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Professional Considerations of Patient Evacuation

Medical Science Publication No. 4, Volume 1

MONDAY AFTERNOON SESSION
19 April 1954

MODERATOR
JOHN M. HOWARD, M. D.


PROFESSIONAL CONSIDERATIONS OF PATIENT
EVACUATION*

LIEUTENANT COLONEL DOUGLAS LINDSEY, MC

Any discussion on the implications of experience in the Korean war must be undertaken in an atmosphere of conscious, continued caution. In spite of how long and drawn-out an 18-month tour of duty felt to me personally, I still realize keenly that the Korean war offers only a fleeting espisode for historical analysis. This is not to say that generalizations cannot be made; they should be. We must continually develop, revise and supersede our policies, plans and procedures. But conclusions must be drawn only after sober, skeptical, philosophical reflection. Generalizations founded on the Korean war stand on a narrow base, and if the process of broadening and projection is not carefully done, the whole structure will topple under the stress of trying to fit it to a very slight alteration of circumstances. There is a tendency either to accept a single experience in Korea as setting the pattern for the future, or to ignore all of our experience there as invalid for future planning on the basis that it was so unusual or specialized as to be generally inapplicable.

I would like to quote just a few examples of hasty conclusions that have been drawn from experiences in the Korean war. At one time, a great difference between cold injury rates between two successive winters was quoted widely as heralding the effect of improved clothing and equipment, and improved leadership and discipline. Yes, these factors did vastly improve between the two winters, but no mention was made of the overpowering effect of the vastly different tactical situations: in the first winter we were fighting desperately, and moving often. In the second winter the lines were stable, the fighting much less severe, and shelter was more plentiful and better developed. This patent error was made in the face of the fact that a similarly fallacious conclusion was made in World War II, in comparing the rates for successive months of the winter of 1944-45 in Europe, and that error was later openly disclosed. Incidentally, the hue and cry over the rigors of the Korean winter obscures the fact that the climate


*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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at the 38th parallel is comparable to that of northern New England and that at the Yalu is no more severe than that of Montana.

I have seen the statement made, with relation to the difficult terrain and lack of communications in Korea, that the problems which we faced in Korea were different from those encountered in any previous operation. It is clear that the author of this statement is enthusiastic, and soundly impressed by his Korean experience, but just as clear that he did not participate in the campaigns in Burma, New Guinea or Italy, nor has he maneuvered in Alaska or trained in the Rockies.

I repeatedly hear officers returning from a limited tour of duty in a limited assignment in Korea extolling the virtues of "the way we did it in Korea" along with heated discussion and forceful proposals to the effect that this is the best way to do it, and the way it shall be done henceforth-all this without realization that the particular interval organization, or mission, or function, or equipment for the unit in question was designed by the responsible planners to fit particular circumstances, or was a frank expedient and improvisation, reluctantly accepted by higher headquarters to make the best of the limitations of a bad situation.

I have seen an official statement made that the bunker aid stations, during the static phases of war, carried heavy excesses of dressings, splints and plasma. Since frequent moving tends to shake a unit down and immobility tends to promote a buildup of supplies, this is an entirely logical conclusion in theory. Typical illustrative photographs of aid stations appear to lend impressive support to this thesis. Further, if the author of the statement had interviewed a number of battalion surgeons their testimony would have wholly supported him. But actually the aid stations were not carrying an excess and were even dangerously low in the basic supplies needed for support of battle casualties. At that same time I was concerned enough about the ability of the forward installations to support the initial phases of a push that I made a survey, based not on interview or observation, but on actual count. The cold fact is that the battalion surgeons did not know what their basic authorizations and requirements were, and I did not find a single installation whose supply of splints, dressings and plasma came up to the basic load, much less exceeded it. The static period promoted the acquisition or fabrication of fancy equipment and frills, but the low flow of casualties during most of the war promoted the acceptance of an abnormal baseline. As soon as there occurred a brisk flow of casualties, it was seldom regarded as "normal" to an "average" battle situation, but there was a tendency to scream for reinforcement in personnel, send in an immediate emergency requisition for supplies and emphasize the moving out of patients as


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rapidly as possible, an emphasis on transportation at a certain expense to treatment.

The point of this last example is that whenever the factor under consideration is subject to objective comparison or quantitative measurement, such comparison or measurement should be made. When the matter is one of opinion, one should get as many separate opinions as possible.

Much of what I have to say will be prefaced by "I feel," "I think," or "I believe," since I alone stand responsible for the conclusions, estimates, and recommendations I present, and since determinations of degree of success or fortune and recommendations as to what things might have been done better, or how, are often matters of opinion. However, this presentation is based in great part on material developed for formal staff studies in Headquarters, Eighth Army. Most of it has been included in various official reports from that headquarters. It represents much careful, objective consideration. I feel that it meets The Surgeon General's injunction to all of us speakers that we offer thoughtful, documented analyses.

In exercising your caution and skepticism in appraising even my own material I ask you to remember-and I will remind you of it frequently-that during most of the Korean war the front was geographically stable. During that same period United States casualties were relatively light, with sporadic periods of heavy casualty flow, limited in time and limited in the sector and units involved. We were able to settle down, smooth out the rough spots and, generally speaking, offer custom-made, personalized professional service to every serious casualty. We will not be able to do this to the same degree in a moving situation, or in a situation with a sustained heavy casualty flow.

In particular, I feel that much of the specific medical research that produced the technical data which are to be presented to you in this symposium was vastly facilitated by the peculiarly favorable circumstances that existed in the latter 2 years of the war. Research, in all the branches of the Military, is following hotly on the heels of the combat troops, and some of the operations research actually goes on out in the combat squad area. The accomplishment of Army medical research teams was phenomenal. I am too conservative a pessimist to state that they could not have done as much in the face of heavy fighting and a moving front, but it would have taken a great deal more effort, inconvenience and administrative and logistic support to do so. In such a situation I think the pattern and orientation of research will change.

No matter how hot the battle and how rapid the maneuver, there is room for clinical research in the forward areas. What I have in mind


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is the type of work that Jahnke and Hughes did in vascular surgery, and a great deal of the work of Artz and Howard (at least 70 percent of it) in which the laboratory element was minor. We need some of this research even farther forward: a number of men with broad surgical background, mature judgment, sincere interest and staunch heart-to go up and work with battalion surgeons, or as battalion surgeons, for extensive periods, then reflect and recommend on what they see.

If the surgical hospital is moving 2 or 3 times a week, 8 to 10 miles per move, I think you will find it rather difficult to carry out there any intensive technical research involving the more complicated laboratory determinations. If it is deemed essential to do so, the mission can be accomplished by reinforcing the host hospital with transportation, personnel and other support facilities. It would appear more feasible, however, to arrive at the same result by giving the team a permanent base more to the rear, feeding to it by air the patients, specimens or data collected and selected by the clinical members of the team working at the forward location.

The system of medical evacuation in Korea is familiar to most of you. It is basically the same as that of World War II and World War I. A medical soldier-the company aidman-accompanies the infantry platoon into combat. He administers emergency treatment on the field of battle and places the wounded man in a sheltered location, if possible, for somebody else to come and pick him up. He cannot linger long; he must keep up with his advancing unit. Casualties in the engagement may number 2 or 40 and the last of the number may be the one who needs him worst, or with the least delay.

Usually, the conditions of fire and terrain are such that the casualty is moved initially by the backbreaking method of litter carry, possibly with relay by surface vehicle. At the battalion aid station he is seen for the first time by a doctor, on whose professional skill the lives of the seriously wounded depend. No surgical hospital or general hospital can save a life that is lost at this station or in front of it.

