|HOME FAQ CONTACTS LINKS MEDCOM SITEMAP ARMY.MIL AKO SEARCH|
ACCESS TO CARE
The Early Years
The small outpost in the Vietnamese delta stood a vigilant watch. For the past twenty-four hours guerrilla soldiers had harassed its defenders with occasional mortar rounds and small arms fire. A radio call for help had brought fighter-bombers and a spotter plane to try to dislodge the enemy from foxholes and bunkers they had built during the night. But neither the aerial observer nor the men in the outpost could detect the Communist soldiers in their concealed positions. At dawn the outpost commander called off his alert and reduced the number of perimeter guards. Then he led a patrol out to survey the area. No sooner had they left their defenses than the enemy opened fire. Two of the soldiers fell, badly wounded, and the rest scrambled back to the safety of their perimeter, dragging their casualties with them.
While the medical corpsmen treated the wounded, a radio telephone operator called their headquarters to the east at Gia Lam. There, when the request for medical evacuation came in, the duty pilot ran to his waiting helicopter and in minutes was airborne. His operations officer had told him that the pickup zone was insecure and that gunships would cover him. Since there were few helicopter ambulances in the theater, this flight would be a long one: forty-five minutes each way. After taking off, the pilots radioed the gunships and confirmed the time and place of rendezvous. On his map he traced his route, out across the paddied landscape, broken only by an occasional village, hamlet, or barbed wire camp.
Five minutes from the beseiged outpost the flight leader of the gunship team radioed the air ambulance that they had him in sight and were closing on him. While the ambulance pilot planned his approach, the gunships made strafing runs over the outpost to keep the enemy down. The outpost commander marked his pickup zone with a smoke grenade, and the ambulance pilot circled down to it from high overhead. As soon as he landed he shouted at the ground troops to load the wounded before a mortar hit him. Once the patients were secured, the pilot sped out of the area and headed toward Lanessan Hospital, radioing ahead to report his estimated time of arrival. Litter bearers from the hospital waited to rush the casualties into the emergency room as soon as the helicopter touched down.
The area where this mission took place was the Red River Delta in northern Vietnam. Gia Lam was the airfield serving Hanoi from across the Doumer Bridge spanning the Red River. The defenders of the outpost were the French in the early 1950s.1 By the end of 1953 the French in Indochina were using eighteen medical evacuation helicopters. From April 1950 through early 1954 French air ambulances evacuated about five thousand casualties.
In these same years the U.S. Army, which had used a few helicopters for medical evacuation at the end of World War II, employed helicopter ambulances on a larger scale, transporting some 17,700 U.S. casualties of the Korean War. Several years later in the Vietnam War it used helicopter ambulances to move almost 900,000 U.S. and allied sick and wounded. The aeromedical evacuation techniques developed in these wars opened a new era in the treatment of emergency patients. With their ability to land on almost any terrain, helicopters can save precious minutes that often mean the difference between life and death. Today many civilian medical and disaster relief agencies rely on helicopter ambulances. For the past thirty years the U.S. Army has played a leading role in the development of this new technology.
Early Medical Evacuation
Although surgeons often accompanied the professional armies of the eighteenth century, the large citizen armies of the early nineteenth century, whose battles often produced massive casualties, demanded and received the first effective systems of medical evacuation. Two of the officers of Napoleon Bonaparte, the Barons Dominique Jean Larrey and Pierre Francois Percy, designed light, well-sprung carriages for swift evacuation of the wounded. Napoleon saw that each of his divisions received an ambulance corps of about 170 men, headed by a chief surgeon and equipped with the new horse-drawn carriages. Other continental powers quickly adapted the French system to their own needs, but the British and American armies lagged a full half century in learning the medical lessons of the Napoleonic era.
In the Seminole War of 1835-42 in Florida, the U.S. Army Medical Department experimented with horse-drawn ambulances and recommended their adoption by the Army. But the Department apparently got no response. A few years later experiments were resumed, and a four-wheeled ambulance proved successful in the West. But by the outbreak of the Civil War in April 1861 the Army had ac-
1This incident is related by Valerie André, a French Air Force medical pilot who flew in Indochina, in her article "L'Hélicoptére sanitaire en Indochine," L'Officier de Réserve, vol. 2 (1954), pp. 30-31.
quired more two-wheeled than four-wheeled ambulances, and even these were in short supply. In 1862 and 1863 scarce ambulances, poorly trained stretcher bearers, and unruly ambulance drivers greatly hindered the Medical Department's efforts to care for the wounded. Ambulances were so scarce that after the first major battle of the war at Bull Run (21 July 1861) many of the 1,000 Union wounded depended on friends and relatives to pick them up in a family carriage. Many more simply straggled the twenty-five miles back to Washington on foot. Three days after the battle hundreds of wounded still lay where they had fallen. The stretcher bearers consisted almost entirely of members of military bands who had been assigned the duty. As one historian noted, "...scrubbing blood-soaked floors and tables, disposing of dirty scabby bandages and carrying bleeding, shell-shocked soldiers had nothing to do with music, accordingly the impressed musicians fled the scene."
