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U.S. Armed Forces Medical Journal, Volume 8, No. 8
U.S. ARMED FORCES MEDICAL JOURNAL, VOLUME VIII, No. 8 (AUGUST 1957)
ARMY AEROMEDICAL EVACUATION
THOMAS N. PAGE, Colonel, MC, USA
SPURGEON H. NEEL, Lieutenant Colonel, MC, USA
Today, the United States Army is in a state of revolutionary change. With the advent of new weapons systems, including delivery of nuclear weapons in both the kiloton and megaton range by a variety of means, it is apparent that the Army of the future, if it is to survive (much less accomplish its mission) on the battlefield of the future, must undergo radical changes in organization, dispositions, and employment. New concepts are based essentially on two inescapable facts. Enemy capabilities for the employment of mass destruction weapons dictate that the Army of the future must be capable of increased dispersion and possess the organic mobility to mass for attack at points of decision and then disperse again to avoid annihilation. This situation establishes a requirement for increased use of organic Army aviation; not only to facilitate tactical mobility, but also to increase the capability, efficiency, and responsiveness, of logistic support, including medical evacuation. The following represents the considered opinion of the Surgeon General of the Army with respect to the subject of Army aeromedical evacuation.
ARMY AEROMEDICAL EVACUATION
A brief review of the historical development of Army aeromedical evacuation will assist in the understanding of the current concept. The Army has long recognized the advantages of aeromedical evacuation, but until recently has not had available aircraft in sufficient numbers for its exploitation in the forward combat area. The feasibility and full advantages of aeromedical evacuation by high-performance, fixed-wing aircraft became apparent early in World War II. Immediately after that conflict aerial evacuation was designated as the primary means for moving patients to the rear of the combat zone. This mission has been most effectively accomplished by U. S. Air Force troop carrier elements within oversea theaters, and by the Military Air Transport Service between theaters and within the continental United States. Pending development of the helicopter and the assault type aircraft there remained,
From the Office of the Surgeon General, Department of the Army, Washington, D. C.
however, little capability for the forward aeromedical evacuation function.
In Korea, circumstances demanded that the advantages of aerial evacuation be extended into the most forward combat area. The paucity and disposition of Army treatment facilities, the nature of the terrain, the type of combat, and the extremely limited surface communications net all combined to establish an urgent requirement for a rapid, atraumatic, dependable means for moving casualties from forward medical facilities to Army hospitals capable of providing definitive, lifesaving surgery. These considerations, plus the acceptance of the helicopter as an organic vehicle of the Army, permitted the fulfillment of an old concept of the Army Medical Service. 1
Shortly after the outbreak of hostilities in Korea, 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, it responded to these calls. By August 1950, this U. S. 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. After 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. In January 1951 the first Army helicopter detachment with a primary mission of medical evacuation became operational, followed in rapid succession by two others.
These nonmedical units were assigned to the Eighth Army Flight Detachment, were attached to forward surgical hospitals, and were under the dispatch operational control of corps surgeons. in August 1952, the Department of the Army authorized the "helicopter ambulance unit," a T/O & E (Tables of Organization and Equipment) organization derived from the Korean experience. In December 1952, the operating helicopter evacuation detachments in Korea were redesignated as "medical detachments, helicopter ambulance" and became medical units for the first time.2 During this period similar detachments were activated within the continental United States and some dispatched to the Seventh Army in Europe.
With only minor changes, the medical helicopter ambulance detachment of today (of which there are 11) is almost identical with that authorized in 1952. In the near future it is expected that a "Medical Aerial Ambulance Company" will be authorized
for the forward aeromedical evacuation mission. This unit, equipped with utility helicopters, will be allocated to the field army to supplement current helicopter ambulance detachments. It is believed that considerable operational, administrative and logistic advantages will accrue from the company type organization.