After such treatment as is indicated at the battalion aid station the casualty is moved-practically always by a mechanical means of transportation, surface or air-through one or more field-type installations before reaching a true hospital. At the hospital he receives definitive surgical treatment and becomes more a "patient" than a "casualty." In this and successive hospitals the patient receives surgical care entirely comparable in quality and scope to that administered in civil hospitals, though slightly different in technic. The major difference is that his hospital care involves several separate hospital staffs in several successive locations. Some of the hospitals in the casualty evacuation system deal customarily only with strict surgical emer-


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gencies. Others, though dealing with traumatic surgery, which in civil life is usually regarded as an emergency regardless of degree, receive patients of a deferred or lesser priority.

Professional considerations are vitally important throughout every stage of this process of moving casualties to the rear and treating them at the same time. However, based on the invitation of Colonel Stone, I have selected for emphasis certain specific points of direct professional interest. These are:

The importance of battlefield treatment.
The professional function of the battalion aid station.
The role of the clearing station.
The mission of the surgical hospital.
Patient holding operations.
Allocation and use of evacuation facilities in Korea.
The utilization of evacuation hospitals.

The Importance of Battlefield Treatment

It is difficult to emphasize sufficiently the importance of initial treatment on the battlefield. What the wounded soldier does in his own behalf, or what his infantry colleagues do for him; and what the company aidman does for a traumatic amputation or gaping wound of the chest, in the thick of battle, in dust and heat or in blowing snow-on these simple procedures depend life and death.

Major Mallory and Dr. Scott have already mentioned these things. I wish only to add my own emphasis and indicate that they are matters for professional concern. A slight improvement in the skill and judgment of the company aidman will save us more human lives than will the attainment of 100 percent perfection in the surgical hospital.

But this development of the company aidman and changes in the standard procedures for infantry first aid must be founded on professional considerations, and the stimulus will have to be provided by professional people. The line are generally satisfied with, or proud of, their aidmen. They extol their hardihood and sacrifice, and other rugged and simple virtues, but express rather little concern over their technical competence.

There are differences of opinion regarding the aidman, even regarding his basic position in the military scheme. Some feel that this man is an infantryman first, to be skilled in the rudiments of first aid as an afterthought. It is true that unless his knowledge of the craftsmanship of battle is adequate he will never reach the side of the subject of his ministrations, and true, also, that in many armies


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he is a member of the loyal regiment of infantry, rather than a member of the Army Medical Corps. Even in our own United States Army Medical Service many feel that he is an inferior being in the medical enlisted field. This should not be. I can take any clever meatcutter, carpenter, or mechanic and develop him into a highly competent surgical operative assistant. Something more than that is needed in the company aidman. It takes men of intelligence, moral purpose and ambition, but, most of all, judgment, which cannot be developed by brief practice and study. We will not get men of this caliber until the professional people in the Army Medical Service realize their importance and support a degree of precedence for the selection, training, and assignment of them.

A word about the litter bearer, who links the company aidman with the battalion surgeon. He is still with us. He was not replaced in Korea by the helicopter, the tramway or the Korean Service Corps. In Korea the helicopter rarely operated forward of the battalion aid station. And even later, when the machine is plentiful, it will not customarily operate on the actual battlefield unless the character of battle has so changed that the infantryman is no longer on foot, nor in an armored vehicle. That time is not nearly at hand.

We tend occasionally to count the short time lag between the battalion aid station and the surgical hospital operating table, and to be smugly pleased without thinking of the time spent forward of the aid station. In a stable, permanently developed sector with tramway or jeep road to the top of the company hill this time is not greatly significant. Without these improvements, and depending on litter haul, the time span is tremendously increased, and the initial treatment, treatment en route and treatment in the battalion aid station are commensurately increased in importance. In virgin terrain in Korea a litter squad could be expected to make approximately 100 to 300 meters per hour in horizontal distance. Thus an aid station 500 meters away from the company on the hill is 2 to 4 hours distant. In special circumstances this time distance increases even more. In a night outpost action, a man wounded before midnight often will not reach the aid station until 1000 the next morning, and I know of one outpost in Korea that required (I am told) a litter haul that was 36 hours round trip. I accept this staggering figure as true, since I personally verified the fact that the litter haul from the main battle positions of each of the three battalions of the regiment was not less than 8 hours. These difficulties were not peculiar to Korea, and we will have the same problems in many of the possible battlefields of the future.


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The Professional Function of the Battalion Aid Station

The professional considerations involved in medical service operations forward of the battalion aid station are not readily apparent to the outside observer, but the problems in the aid station itself are more orthodox and more familiar to you.

Here we have a graduate M. D., and we have equipped him well to perform professional resuscitation. Some of his professional capabilities have been outlined by Major Mallory and Dr. Scott. The physical appearance of his office may vary widely. It may be a hastily parked vehicle, with blankets, splints and a few opened chests. It may be a bunker, with electric lights, white sheets, a bubbling sterilizer and neat shelves of drugs and dressings. At any of these places we can do as good a tracheotomy or thoracentesis as on any university hospital pediatric or surgical ward. We can cut down on a vein and give blood under pressure. The distribution of blood to forward stations is something we did not have in World War II. It is an improvement in service we can keep up in the future, and is not to be considered a luxury made possible by the static situation in Korea, to be lost in the event of moving warfare.

In spite of these facilities, professional resuscitation was often neglected. And a lot of us are to blame. Through two World Wars and Korea we have passively sustained, or actively contributed to the discouraging misconception that the battalion surgeon is nothing more than a commissioned aidman. Many of these men believe that, and when they do believe it, they act it. With that attitude and the availability of the helicopter they become transportation agents and their activities there seldom exceed the changing or reinforcing of the dressing, the starting of one bottle of blood or dextran, and moving the patient out as rapidly as possible, almost first come first served. One too rarely sees a casualty retained in the aid station for intensive therapy to insure that he will stand the trip to the rear and not arrive at the surgical hospital dead or dying.

One of the best characterizations of the battalion medical officer (1) indicates that ". . . he must retain coolness and calmness and must show a near perfection of surgical judgment under the most adverse conditions. Surgical judgment is that indefinable but essential attribute compiled of just the right mixture of a stable nervous system, past surgical experience, common sense, and an ever-ready diagnostic ability." I am sure we all agree. Yet we persist in labeling the position one for MOS 3100: Medical Officer, General Duty. The people who hold this MOS are typically either lieutenants fresh out of internship, without advanced training, or general practitioners, also-too often-without graduate training. We persist in this even


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in the face of a great scarcity of men of this MOS, and a great surplus of specialists of various sorts, who are better suited for the job.

By far the best battalion surgeons we had in Korea were the specialists who went into those jobs by reason of that scarcity and surplus. Of the battalion surgeons I knew well, the three best were a board-qualified surgeon, a board-certified internist, and a board-qualified obstetrician. We can use the untrained and inexperienced men in hospitals in the rear, where they can work and learn under supervision. The battalion surgeon stands on his experience alone, and we must have the best for the job. When the time comes in major mobilization that we do not have a surplus of residency trained men, we must provide the battalion surgeon with specialized military professional training to qualify him for this job.

One professional problem in battalion medical service that we have not squarely met is the question of just what is the function of the Lieutenant, Medical Service Corps, who is assistant to the battalion surgeon. Are we offering him as a "stand-in" substitute for the battalion medical officer? Surely not, with the limited training and experience that he has. When a battalion surgeon is killed or wounded or goes on leave the MSC officer does not succeed him; a medical officer replacement comes from the collecting platoon or the medical battalion. Is the MSC officer there as an administrative or managerial or tactical assistant? Surely not. This is a travesty against sound principles of management, a farce in the face of need for personnel economy, duplicating the functions of the platoon sergeant, and an insult to the everyday business judgment of the average practitioner of medicine.