At the second battle of Bull Run (29 August 1862) the large number of civilian drifters hired by the Quartermaster Corps to drive the ambulances simply fled the scene at the first few shots. The Surgeon General quickly rounded up about two hundred more vehicles from the streets of Washington and accepted civilian volunteer drivers, who proved to be worse than the first lot. Many broke into the medicine cabinets on the ambulances, drank the liquor supply, then disappeared. Those who made their way to Bull Run were found stealing blankets and other provisions, and some even took to rifling the pockets of the dead and dying.
Over the course of the war, however, the Union system markedly improved, thanks to the efforts of Maj. Jonathan Letterman, Medical Director of the Army of the Potomac. Letterman recommended sweeping reforms in the ambulance system and the creation of an orderly group of medical clearing stations to the immediate rear of each battlefront. The mission of the ambulances was to bring all casualties to the clearing stations as rapidly as possible. The station would then sort the casualties, a process known as triage. As soon as possible the surgeons went to work on the serious casualties whom they deemed savable and sent them to hospitals in the rear. The most seriously wounded were often set aside, many to die before they reached the operating table. The lightly wounded were treated later and retained near the front. Two goals suffused Letterman's new system: to reduce the time between wounding and lifesaving (definitive) surgery, and to evacuate a casualty no farther to the rear than his wounds demanded. This would result in a hierarchy of medical services, a chain of evacuation that carried a patient to more specialized care the farther he moved from the front.
On 2 August 1862 Maj. Gen. George B. McClellan ordered that Letterman's plan be placed into effect in the Army of the Potomac. Ambulances were to be used only for the transport of sick or wounded soldiers. Stretcher-bearers and hospital stewards were to wear distinc-
tive insignia on their uniforms. Ambulances were to move at the head of all wagon trains, not the rear. Only medical corpsmen were to be allowed to remove the wounded from the battlefield. Although ambulances, horses, and harnesses were to be under division control, all ambulance drivers were to be under Medical Department control, trained for their work, and not allowed to assume other duties such as assisting surgeons in the field hospitals. They were also expected to be of proven good character. In March 1864 President Lincoln approved a congressional act creating a uniformed Ambulance Corps, based on Letterman's plan, for the entire Army of the United States. Although the Ambulance Corps was disbanded at the end of the war, it had served remarkably well when it was needed. The Medical Department during the war had never overcome serious problems in the supply of medicine and the construction of field hospitals. But its numerous horse-drawn ambulances had effectively removed the wounded from the battlefields, even during the massive conflict at Gettysburg.
In the Spanish-American War and World War I, the U.S. Army had to relearn many of the medical lessons of the Civil War. By World War I ground evacuation of casualties could be accomplished by motor-driven ambulances, but the increased speed was offset to some degree by limited road access to the widely dispersed front lines in France and the Low Countries. World Wars I and II showed that automotive transport, while effective for backhauls from clearing stations to field hospitals and evacuation hospitals, was of limited value in evacuating casualties from the spot where they fell.
Early Aeromedical Evacuation
The first aeromedical evacuation occurred in the Franco-Prussian War of 1870-71. During the German siege of Paris, observation balloons flew out of the city with many bags of mail, a few high-ranking officials, and 160 casualties. Thirty-three years later at Kitty Hawk, North Carolina, Wilbur and Orville Wright proved that manned, engine-powered flight in heavier-than-air craft was actually possible. In 1908 the War Department awarded a contract to the Wright Brothers for the Army's first airplane, and in July 1909 accepted their product.