This rather brief historical account brings us to current Army Medical Service doctrine pertaining to forward aeromedical evacuation. These doctrinal statements have been developed after thorough evaluation of experience data, current doctrine and procedures in the light of what is known of warfare of the future.
Aeromedical evacuation within the combat zone is an accepted mission and capability of organic Army aviation. The "Memorandum of Understanding relating to Army Organic Aviation" between the Secretaries of the Army and the Air Force, dated 4 November 1952, states that the Army will provide "aeromedical evacuation within the combat zone, to include battlefield pickup of casualties, their air transport to initial points of treatment and any subsequent move to hospital facilities within the combat zone." The medical evacuation mission of Army aviation was recently affirmed by the Secretary of Defense.
Warfare of the future will be characterized by an increased use of organic Army aviation for both emergency and routine aeromedical evacuation within the combat zone. This is in consonance with the increased dispersion of tactical and logistic support units and the increased dependence upon aerial lines of communications.
Within the Army, the Army Medical Service has the basic technical responsibility for all medical evacuation, whether by surface or aerial means. In order to ensure selectivity of evacuation and timeliness of treatment, the medical service must retain control over all evacuation; to include as a minimum the designation of patients to be moved, forward pickup sites, destination hospitals, and the provision of medical attendants and equipment.
The current concept for accomplishing the Army aeromedical evacuation mission (i. e., emergency evacuation of seriously wounded by organic medical aircraft, and support by nonmedical aviation elements on the request and under the jurisdiction of the medical service) is more desirable than certain previously proposed concepts of elimination of organic medical aviation, making all aeromedical evacuation the exclusive mission of nonmedical Army aviation units. Specifically, the proposed concepts (1) place the welfare of patients secondary to other logistic considerations and missions, which is contrary to the national philosophy and detrimental to individual and unit morale; (2) lack responsiveness to emergency evacuation requirements;
(3) reduce medical control over the movement of patients, which reduces selectivity in evacuation, delays ultimate treatment, and leads to over evacuation, depleting combat strength; (4) preclude most effective utilization of critical medical means, including professional specialists and available hospital support; (5) fail to provide adequate property exchange concurrent with evacuation; reducing the continued capability of forward mobile medical treatment facilities; and (6) require diversion of logistic and tactical aircraft to missions for which they may not be designed or configured, reducing the effectiveness of over-all Army aviation support.
The Army Medical Service requires sufficient organic aviation of the proper type to enable it to accomplish its continuing mission of rapid evacuation of the severely wounded directly to appropriate medical treatment facilities. Ambulance aircraft should not be special-purpose from the design or procurement standpoint, but should be single-purpose in the operational sense that they will not be used for any but medical missions. Ambulance aircraft should be marked with Geneva Red Crosses and should be manned with medical crews, including pilots, to afford additional protection to patients and to medical facilities where they may land. This provision of single-purpose ambulance aircraft is considered no more uneconomical than the provision of fire-fighting trucks and field ambulances, by the Army, or air- and-sea-rescue aircraft by the Air Force and Navy.
In the future, both fixed and rotary wing ambulance aircraft will be required for the combat-zone aeromedical evacuation mission, due to the increased dispersion of tactical formations and supporting medical treatment facilities, and the need for maximum flexibility, reliability, and selectivity in medical evacuation.
Ambulance helicopters are required for the forward pickup of casualties and their transportation to initial points of treatment and to hospitals capable of resuscitative surgery. Such helicopters should possess a small silhouette, be capable of transporting two litter patients and one medical attendant internally, and capable of flight under marginal weather conditions. The Bell XH-40 helicopter, which should be available soon, is well suited for this mission. Pending the availability of an adequate utility helicopter, it is believed that a combination of the capabilities of current reconnaissance and utility helicopters will minimize the limitations of each type aircraft.