There just is not enough administration in a battalion medical platoon to call for an officer to manage it and there are not technical or subprofessional duties appropriate to officer grade. Warrant officer? Perhaps, as the top rung of the enlisted field medical career ladder. But officer-no. This position appears wholly anomalous until we look to history for the explanation and find it to be not an anomaly but, now, a useless vestigial appendage. Prior to 1944 our Tables of Organization gave two medical officers to the infantry battalion: a Battalion Surgeon, and an Assistant Battalion Surgeon. It was considered that our medical manpower resources, even on our lush staffing of World War II, could not support both positions and one was reluctantly dropped. It was not that the job did not exist, but we did not have men to fill it. The Marines still have two doctors per battalion and I have not heard the incumbents of those positions complaining that their services were not needed, nor that one of them was primarily a platoon administrator.


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In World War II the first group of Medical Administrative Corps (MAC) officers was specially selected and specially trained. Frankly, I learned a great deal about combat medicine from the second lieutenant, MAC, who was on the ground when I came in to take over as an Infantry Battalion Surgeon. This is both a tribute to his own ability and a frank appraisal of the sketchy nature of the training I had received in military medicine. The first group of MAC assistants included typically two types of men: oldtimers in the Medical Department, well versed in their trade, and commissioned as officers in the expansion of the Army; and others of less military experience, commissioned in the medical branch on the basis of paramedical civilian background. They received intensive training in advanced first aid, and went out with commendable enthusiasm to do their share in a major war.

These conditions do not pertain now, nor did they pertain during the Korean war. In the first few months in Korea, career Medical Service Corps officers-Adjutants, Registrars and Supply officers-went out from administrative positions in the Far East Command and substituted for the Battalion Surgeons and Regimental Surgeons that the Army did not have. As lieutenants, captains and majors they actually assumed the responsibilities of Medical Corps officers and carried out professional functions.

During the latter part of the Korean war, our typical assistant Battalion Surgeon was an officer on his first field assignment, with a few weeks of medical service training, after a direct commission on the basis of a bachelor's degree in anything from law to anthropology, or officer candidate school training in infantry or artillery. The former group could not be fully considered as officers, but only as commissioned technicians, and working at the moment out of their technical field. The latter group could be considered, at best, forced emigrants from the combat arms, and at worst, fugitives from a rifle platoon.

If we are going to train this officer sufficiently well to have him function as an effective medical assistant, we are going to have little time left out of a 3-year Reservist's career. Worse, we will be embarking on the treacherous policy of giving some appearance of accepting a second-rate class of physicians. Even if we gave the officer a great deal more training, it would be foolish to expect that he would render any technical or subprofessional service that could not be performed immeasurably better by a good sergeant with 6 years of experience in the Army Medical Service, and the latter would be performing the obviously legitimate function of a nonprofessional technical assistant.


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The Medical Service Corps certainly cannot sincerely mourn his loss. A year or so of service in a position combining, in effect, the duties of a senior dispensary clerk and a medical technician is not valuable preparation for an ultimate position of great responsibility in the administration of a hospital, or management of a medical depot.

The type and extent of medical care offered within the battalion aid station has been admirably presented by Major Mallory. I have been asked by Colonel Stone to discuss the professional considerations involved in evacuation of patients from the battalion aid station. They can be rather simply outlined:

1. The battalion aid station is no place to maintain a ward-the patients should be returned to duty or moved on as soon as they can travel.

2. No patient should be evacuated who has not received the benefit of treatment which is available at the aid station:

a. Bleeding should have been stopped, unless stopping it requires an actual operative procedure.

b. A patient in shock should be improving, or stabilized, unless it appears clear that treatment beyond the facilities of the aid station is the only means of improvement.

c. A major fracture of a long bone should have been adequately splinted.

d. The basic mechanics of respiration should be intact.

3. No patient should be evacuated unless be is in condition to survive the journey under the specific conditions he faces; and, conversely, the sequence and means of evacuation should be a matter of specific priority and individual selection.

These criteria admittedly seem trite. Let me assure you that they are violated often enough to require continuing supervision to insure their enforcement.

None of these considerations require elaboration except possibly the statement that the battalion aid station has no holding ward. I reconcile this with the accepted handling of a mild combat-induced anxiety state by choosing to regard these men, held overnight for a little rest and reassurance, not as true patients. The further forward they are retained, the better the result. This principle does not hold so strongly in the case of minor medical illnesses, and a more appropriate place to hold these patients for treatment and recovery is the regimental collecting station.

A restriction against holding patients at the battalion aid station in no way impedes the battalion surgeon in his mission of preventing the loss of military manpower of the battalion, or detracts from the importance of that mission. He should be able to treat promptly,


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and immediately return to duty, a significant proportion of the wounded who reach this station. Not every little wound requires a formal débridement, and rear hospitals see too many utterly trivial wounds for which a band-aid would have been sufficient treatment. Occasionally we may err, and cover with a dressing and dismiss with reassurance a trivial scratch which actually is a significant wound of entrance. Conscientious diagnosis and judicious followup will make our misses in this type of case actually more rare than they are in traumatic surgery in civil life.

Evacuation from the battalion aid station is typically by two means: surface ambulance and helicopter. Evacuation from the aid station by litter bearer was almost never required. Physical conditions usually permitted the 3/4-ton ambulances of the division medical battalion to be used as far forward as the battalion aid stations, but tactical considerations or formal policy of the division or regiment often precluded their use ahead of the regimental collecting station, in which event the surface vehicles utilized were the litter-jeep ambulances of the regimental medical company. This vehicle is an abominable improvisation retained in service because of our failure to develop anything better. The six-wheeled, semienclosed jeep ambulance proposed by General Shambora from Army Field Forces during World War II would have been the answer, but it was not accepted. The new 100-inch wheelbase, 1/2-ton vehicle may be the answer, but I have seen little come of it yet.

The 1/4-ton litter-jeep ambulance has few flat limitations, but a number of relative drawbacks. It is awkward and uneconomical. In cover and comfort to the patient it is no better than a litter haul, but it moves somewhat faster and is much easier on the litter bearers.

The new 3/4-ton ambulance (M37) is, on the whole, a good vehicle. It is heated and lighted and has space for an attendant to work. It takes a little finagling to load into it patients with large splints, but otherwise it has almost no limitations, from a professional standpoint, for use in the forward areas.

The indications for helicopter evacuation expand in direct proportion to the availability of the machine. I doubt if we should ever consider using it for routine evacuation; that would be a luxury we can ill afford. Here is my listing of indications, in order of priority:

    1. True surgical hospital cases: wounds of the belly, chest and head; and any case with uncontrollable hemorrhage or unresponding shock.

2. Other serious cases, when the time, distance and other circumstances of available surface evacuation indicate significant detriment to the patient: fractures, major extremity wounds,


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    heavily sedated or comatose patients, hemorrhagic fever, major burns.

3. Other patients, on the basis of comfort and convenience of the aerial means, for example: mumps, moderate burns, major contusions and sprains, less severe wounds.

4. Routine: consultations, laboratory referrals, colds, minor wounds.

We had, in Korea, sufficient lift for the worst of the priority 1 group, except during a few periods of unusual activity. This lift could not be portioned out with 100 percent efficiency, and sometimes the machines were down for maintenance, or off on less important missions, or the night was too dark to fly. Roughly speaking, something less than half of the true surgical hospital group was moved by helicopter.

No formal establishment of priorities was necessary. When casualty flow was heavy the unit surgeons selected the worst cases. When casualty flow was light, unit surgeons made almost as many requests for helicopter missions, but were far more liberal in selection, and many of the second priority group could then be taken care of. A tenfold difference in casualties between two successive months would be marked by only a 20 percent difference in missions flown.