Two enterprising Army officers quickly noted the medical potential of such aircraft. At Pensacola, Florida, in the autumn of 1909, Capt. George H. R. Gosman, Medical Corps, and Lt. Albert L. Rhoades, Coast Artillery Corps, used their own money to construct a strange-looking craft in which the pilot, who was also to be a doctor, sat beside the patient. On its first powered flight the plane crashed into a tree. Lacking the funds to continue the project, Captain Gosman
went to Washington to seek money from the War Department. He told one conference: "I clearly see that thousands of hours and ultimately thousands of patients would be saved through use of airplanes in air evacuation." But his audience thought the idea impractical. In May 1912 other military aviators recommended the use of air ambulances to the Secretary of War, but the War Department still thought airplanes unsuitable for such a mission. During World War I Army Aviation grew steadily, but its planes served as air ambulances only sporadically.
As they had with ground ambulances, the French pioneered the use of airplanes as ambulances. During maneuvers in 1912 an airplane helped stretcher parties on the ground locate simulated casualties. The French then designed a monoplane with a box-like structure under its fuselage for moving casualties to field hospitals. In October 1913 a French military officer reported, "We shall revolutionize war surgery if the aeroplane can be adopted as a means of transport for the wounded." During World War I the French did occasionally move the wounded by airplane, especially in November 1915 during the retreat of the Serbian Army from a combined German, Austrian, and Bulgarian attack in Albania. Although the type of aircraft used in Albania was adequate in this isolated emergency, it was hardly fit for routine use on the Western Front.
For the rest of the war the French Army gave little attention to aeromedical evacuation; they had too many casualties and too few aircraft to be concerned with it. But one French military surgeon, Dr. Eugene Chassaing, managed to keep the idea alive. When he first asked for money to build air ambulances, one officer responded, "Are there not enough dead in France today without killing the wounded in airplanes?" Despite such criticism, Chassaing acquired an old Dorland A.R. II fighter and designed a side opening that allowed two stretchers to be carried in the empty space of the fuselage behind the pilot. After several test flights of the craft, he was permitted to place six such aircraft into operation. In April 1918 two of these planes helped in the evacuations from Flanders, but the fighting grew so intense there that French higher authorities would not sanction continued use of the planes. Late in 1918 Dr. Chassaing received permission to convert sixty-four airplanes in Morocco into air ambulances, and all were used in that country in France's war against Riffian and Berber tribesmen in the Atlas mountains. The French experimented with air ambulances throughout the interwar period.
By the end of World War I the U.S. Army had also begun to reexamine its position on air ambulances. In 1920 the Army built and flew its first aircraft designed as an air ambulance, the DeHavilland DH-4A, which had space for a pilot, two litter patients, and a medical attendant. In 1924 the Army let its first contracts for air ambulances,
and in the next few years it occasionally used its air ambulances to provide disaster relief to the civilian community. In April 1927, after a tornado struck the small town of Rocksprings, Texas, the Army sent eighteen DH-4 observation planes, two Douglass transports, and a Cox-Klemin XA-1 air ambulance. These planes flew in physicians and supplies to treat 200 injured citizens, some of whom the Cox-Klemin then flew out to more sophisticated medical care in San Antonio.
The decade after the war also saw the development of rotary-wing aircraft. In December 1928 the United States received from France its first sample of a rotary-wing aircraft-the autogiro, which used one motor-driven propeller for forward motion and another wind-driven propeller for vertical lift. By 1933 one U.S. manufacturer had designed an autogiro ambulance to carry a pilot and three patients, two recumbent in wire basket (Stokes) litters, and one sitting. In the December 1933 issue of the Military Surgeon, Lt. Col. G. P. Lawrence foresaw the military uses of this air ambulance. Since the autogiro could not hover, rough terrain, forests, and swamps would still require ground evacuation of casualties. But autogiros working from nearby landing areas could backhaul the casualties to medical stations. The advantages seemed indisputable:
Autogiros, not being limited by roads, would find more frequent opportunities to open advanced landing posts than would motor ambulances. They could maneuver and dodge behind cover so as to make hits by enemy artillery quite improbable. At night they could potter around in the dark, undisturbed by aimed enemy fire, until they accurately located the landing place, outlined by ordinary electric flash lights in the hands of the collecting company, and then land so gently that the exact estimation of altitude would be immaterial.
In 1936 the Medical Field Service School at Carlisle Barracks, Pennsylvania, tested the medical evacuation abilities of the autogiro Though the results were promising, the Army's budgetary problems prevented funding a rotary-wing medical evacuation unit.