Ambulance airplanes are required primarily for the longer lateral and rearward movement of patients needing special surgical treatment that may not be available in every forward hospital, or to bypass intermediate hospitals with long surgical lags. In addition, they improve the flexibility and selectivity as well as the economy
and reliability of all forward aeromedical evacuation. The increased speed, range, and stability of fixed wing, aircraft, their reduced initial and maintenance cost, and reduced sensitivity to wind velocity and differential more than compensate for their increased landing-site requirements and their relative sensitivity to ceiling and visibility minimums. Such utility aircraft would operate from landing strips already prepared for other tactical and logistic purposes.
The company-type organization for the aeromedical evacuation function is superior to the current cellular detachment concept. Characteristics inherent to Army aircraft permit centralized company control, and considerable administrative, logistic and operational advantages may be achieved.
Medical air evacuation units, either fixed or rotary wing, should be assigned to the field army, to permit full exploitation of their capabilities and to facilitate shifting of evacuation support to meet actual requirements. Attachment to major subordinate commands should be limited to isolated or independent operations when centralized control of evacuation is infeasible.
The current procedure for requesting emergency aeromedical evacuation missions is adequate, but electronic means need considerable improvement to increase their reliability. The consensus is that there is no real requirement for a separate communications net for the control of aeromedical evacuation. The use of common electronic means is more economical, and other than medical agencies are involved in and should know about medical evacuation missions.
The Army Medical Service does not require sufficient organic aviation for the entire Army aeromedical evacuation mission. The movement of non-emergency patients by air can be accomplished economically by making use of utility and cargo aircraft in conjunction with normal logistic missions, provided there is adequate medical control over the movement of patients. To the extent feasible, all Army aircraft should be designed so as to be capable of transporting patients when required and upon the request of the medical service. Aeromedical evacuation should be retained as a secondary capability and mission of appropriate Army aviation units, to provide economical aerial movement of non-emergency patients when surface evacuation means are nonexistent or inadequate.
The Army Medical Service must maintain jurisdiction over all Army aeromedical evacuation, regardless of the category of the patient or the source of the aircraft. This does not imply actual medical control of nonmedical aircraft, but does include such matters as the designation of forward pickup sites and rearward destinations, provision of necessary medical personnel and equipment, and surveillance of casualties in flight. All movement of
patients must be planned, programmed and controlled. Beebe and DeBakey stated, "Nonselective evacuation of battle casualties undertaken for bed clearance, measured by transport capacity, timed by transport availability, and followed by distribution to hospitals based on bed credits, invites wound complications, retards recovery, and prevents return to duty." 3
The selectivity which is inherent to Army aeromedical evacuation must be emphasized. This characteristic is less appreciated than the more obvious advantages of speed, range, and flexibility. Actually, it is a function of these three factors. With adequate medical control of forward aeromedical evacuation, the individual casualty is no longer doomed to evacuation to that particular hospital which happens to be in support of his unit. He may now be moved rapidly and safely to that hospital facility best staffed, equipped, and situated for the care of his particular type of wound. This, in effect, places specialized surgical treatment in direct support of every forward surgeon.
This selectivity further promotes the effectiveness and economy of forward medical service. Specialist personnel may now be concentrated in designated facilities, and there is no requirement for staffing each hospital for the care of every type of patient. Surgical lags may be minimized and the patient loads equalized among available hospitals. The capabilities of forward treatment facilities are preserved by effective property exchange. The mobility of forward medical facilities is improved by the existence of a means for rapid atraumatic evacuation of large numbers of patients, permitting such units to displace without leaving large holding detachments.
1. Neel, S. H., Jr.: Medical considerations in helicopter evacuation. U. S. Armed Forces M. J. 5: 220-227, Feb. 1954.
2. Neel, S. H., Jr.: Helicopter evacuation in Korea. U. S. Armed Forces M. J. 6: 691-702, May 1955.
3. Beebe, G. W., and DeBakey, M. E.: Battle Casualties. Charles C. Thomas, Publisher, Springfield, Ill., 1952. p. 257.