Hemorrhagic fever patients, or reasonable suspects, were arbitrarily accorded first priority, and many of us felt that the rapid and smooth evacuation to a conscientious nursing staff contributed as much to the lower mortality as did the complex and intensive treatment after admission. I have, however, listed these patients in the second bracket, so that priority 1 will serve also as the criteria of selection for evacuation from the battalion aid station to the surgical hospital. Generally speaking, with the helicopter lift that we had in Korea, any evacuation by helicopter from the battalion aid station habitually meant an admission to the supporting hospital, with the exception of the hemorrhagic fever patients who were flown all the way back to the hemorrhagic fever center, or transferred (near the surgical hospital) to light fixed-wing aircraft for the longer rear lap. When a decrease in casualties made possible a broadening in selection of patients for helicopter evacuation, the surgical hospitals took a wider variety of patients. Thus in a quiet period a casualty with a bullet wound through the thigh was flown to the surgical hospital and operated on there. When things started popping, he went by ambulance and rail and was operated on in Seoul, or even Pusan.

The group of patients who are not first priority surgical cases are right now of greater interest to me than those who are. They have not been so much publicized, their plight is not dramatic, success or failure of treatment is not as clearly portrayed as is an unequivocal change in mortality statistics. They rarely die from direct results of their


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wounds. But they are far greater in number. They take a greater sum total of time and effort in treatment in a theater of operations and they offer more prospect of salvage for further military service.

This is perhaps the time to bring in my own classification of wounds by relative severity. It has no recognized standing; the adjectives cannot be held officially equivalent to any accepted military term; but it is very handy for rhetorical purposes.

The "band-aid" wound is trivial or insignificant, if the physical and psychological makeup of the soldier is such that he dismisses it after a wipe with a dirty handkerchief. It is minimal if the soldier insists on bringing it in to the medical officer, for an official tag to make him eligible for the Purple Heart.

The slight wound that requires only débridement and delayed closure is minor if it can be treated at the division clearing station. The soldier definitely has been wounded. He can be treated and returned to duty by the medical service of the combat division.

The soldier with the moderate wound cannot be restored to duty from the division clearing station because of the time required for healing and convalescence, but the wound may be appropriately subject to débridement at the division clearing station with the patient being immediately moved to a rear hospital for further treatment, or the casualty with the moderate wound may be moved through the division clearing station to the evacuation hospital for operation there.

The major wound is the typical evacuation hospital case: second priority for helicopter evacuation beyond the surgical means of the clearing station but not demanding immediate lifesaving surgery.

The critical wound is the so-called "nontransportable" of World War II, the typical surgical hospital case, first priority for helicopter evacuation.

The Role of the Clearing Station

The function of the clearing station in the surgical treatment of the minor, and certain of the moderate, wounds was somehow quietly forgotten between the end of World War II and the middle of the Korean war. It came as a shock to the Surgeon of Eighth Army and his staff that the clearing stations supporting the several sharp actions in the fall of 1952 had degenerated into simple relay posts, where patients were logged out of the division, and transferred to ambulances of the field army medical service. Part of this was certainly due to the fact that the shortage of medical officers forced us to operate clearing stations with 4 or 5, or even 3 officers, compared to 11 provided by the Tables of Organization. That this was not the whole answer is proved by what the clearing stations were able to do with a limited staff later in 1952 and in 1953.


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The doctors were unhappy, and justifiably so; their professional tasks were frankly menial. A tremendous technical and professional personnel potential was going to waste, as were expensive equipment and facilities comparable to those of a well-run hospital emergency ward: oxygen, suction, blood, refrigeration, laboratory, good lights, basic surgical instruments, and a $2,000 operating table-three complete sets of equipment, one in each platoon of the company. But the worst of it was the tremendous burden of minor and moderate wounds that were thrown on the evacuation hospitals. Even with a normal allocation of evacuation hospitals this is not the best handling of such cases, and with the extreme scarcity of evacuation hospital beds in Eighth Army the implications were serious. In an evacuation hospital admitting ward a man with a minor wound finds himself repeatedly and properly, but almost indefinitely, put back at the foot of the list because of higher precedence accorded the more serious casualties who continue to come in. At the clearing station he is, by virtue of the lesser severity of his wound, at the top of the list for operative treatment. After débridement he can wait out evacuation, transfer and admission at various stages without harm.

Rather surprisingly, we ran into a certain amount of resistance or, shall we say, reservation of approval, from consultants at higher levels, when the campaign for resurgence of the surgical function of the clearing station was opened. The objections were on clinical professional grounds; the operational advantages were accepted. The main objection is evident: The clinical determination of a wound as "minor" can never be absolutely certain, since even the most insignificant appearing puncture of the thigh may involve the abdomen, or a trivial laceration of the shoulder may involve the chest. This criticism is not wholly valid. We must not discredit clinical judgment in favor of wholesale x-ray and laboratory examinations. And, at the battalion aid station or clearing station, when the clinical diagnosis is that the wound of the thigh does not involve the belly, the patient automatically is placed in a low priority and evacuated by surface transportation to an evacuation hospital. If the initial clinical diagnosis is wrong, the proper diagnosis will then be made only after the long delay of evacuation or after development of significant peritoneal symptoms en route. Surely this is not preferable to making the diagnosis at the clearing station by débridement and surgical exploration of the wound track.

The system received enthusiastic approval and support by the Surgical Consultant to the Eighth Army Surgeon, whose criteria for operation at the division clearing station have been published (2). Wounds


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involving the cranial, pleural, and peritoneal cavities, and wounds with fractures of long bones or associated vascular or peripheral nerve injury were excluded.

The need for equipment and personnel to administer general anesthesia was expressed by several divisions. On this subject there are mixed feelings. In one instance we furnished apparatus to a division which had a qualified medical officer anesthetist assigned, and it was profitably used. As a policy I am against it. In practically all cases that meet the spirit of the criteria for operation at the clearing station it can be done under local anesthesia.

X-ray equipment is another question. It is not particularly dangerous to use; at least mistakes are not so likely to be fatal in radiology as in anesthesiology. I fail to see that it is essential for the performance of minor surgery of high professional quality, or for the selection of patients for operation. But I feel that it might be justified, on the basis of reduction of manpower loss from disease and nonbattle injury, provided the situation were quiet, or the requirements for additional personnel, transportation and electric power in the division medical battalion were clearly met. The Table of Equipment of the clearing company may be the place to use up (on the basis of one per company, not one per platoon) the recently developed 15 ma. units which most of our hospitals ignored as useless and wanted no part of.

To summarize the role of the clearing station, and the professional considerations in its operation:

Functions:

1. To serve as an infirmary for minor medical illnesses, and an emergency ward for wounded.

2. To treat and return to duty appropriate patients.

3. To log out from division records those casualties requiring treatment by other installations, for whom replacement will be required.

4. To offer small-scale "medical center" services for the practitioners in forward units: laboratory, pharmacy and consultation.

Professional considerations in evacuation from the clearing station are:

1. Is further evacuation necessary; or can the patient be treated, held and returned to duty without losing him from the division?

2. Is immediate major surgery necessary? If so, the patient will be transferred to the adjacent surgical hospital, which is also receiving patients by helicopter direct from the battalion aid station.


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3. If the wound does not require immediate major surgery, is it properly operable at the clearing station? The patient will in either event be transferred to a rear hospital-after, or for the purpose of, surgery.

The Mission of the Surgical Hospital

A great deal has been said, written and discussed about what the surgical hospital is supposed to do, and how. Some of the presentations are hasty or prejudiced; a few are contradictory; many are controversial. In spite of the fact that the basic Table of Organization and Equipment was evolved only in 1945, and the only actual experience with the organization was obtained in Korea, which I have already cautioned is a limited experience, I feel that the mission of the unit is perfectly clear. It is the mission officially proclaimed in the Training Circular, Field Manuals, and Table of Organization and Equipment: to provide a mobile surgical facility for the treatment of seriously wounded casualties within the division area.