World War II brought the first widespread use of fixed-wing aircraft for military medical evacuation. In May 1942 the Army Medical Service activated the first U.S. aeromedical evacuation unit, the 38th Medical Air Ambulance Squadron, stationed at Fort Benning, Georgia. The war also stimulated further research on rotary-wing aircraft, both in Germany and the United States. Although Allied bombing raids destroyed the factories that the Germans intended to use for helicopter production, research and development in the United States proceeded apace. On 20 April 1942 Igor Sikorsky staged a successful flight demonstration of his helicopter. By March 1943 the Army had ordered thirty-four Sikorsky helicopters, fifteen for the U. S. Army Air Forces, fifteen for the British, and four for the U.S. Navy. These and
later versions of the Sikorsky could be quickly converted to air ambulance use by attaching litters to the sides of the aircraft.
Tests at the Army Materiel Center in the summer of 1943 suggested that the helicopter could be an effective air ambulance. On 13 August 1943 the Army Surgeon stated that he intended to fill the need for a complete air evacuation service in combat zones by employing helicopters, regardless of terrain features, as the only means of evacuation from front lines to advanced airdomes. Further successful tests of the litter-bearing helicopter in November 1943 supported his decision. But helicopters were not yet abundant, and the Surgeon's plan came to nothing.
The helicopter nevertheless managed to prove its value as a device for rescue and medical evacuation from forward combat areas. In late April 1944, Lt. Carter Harman, one of the first Army Air Forces pilots trained in helicopters at the Sikorsky plant in Bridgeport, Connecticut, flew for the 1st Air Commando Force, U.S. Army Air Forces, in India. On 23 April he took one of his unit's new litter-bearing Sikorskys to pick up a stranded party with casualties about twenty-five kilometers west of Mawlu, Burma. When he returned to India he had flown the U.S. Army's first helicopter medical evacuation (medevac) mission. Soon helicopters became an item in high demand. Maj. Gen. George E. Stratemeyer, commander of the Eastern Air Command, requested six of them for the rescue of five of his pilots who had crashed in inaccessible areas and for similar rescue missions. In the spring of 1945 helicopters evacuated the sick and wounded of the 112th Regimental Combat Team and the 38th Infantry-Division from remote mountain sites on the island of Luzon in the Philippines.
Most evacuation from the front lines in World War II, however, was by conventional ground ambulance. The Army Medical Service did improve its services, greatly reducing the mortality rates from those of World War I. New drugs, such as penicillin and the sulfonamides, and the stationing of major surgical facilities close to the front line, saved hundreds of thousands of lives. Airplanes evacuated over 1.5 million casualties, far more than in World War I, but this role was largely limited to transporting casualties from frontline hospitals to restorative and recuperative hospitals in the rear, rather than from the site of wounding to life-saving surgical care. At the end of the war Army aeromedical evacuation still lacked a coherent system of regulations and a standing organizational base. Before it could acquire these, Army aviation would have to survive the upheaval attending the creation of the United States Air Force.
The National Security Act of 1947 established the United States Air Force as a separate military arm and at the same time stripped the Army of most of its aircraft, leaving it only about two hundred light planes and helicopters. The general mission of Army aviation was
limited to furthering ground combat operations in forward areas of the battlefield, a mission that fortunately encompassed responsibility for emergency aeromedical evacuation from the front. However, when the Korean War opened three years later, the Army Medical Service still had no helicopter ambulance units.
The Korean War
The Korean War resulted in a rapid, new buildup of American military forces, which had been precipitously reduced after World War II. This was no less true for the Army Medical Service than for other U.S. military agencies. At first, in July 1950, only a single evacuation hospital and one Mobile Army Surgical Hospital (MASH) supported all U.S. forces in Korea. By the end of the year these medical resources had grown to four mobile surgical hospitals, three field hospitals, two 500-bed station hospitals, one evacuation hospital, and the Swedish Red Cross Hospital near Pusan. The medical buildup was timely, for between 7 July and 31 December 1950 United Nations forces suffered nearly 62,000 casualties. Medical support expanded even further in 1951.
The Korean War resulted in the first systematic use of helicopters for evacuation of casualties from the battlefield. The rugged, often mountainous terrain and the poor, insecure road network in wartime Korea made overland movement extremely difficult. Transport of wounded and injured ground troops from the front line rearward by litter bearers or jeep ambulances seriously aggravated the patient's condition, caused deepened shock, and often produced fatal complications just before the war broke out Lt. Gen. Walton Walker, the Eighth U.S. Army, Korea (EUSAK) commander, told his senior surgeon that in event of hostilities he wanted mobile surgical hospitals placed as close to the front lines as possible. During the war the mobile surgical hospitals, stationed from five to forty kilometers behind the front, served as the main destination of ground and air ambulances bringing casualties from clearing stations at the front. Most of the casualties arrived in ground ambulances, but 10 to 20 percent were brought by helicopters. The Air Force and Navy also used helicopters for medical evacuation, but the Army's helicopter ambulance detachments carried the great majority of the wars helicopter evacuees.
