determine feasibility of fixed-wing Army aircraft for medical missions as well as studying the over-all forward air evacuation system.-Editor
tenance problems inherent to fixed-wing aircraft are offset by certain disadvantages. These include the maintenance problems incident to providing three instead of two aircraft for the Medical Service, the necessity for considerable additional training for Army Medical Service pilots (now qualified in rotary wing aircraft only), and the requirement for improved airstrips for medical evacuation.
In the forward combat area, of primary concern is the elapsed time from wounding to initial definitive surgery. While fixed-wing aircraft are faster when airborne, the necessity for surface evacuation between airfields and medical facilities plus the duplication of handling patients detract from any apparent advantage of speed. For longer evacuation flights, not feasible for helicopters, fixed-wing aircraft of the Air Force and other Army aviation agencies are available. The primary requirement for fixed-wing aircraft within Army medical units at present is for the control of helicopter elements. The necessary command and liaison visits, the distribution of critical spare parts, and the aerial resupply of whole blood entail missions which would be favored by organic fixed-wing aircraft. However, these requirements are currently satisfied by requesting supplemental aviation support.
The flexibility of medical evacuation can be improved by the provision of certain auxiliary equipment for both reconnaissance and utility-type helicopter. Flotation gear is required if the Army Medical Service is to accomplish its accepted mission of evacuation anywhere within the army area, including adjacent offshore waters. The H-13 aircraft requires additional instruments to enable it safely to accomplish night missions and those flown under marginal weather conditions. It is not necessary that complete navigation instruments be provided because the accompanying loss in allowable cargo load and the requirement for a copilot will offset any advantages accruing therefrom. The Air Force with its specially equipped air rescue helicopters can execute such occasional missions as may exceed the capabilities of aircraft of the Army Medical Service.
In a brief account of the evolution of medical helicopter evacuation in Korea, emphasis has been put on the principles developed and lessons learned. The progressive assumption by the Army Medical Service of its forward air evacuation mission has been outlined, and the importance of supplemental helicopter evacuation support by nonmedical aviation agencies has been described. The superiority of the company type organization for medical helicopter evacuation elements is pointed out and a rec-
ommended balanced unit is proposed. The desirability of providing the Army Medical Service with both reconnaissance and utility-type aircraft leads to the recommendation that such aircraft be provided on a 3:1 ratio. Currently available evacuation helicopters can be improved by modification of certain ones with flotation gear and additional navigational aids. There is a requirement for broadening the career pattern for Medical Service Corps pilots to ensure normal logical progression in aviation and other normal functions of the Army Medical Service. Critical evaluation of these experiences and lessons learned in Korea will prove particularly beneficial to the Army Medical Service as it develops its helicopter evacuation program for the future.
1. Neel, S. H., Jr.: Medical considerations in helicopter evacuation. U. S. Armed Forces M. J. 5: 220-227, Feb. 1954.