You are all familiar with comparable units used in World War II: the Portable Surgical Hospital in the Pacific, and the Field Hospital platoon (reinforced with surgical teams) as originated in the Mediterranean and later successfully used in Europe. These two organizations met the pressing need for major surgical facilities located well forward. When the front is moving, "well forward," of course, means truly mobile. Our former surgical hospital, which many of you may not remember, was a 400-bed unit, well equipped, but unwieldy.

In the early days of the Korean war the surgical hospitals were expanded into 200-bed units comparable to half-scale evacuation hospitals. They were located well behind the division cleaning stations, on the line of communications between the divisions and the so-called evacuation hospitals, which then in reality represented a combination between station hospitals and communications zone general hospitals. The 200-bed unit received any and all patients from the divisions, thus contributing indirectly to the deterioration of the clearing stations.

The initial reasons for using the surgical hospitals in this manner did not long persist. It was found feasible and quite desirable to locate the surgical hospitals well forward and to institute an effective selection system in the clearing stations. Although it was not until February 1953 that the 200-bed Table of Distribution surgical hospitals officially returned to 60-bed Table of Organization status, they functioned as the latter throughout 1952. They were not, however, located always directly adjacent to division clearing stations. Divisions on line were rotated frequently, and a United States division was often replaced by a division of the Republic of Korea Army. In view of the well-developed communications we had at the time,


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and in deference to the convenience of the units and the heavy investment they had in comfort and luxury construction, they were left slightly to the rear of divisions, in central locations from which they could normally support any division sector within the corps. It was not that they could not operate forward, or could not keep up with a moving division. Each of them proved, in realistic training exercises (in which the Communists happened to cooperate unknowingly by throwing local attacks and producing casualties), that they could leave behind their buildings and walkways and clubs and fancy quarters, load up the tentage, and go. They did beautifully. They proved the adequacy of the current personnel structure, equipment list and training doctrine.

Table of Organization and Equipment 8-571A (15 October 1952) is instrinsically adequate. It can and will be developed and improved upon, but right now it provides for an organization that can turn out professional work of a consistently superior quality.

The hospital needs a 5 to 10 percent increase in enlisted personnel, in the administrative and specialist fields, and a redistribution of duties among the personnel now on the Table of Organization. It needs a moderate increase in electric power, and a definite increase in tentage. About one-third of the tentage needed to set up a perfectly orthodox installation is not authorized by the Table of Equipment, which provides nothing except pup tents for personnel quarters, and no shelter for the mess except a kitchen fly. But any proposed change must be exhaustively considered on both clinical and operational professional grounds. The restrictions on personnel available to us in Korea, and likely to be available to us in the future, are painfully tight, and almost harshly inflexible. In ultimate principle the decision we may have to make with reference to a major addition will seem crudely blunt: Will the sum of our military patients benefit more from a smaller number of units that are a little better, or from wide distribution and close support by the same or greater number of units that meet the then current standards of best professional practice?

The surgical hospital is designed, equipped and staffed to perform-with the highest professional standards-formidable initial surgery of all types. Its special characteristic in this respect, distinguishing it from evacuation hospitals, general hospitals and large station hospitals which can, technically, perform the same operative procedures, is that it is small enough, light enough and flexible enough to offer this surgery in a physical location which assures a reasonable minimum time distance from point of wounding to the operating table. Being small, its facilities should appropriately be reserved for the treatment of those patients for whom time lag is of pressing importance. I


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offer the following as a loose list of wounds in order of anatomical and physiological priority for admission to the surgical hospital:

Uncontrollable hemorrhage or shock
Belly
Throat
Head
Chest
Extremities: gross wounds, or those with known or suspected major vascular damage.

A detailed discussion of the treatment accorded these wounded is beyond the scope of my presentation.

The professional considerations in arranging evacuation after treatment-selection of the time, the means, and the channel or destination-are relative, depending on just how fast business is at the moment and is expected to be in the near future. I might illustrate this by presenting several of the criteria that were utilized at various times for deciding the time of evacuation of patients with one particular type of wound-perforation of the large bowel. When things were unusually quiet in early 1952, our surgeons had time on their hands and hospitals had beds to spare. Some of the men were then repairing the bowel and exteriorizing it for observation, or even making primary repair and closing the abdomen, depending on private nursing and close surgical postoperative care to insure a successful result. I mention these choices to denounce them as inappropriate for general use in forward area military surgery, but a third method illustrates the detailed and extensive treatment that we could give during a slack period. In some cases a proper colostomy was performed, and the patient held at the surgical hospital for final healing, and re-anastomosis of the bowel before he was evacuated further.

When things are not quite that quiet, the patient was held until the colostomy was functioning well and he could help take care of it during evacuation.

When the front was not calm, but tactical action was still sporadic, the patient might be held until the incision was clean and healing. When things were busier, he might be moved as soon as bowel sounds were restored. When the situation was really busy he might have to be moved the day following operation, and when the situation was frantic he might have to move out as soon as he recovered from anesthesia, to make room for someone in a more desperate situation.

The minimun requirement for evacuation of a patient with a neck or deep face wound is the cessation of bleeding, and adequate airway and unequivocal recovery from post-anesthetic nausea. In spite of the discomfort, an ambulance is preferable to a helicopter, until such time


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as we get an adequate helicopter ambulance with room for an attendant to work. Our present 3/4-ton ambulance makes good provision for nursing care en route, in fact, far beyond the technical capacity of our ambulance drivers, who are usually medics in a very limited sense. For special cases, a qualified technician from the hospital can go along for the next lap.

For head cases I must give an equivocal answer. I am still told by some that these patients travel better preoperatively than postoperatively, but I am not wholly convinced. The urgency of an untreated head wound is an overpowering stimulus to assume a manifest risk of transportation. If they die en route, we have done our best and death is held to be prima facie indication that they were unsalvageable. Once they have reached the care of the neurosurgeon, he is understandably loath to release them until he can confidently predict a safe journey. Like most general surgeons I will dodge neurosurgery and request to be relieved of the decision, but if I must state the criteria, as far as I am concerned the head wound patient can be moved as soon as the surgery is over, the patient is in proper position or on the proper apparatus, and his blood pressure is stable. These patients do require competent technical attendance en route. Their relatively small number, their serious condition and their need for close attention warrant the making of special evacuation arrangements. In Korea they were periodically collected by special helicopter lift (preferably by the larger H-19, with room for an attendant) and flown to rear airfields to meet pre-scheduled aircraft for immediate evacuation to Japan. They ordinarily did not pass through evacuation hospitals or intermediate holding facilities.

As for chest wounds, I feel that there is little excuse for evacuating any man from a surgical hospital with a functionally open wound of the chest. Some sort of surgical or dressing closure can be effected. In spite of their inherent appeal, I take a dim view of all sorts of tubes, flutter valves, indwelling needles, or drainage systems. The chest patient should not be evacuated until he is sufficiently stabilized that he can be cared for by intermittent thoracentesis, at intervals that can reasonably be met during the evacuation as planned.

The patient with an extremity wound and vascular injury should, ideally, be evacuated only after the initial reaction of the tissues to trauma is subsiding and the probable outcome from a circulatory standpoint is no longer in doubt. If the adequacy is evident, the consideration is one of mechanical stability of the repair during movement by the means contemplated. If adequacy is yet in doubt, the patient should he held so that he may have the benefit of all available measures to tide the limb over. If the circulation is patently inadequate, the extremity should be dressed to protect it from further


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trauma, but it may as well demarcate during evacuation as in a hospital.

The patient with a grossly damaged extremity does not travel well. A truly mobile rig for an amputation stump is very difficult to fabricate. If the volume of casualties does not preclude it, no patient should travel in a cast that is less than a day old: that day, of course, includes some close observation. No patient should ever leave the surgical hospital in a cast unless the cast is split.

The choice of mechanical means of transportation is based more on the severity of the wound (or rather, the general condition of the patient) than on the anatomical location or type of wound. The ambulance train offers the best facilities for care en route, and gives the smoothest ride; these advantages are balanced against the longer time. The cargo aircraft is second best, except that the shorter time in transit is a partial compensation. The large H-19 helicopter and the 3/4-ton ambulance are comparable to each other in facilities for patient care, though vastly different in speed, comfort and cost. In respect to care en route the small H-13 helicopter does not even come up to the standards of the litter jeep, but its versatility and speed make it an exceedingly valuable machine. Having weighed these various considerations in selection of the means we then come up against the one that is overriding: which one is available at the time?

The traditional means of evacuation from the division clearing station or surgical hospital to the evacuation hospital is by ambulances from separate ambulance companies of the field army medical service. This held true in Korea, but only for the initial stage of the trip to the rear. Patients were transferred from ambulances at the earliest possible point, to make the greater portion of the rearward journey by air or rail. This transfer was indicated on two considerations: the health and comfort of the patient, and the pressing need to conserve our limited ambulance lift.

Patient Holding Operation

At each point of transfer-the railhead or airhead-a facility for the temporary holding of patients is mandatory. At airheads the requirement is based in part on the irregular and unpredictable nature of air transportation. At railheads this factor is less prominent, but then there is the additional requirement for holding patients during the period of buildup of the trainload before the scheduled loading time, even if the rail system is considered absolutely dependable. Our holding facilities in Korea were kept adequate in number and distribution, even when this meant subordinating or shortening other medical support operations.


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The holding unit has never been regarded as glamorous, and there is a tendency to forget the importance of its position in the provision of uninterrupted medical care of the wounded. The stress of an ambulance ride of 1 to 3 hours, from the surgical hospital to a tent on an airstrip or a rail siding, is not insignificant. Added to this is the period of waiting on an average several hours more; sometimes as short as a few minutes, and occasionally longer than a day. The holding station is no place for any patient who is still in the process of resuscitation, but it accumulates patients of all grades of helplessness, with wounds of all locations and all degrees of severity, and in various stages of treatment. These add up to a requirement for a professional operation of some extent.

Our holding units in Korea were adequate in capacity, physical facilities and equipment, but I was never particularly proud of the caliber of their professional work. The screening and rescreening of patients, interim medical care and nursing-even in the simple arts of bedding down and feeding the litter patients-left a great deal to be desired. There is nothing wrong with the "system" that requires that this be so. On-the-job training, repeated indoctrination of personnel, and continued interest and supervision by nursing and surgical consultants will take care of it in time.

Allocation and Use of Evacuation Facilities in Korea

Our allocation of ambulance companies in Korea was about half what was required. I make this blunt statement with confidence that I can support it both on theoretical and practical grounds. I will mention it further in my later discussion on Evacuation and Specialty Centers. But you may ask now: How can it be said that we had only half enough when we obviously did well enough with what we had? We were able to operate an admirable evacuation service only as a result of the following special blessings:

1. The availability of common carrier (rail and air) transportation in the forward position of the combat zone.

2. The low average casualty incidence during most of the war.

3. The courtesy of the Communist air force, and our faith in the ability of the United States Air Force to maintain air superiority.

In the eastern half of the front, evacuation was principally by air. The forward rail network was wholly lacking. A single-track line ran up from the south to a point just over the combat zone boundary and angled over to connect with the main western line at Seoul. In the forward portion of the combat zone there were four major valleys or plains, each with an airfield located not more than 11/2 to 2 hours away from the usual location of division clearing stations and surgical


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hospitals during the latter half of the war. Holding units at the airfields assembled the loads of patients of all types (toothaches, backaches and consultations included), logged them in and out, and prepared the flight manifest before the aircraft arrived. And, of course, they held and cared for the patients during the process. The typical length of stay for patients was 3 or 4 hours, sometimes overnight for those with minor injuries evacuated direct from division clearing stations, sometimes only a few minutes for seriously wounded patients handled specially on an "appointment" basis. These figures apply, of course, only if the airplane flies as scheduled. I bitterly recall one month in which weather closed a key field for 13 days, 10 of them in distressing direct succession. At such times we necessarily used ambulance transportation, at a minimum of 11 hours per round trip. Under those circumstances we simply could not have supported a division attack against determined resistance, without evacuating the less seriously wounded on ammunition and supply trucks returning to the rear over the same long haul. In general, we could not have operated an efficient medical evacuation system in the eastern sector without the help of the Air Force. We are deeply grateful for the favor. It is not a statutory function of the Air Force to provide air evacuation within the field army area, but only from the combat zone to the communications zone. This is an assigned function of Army aviation, but diversion of all of the aviation in Eighth Army to purely medical missions could not have done the job, nor will Army aviation ever be able to do it with aircraft of the present type.With the exception of the H-19 helicopter, no Army aircraft in current use is an adequate patient-carrying vehicle. And the H-19 is far too expensive and complex a vehicle to use for routine hauling.

It may be heresy to suggest it, but Army aviation, or more specifically Army Medical Service aviation, should include aircraft comparable in capacity to the workhorse C-47: say, light assault transports of the C-122 type. Such a vehicle could be profitably used in the lateral and rearward movement of patients entirely within the army area, and there is no more basis in statute or logic that it be operated by the Air Force than that the Navy take over from Army engineers the operation of river-crossing rafts. A flight of six C-122's could have been economically employed by Eighth Army even during its quietest periods, and a squadron of 18 would have been barely sufficient during the most active times.

My only criticism of air evacuation in Korea was in the mechanism of control. Once the aircraft was allocated and scheduled, the service by the air crews and medical crews was superb. But getting the aircraft was a constant struggle, at least during the latter half of the war. We had to call Japan, a day in advance, for every aircraft that we


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used, even though it was used only between two of our own units in Eighth Army. We were required to substantiate our request with the actual numbers of litter patients and ambulatory patients to be moved. We naturally took to the crystal ball rnethod of making such computations, since many of our patients to be lifted tomorrow have not yet been shot today. When our forecasts were badly off, or even initially when we made any unusual or ostensibly odd request for air lift, we were criticized by the people in the Air Force medical evacuation unit and called upon for an explanation. I have spent hours of valuable time, and many dollars of the taxpayers' money, for long calls over Japanese toll lines trying to make, without breaching security, an explanation which, I sincerely believe, is of no legitimate concern to the Air Force except as a matter of historical information. If air evacuation is going to be useful and dependable, our allocation of lift capacity should be definite, and the answer at the other end of the telephone should be positive: "Yes, we can do it," or "No, we cannot do it" (the lift is technically not feasible, or aircraft are not available), or "We can do only so much of it, or we can do it at another time," never a negative and indecisive "Why do you want it done?"

We did not have the same problem with rail evacuation, which supported our medical units on the western half of the front. The hospital ward cars and the medical crews belonged to a unit of the Army Medical Service; the railroading was in the hands of units of the Transportation Corps. Both these units functioned under the communications zone organization which supported Eighth Army, but with respect to the service they rendered and the channels of request and control, they might as well have been integral elements of the office of the Army Surgeon.

The usage of rail evacuation in Korea was prominent at all stages of the war. In the Pusan perimeter the rail system was well developed. In the fluid phases there were many examples of effective utilization of various short stretches of track and all sorts of odd rolling stock. During the latter half of the war there were two preeminent features: first, the extensive use of rail transportation-there was even a baggage express system up to several of the division areas, and we belatedly started moving some of our blood shipments by rail-and second, the proximity of rail operations to the frontline. Some of the major and long-used railheads were within range of enemy light and medium artillery (the enemy proved that for us), but even so there were raised eyebrows in the Army staff when the medics established a holding facility at a lonesome terminus only 9,000 meters from the frontline. This installation was frankly invaluable in support of the Triangle Hill and Whitehorse Mountain operations.


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Except in periods of consistently active battle it was unnecessary to run ambulance trains more often than once daily; the two to four divisions supported by that rail line generated a one-train patient load each day. The hub of our rail operations was Seoul. There the seriously wounded patients were off-loaded for air transportation to Japan. Less seriously wounded men-those who could be expected to recover within the time period of the current evacuation policy-went on down the line to hospitals in the communications zone.

Except for such patients as were flown by helicopter direct to hospital ships in the harbor at Inchon, the 1st Marine Division was supported by rail, from Munsan, through Seoul to Inchon. With the extreme tides that occur at Inchon it was necessary to schedule the trains for the port siding at the time of a high or rising tide. Since hospital ship patients who were evacuated from the ship to Japan also came in by rail from Inchon to the airfield, this was an operation that epitomized tri-service cooperation.

The function of the hospital ship in Korea is indicated by the fact that it retains that title yet, while the late "hospital" train is now more aptly called an "ambulance" train. The hospital ship was utilized as a floating hospital, primarily as an evacuation hospital for the 1st Marine Division. Its role in the transportation of patients was only incidental. As ships were replaced and moved back to their base in Japan they might carry along a few special patients; the bulk of their load was transferred to the new ship arriving on station.

Evacuation to Japan was almost entirely by air, using the larger aircraft; normally the four-engine C-54's (later replaced by the C-124's), occasionally two-engine C-46's. The aircraft were obtained through the same channels used in arranging intra-Korea evacuation. Requests were made to the Air Force medical evacuation squadron in Japan. These requests were initiated by Eighth Army. Theater headquarters maintained the medical regulating function by controlling the hospital of destination in Japan.

This link in evacuation worked well. It is an entirely normal function of the Air Force. Aircraft were usually available in adequate quantity and there was less bickering involved. The extreme fluctuations in our requirements naturally inconvenienced Air Force and theater planning. This fluctuation was due to two factors: our inability in Korea to shift patients laterally to the full extent desired, and the lack of any significant cushion of beds to absorb sharp increases in casualty load.

The Utilization of Evacuation Hospitals

The lateral redistribution of patients is a process of far greater importance than is indicated by the little attention it has received.


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The essential time consideration in the initial evacuation of a wounded man is not how soon we can get him to a hospital, but how long it will take to get him on the operating table. The nearest hospital becomes swamped first. The surgical backlog, expressed in hours of surgical lag from time of admission to time of operation, becomes so high that even with conscientious application of clinical priorities a critically wounded soldier will be much better off by going a longer distance to a hospital that is ready to treat him immediately. This principle was practiced in World War II, in the control by the Army Surgeons of the distribution of patients by ambulance from divisions to the several supporting evacuation hospitals to the rear. The development of the helicopter and intra-Army air evacuation made possible the shifting of seriously wounded patients laterally (or even forward) between the surgical hospitals located across the front.

In one of the actions on "Porkchop" the casualties quickly tied up the surgical hospital in direct support, overflowed to the nearby Norwegian Surgical Hospital and loaded the facilities of the nearest neurosurgical detachment. The next patients with head wounds were then flown by Army helicopter to the hospital ship at Inchon. The less seriously wounded were culled out and moved to the evacuation hospital near Seoul and the seriously wounded were spread out to other surgical hospitals across the front. Finally it was necessary to move several aircraft loads of those with minor wounds entirely across the front to the eastern evacuation hospital, which was, at the time the action broke, out in the field in tents on a training problem, conveniently located right on an airstrip. Thus this single action, occurring entirely in the sector of one regiment of one United States division, filled every operating table in Korea except those in the one surgical hospital on the far right.

The impact of the seriously wounded on the surgical hospitals in this instance was less disrupting than the avalanche of lesser wounded on the evacuation hospitals. To make room for them it was necessary to dump wholesale loads of common colds, consultations, and other trivia on the hospitals in the communications zone, or in Japan, and even so the surgical lag at the evacuation hospital for operation on some minor wounds rose to 30 to 36 hours, even after the long period of delay in evacuation from the front.

This is what I mean by saying that we operated on a shoestring in Korea. Without dependable rail transportation and freedom of the air, a sustained casualty flow of major degree could not have been accommodated by the medical support we had in Korea except with periods of stagnation aud significant lowering of fundamental professional standards.


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By the summer of 1952, successive reductions in the troop ceiling on medical units in Eighth Army and the Far East Command, and the dwindling of the replacement stream to the point that we could not staff the units we had, brought Eighth Army down to two functioning evacuation hospitals. One was in the east, and the other in the west, and they hardly could have given effective mutual support in the event of movement forward or rear. They were kept busy most of the time with station-hospital-type patients-disease and nonbattle injury. Even with expansion of number of beds their ability to absorb a sudden increase in admissions was limited to one full train-load of patients, or eight C-46 aircraft loads. By the time the second lift came in, arrangements had to be completed for the simultaneous transfer of patients to Japan or the communications zone before the second group could be cared for.

Allocation of Medical Manpower Resources

These arrangements were made and were executed. The hospitals in Japan supported the combat operations as if they were in Korea and wearing the patch of Eighth Army. The medical service in the Far East did not just "get by"-it turned out superior work. The medical service was not unduly imposed upon by these successive reductions in troop strength-the whole of Eighth Army was cut, and the whole war in Korea was fought on a shoestring by all the combat arms and supporting services. The Far East Command as a whole was spread extremely thin for its mission. But still all up the line, our troops are spread to meet the cold war over the whole world.

I wish to give no implication of complaint, but of caution. Do not accept the troop basis in Korea as an optimum for planning. Do not accept it as even an adequate minimum for Korea. The medical service in Korea functioned as well as it did by virtue of special circumstances that are not dependable assets to draw on in the future.

In particular I warn you not to accept the physician: troop ratio of 1950-53 as an acceptable standard. We did all right on 3.9 or so per thousand, worldwide, with most of the troops in the Army, Navy and Air Force on nonfighting fronts, and those in Korea favored by the special circumstances I have mentioned. If we had met with reverses or sustained heavy action, and if the medical service had stagnated as it might have, I am sure that medical manpower resources would have been released to the Armed Forces on a more liberal basis. I am alarmed to see a figrure of 3.5 per thousand bandied about with the implication that it is to set the standard for any future war, not just the period of uneasy peace. And I am amazed that outside agencies take pride in having been instrumental in establishing such


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an arbitrary and restrictive allocation of medical manpower resources for national defense.

I am confused by the continuous harping on the desirability for further curtailment of assignment of Medical Corps officers to nonprofessional duties. In World War I there were approximately 6.5 physicians, and 0.5 administrative officer per 1,000 troops. Now the total of 7 per thousand is split differently: approximately 3.5 Medical Corps officers and 3.5 Medical Service Corps officers. A good part of the increase in Medical Service Corps positions is legitimately due to increasing complexity of administration and operating of ancillary services. But not in the last decade do I recall a single instance in which the reduction in proportion of Medical Corps officers was accomplished by replacement in our manning tables by officers of the Medical Service Corps.

We have cut Medical Corps positions too far, and I flatly do not believe a ratio of 3.5 doctors per thousand is right. We have, in too many instances, compounded and confused the administration by adding personnel who are not really needed. I fail to see why a lieutenant is needed in addition to a sergeant to command a section (not a platoon, just a section) of nine litter jeep ambulances, or a section of six litter squads. I cannot conceive of a reason why a regimental medical company requires both a captain, administrative officer, and a lieutenant, mess, supply and motor officer. Nor can I imagine what keeps the administrative officer who is assistant platoon leader in the clearing platoon profitably occupied. Eighth Army officially and voluntarily offered, through both command channels and technical channels, to give up nearly 200 officer spaces for Medical Service Corps officers in tactical units, and this without hope or intent of increasing the number of our scarce Medical Corps officers. In other words, that portion of the 3.5 MSC's per thousand troops that these officer positions represented was in no way contributing to the reduction of MC's to 3.5. They represent in my opinion nonessential padding, and poor contributions to the prestige and importance of the Medical Service Corps. The future of that Corps appears to me to lie in its quality, not in its numbers. It is of interest to note that we did not propose reductions of MSC personnel in hospital units, nor did we propose to cut out a single position in grade higher than lieutenant.

The often repeated cry against placing medical officers in "administrative" or "nonprofessional" positions is not well titled. I would prefer to call it a cry against "nonclinical" positions, except that it would then include objections against officers in laboratory research, which is nonclinical endeavor, but certainly not one we want to reduce. There is utterly no doubt in my mind that my own last four duty


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assignments were intensely professional: commander of the medical battalion of a division; airborne division surgeon; operations officer for a field army surgeon and commander of a medical group. Yet all of these are positions which have been neglected in assignments; have been filled on occasions by Medical Service Corps officers by default; and have been held, by some, in private conversations, as coming within the group of administrative assignments from which medical officers should be relieved. This is a farce, but a strangely popular one.

Summary

I would like to summarize my discussion of professional considerations in evacuation with a listing of some essential features of a modern field medical service, with comments as to where and why we succeeded, and where, what and how we might have done better:

Exceptional
in Korea

 

Greater emphasis in future

 

Battlefield recovery, and treatment within the division.

X

X

Evacuation of forward units by helicopter.

 

X

Close support of divisions by surgical hospitals.

X

 

Evacuation hospitals to absorb the bulk of casualties.

X

 

Specialty centers for utilization of scarce personnel.

 

 

Adequate surface transport for evacuation.

X

X

Aerial evacuation within and from combat zone.

X

 

Preventive medicine service.

 

X

Organized current research program in combat zone.

 

 

Quality of professional care throughout.

 

My listing of check marks in the "exceptional" column is an evidence of prominence, not quality.

Division medical service in Korea was good, but most of those connected with it will agree with me that it needs more medical officers than we could supply from our resources in Korea and the Far East, and it needs more interest in the matter of selection, training and assignment of officer and enlisted personnel. It deserves a great deal more attention from the research people. And it stands to profit us more by such research than does any other field.

The value of helicopter evacuation from aid stations is apparent and has been widely discussed. The first trial in Korea was a great blaze of glory. The machine is here to stay; the program will coast into the future of its own momentum. If anything, we need to see that the machine is not oversold, and that sober attention is given to the relative cost of the use of such an expensive means, the propriety of using commissioned officers as ambulance drivers, and the development of a vehicle which is technically adequate for the transportation of patients. Let me lay one ghost here: the helicopter is not vulnerable to enemy air, at least no more so than the jeep or truck.


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Korea was the first trial of the surgical hospital, and its debut was also brilliant. We do need further emphasis on the development and use of this unit, particularly its role in close physical support of the division. This function will never rightly be lost to rear hospitals by virtue of swifter and more capacious and more flexible air transport-at least not while the infantry moves on the ground and is supported in most part by surface transportation.

The utilization of evacuation hospitals in Korea was prominent in a negative sense, as pertains to service to battle casualties, and in a positive sense only with respect to the great amount of work that was done for the nonbattle sick and injured. This applies, of course, to evacuation hospitals generally. As individuals, the two we had assumed a tremendous load as a result of the missing ones that we needed, and they did yeoman work. The shortage of evacuation hospitals and the resulting inability to absorb sudden heavy casualty loads was the most disturbing single deficiency in the organization of the medical service in Korea.

Although the military surgeon must be a true general surgeon, prepared to operate on anything between the scalp and the toenails, expert service must be provided in certain of the professional specialties. We cannot hope to do this by apportioning the specialists so that each medical unit has its across-the-board share. Some of the units will wind up with half a neurosurgeon. The specialist with limited training in his field works better with and under guidance of his colleagues, and the answer is the concentration of certain specialists at designated centers. This will be the subject of a separate presentation.

It may seem prosaic to you, but I wish to stress again the need for adequate surface transport for evacuation. So long as most of the fighting men are on the ground, and most of the tonnage of food and gasoline and ammunition to support them comes by pipeline, road and rail, we must have an adequate surface evacuation system. The helicopter can, technically, eventually replace any of our standard cargo or evacuation vehicles. And it will-for certain units, certain special functions and certain tactical operations. Fixed-wing aircraft and the convertiplanes that will come during our term of service cannot replace any significant numbers or types of standard surface vehicles. They supplement and complement, and contribute to flexibility. They will save lives, but not units and personnel spaces.

The prominence of the use of rail transportation and evacuation in Korea is a feature that is not likely to disappear in the future. A rail system and a determined field army engineer make a combination that is far less susceptible to destruction by enemy action, by either conventional or atomic weapons, than the public has been led to be-


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lieve. The trains ran in North Korea, they ran in Germany in World War II, and they ran into Hiroshima almost immediately after the bomb. They may not have run on time, or smoothly, but they hauled tonnages that would require a staggering airlift to compete.

Air evacuation in Korea was outstanding. As I have said before, we could not have operated our medical service without air evacuation, within Eighth Army and to Japan, and without depending on the Air Force to fulfill its first duty of attaining and maintaining air superiority. For the future we need a great deal of attention to developing a type of aircraft for evacuation within the field army, and developing the organization and control of the system.

Preventive medicine service was in Korea, and will be in the future, accomplished in keeping with the finest and deepest traditions of the Army Medical Service.

Combat zone medical research in Korea was certainly exceptional. It will continue to be a prominent element in the future and will, I hope, push forward in the combat zone, even in face of the difficulties of mobile warfare. It will be altered slightly in orientation and methods, and it has reached such proportions in personnel, service support and scope to indicate the need for formal organization and control.

You will note that I have not starred the final consideration of overall professional quality, either for Korea or for the future. Military medicine goes along with civilian medicine and leads it or follows it in all its aspects. The difference in our military practice between World War II and Korea reflects the startling advances in medicine of the past decade. The Army is as interested in the standards of medical education and medical practice as is any civilian agency. We draw our doctors from American medicine. From a healthy population we draw our soldiers and we are supported by a productive industry.

For this reason I am depressed to see statements made which indicate that the Military is in competition with civilian medicine, in particular the open implication that the requirements of the Military for medical manpower threaten the quality of medical care of our population as a whole. This is selfish foolishness. Medicine on the home front in World War II did not suffer in quality-only in sweat and inconvenience. And at that time there was a vastly greater proportion of American medicine in uniform.

I arn certain that the Military deserves a more liberal access to and use of medical manpower than the starvation level we have worked under for the past few years. All of you who have had anything to do with assignment or management of personnel in Korea, in Japan or in the United States know full well that we led a hand-to-mouth


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existence. Every transfer of a single individual overseas was followed by a fingernail-chewing suspense waiting for his replacement to return. Every loss of an individual from overseas-even on his return for emergency leave or board examination-was keenly felt, and required all sorts of shuffling of people to cover the vacancy. Divisions in the United States, supposedly training or ready for a combat role, existed on one or two medical officers per division, with noncommissioned officers or Medical Service Corps officers running sick call.

As is the quality of American medicine as a whole, so will be the quality of medicine in the Army. Although the process of evacuation of the wounded has little counterpart in civilian medicine, it is a truly professional endeavor-in its planning and management, and in balancing the administrative requirements and limitations against the probable professional outcome. We must get more Medical Corps officers out of wards and clinics and into field units. The quality of medical evacuation, including the medical care en route, will depend on the amount of professional interest and ability that goes into it.

This is the prime of the "Professional Considerations of Patient Evacuation."

References

1. Conn, H. R.: In speaking to the Field Medical Service School of the Marines.

2. Ginn, L. H., Jr., and Ziperman, H.: Surgery in Division Clearing Stations. Military Surgeon 113: 443, Deceniher 1953.