The Air Force, however, pioneered the use of helicopter ambulances in Korea. In July 1950, just after the war broke out Helicopter Detachment F of the Air Force's Third Air Rescue Squadron began to receive requests for evacuation of forward Army casualties in areas inaccessible to ground vehicles. Col. Chauncey E. Dovell, the Eighth Army Surgeon, arranged a test of the Third Air Rescue Squadron's H-5 helicopters in the courtyard of the Taequ
Teachers' College. On 3 August he and Capt. Oscar N. Tibbetts, the squadron's commander, met at the college and examined one of the H-5's. A Stokes litter fit into the compartment of the H-5 very well, but the handles of the standard Army litter had to be cut off. With two patients and Colonel Dovell on board, the H-5 lifted off, easily cleared the surrounding telephone poles and buildings, and returned for a perfect landing. Colonel Dovell asked to see a long flight, so the pilot flew him and the two patients out to the 8054th Evacuation Hospital at Pusan, 100 kilometers away. On 10 August, at Colonel Dovell's request, Lt. Gen. Earle E. Partridge, commander of the Fifth Air Force, authorized the use of these and other Air Force helicopters for frontline evacuations. The Air Force continued to evacuate the Army's frontline casualties until the end of the year, allowing the Army time to organize and ship to Korea its own helicopter detachments.
Late in the year the Army deployed four helicopter detachments to Korea. These units, each authorized four H-13 Sioux helicopters, contained no medical personnel, but were under the operational control of the EUSAK Surgeon. Each was attached to a separate mobile surgical hospital, with a primary mission of aeromedical evacuation. The crewmembers drew their rations and quarters from the MASH, and their aircraft parts and service from wherever they could be found. The 2d Helicopter Detachment became operational on 1 January 1951; the 3d, later in January; and the 4th, in March. The 1st Helicopter Detachment, which arrived in February, never became operational because commanders transferred all of its aircraft to other nonmedical units. At the height of the Korean conflict the three operational helicopter detachments controlled only eleven aircraft. But by the end of the war they had evacuated about 17,700 casualties, supplemented by a considerable number of medevac missions performed by nonmedical helicopters organic to division light air sections and helicopters of Army cargo transportation companies. Marine and Air Force helicopters had also made a sizable number of frontline evacuations.
The independence and therefore the value of the air ambulance units increased after the introduction of detailed standard operating procedures. Typical of those adopted by the detachments was the list that Lt. Col. Carl T. Dubuy, commander of the 1st Mobile Army Surgical Hospital, drew up in early February 1951. Evacuation requests were to be made only for patients with serious wounds, or where surface transport would seriously worsen a casualty's injuries. The helicopters would be used strictly for medical evacuation and reconnaissance, and would not be used for command, administrative, or tactical missions. Each request for a helicopter was to include a clear and careful reading of the coordinates of the pickup site. The ground commander was to try to find the lowest pickup site around
to ease the strain on the minimally powered H-13 helicopters that performed the bulk of medical evacuations in Korea. A request was not to be made for a landing zone subject to hostile fire; if trouble did develop, the men on the ground were to wave off the helicopter. Dubuy recommended the use of colored panels to form a cross to mark the pickup site, and he also favored some indicator of wind direction and velocity, such as grass fire. He suggested that if the helicopter flew past the pickup zone without recognizing it, the soldiers on the ground should fire flares or smoke grenades to attract the pilot attention. (The aircraft had no radios.) Colonel Dubuy sent these recommended procedures to the commanding general of the 7th Infantry Division, which the 1st Mobile Army Surgical Hospital then supported, but the division afforded the list only a haphazard distribution.
In January 1951 all four pilots of the 2d Helicopter Detachment took part in a mission that, although it violated the precept that helicopters would not be flown within range of enemy weapons, saved several lives. On the morning of 13 January, Capt. Albert C. Sebourn of the 2d Detachment received an urgent request for air evacuation from a unit at a schoolhouse surrounded by a large Chinese Communist force near Choksong-ni. The unit was a Special Activities Group (SAG), an elite, battalion-size organization of airborne and ranger-qualified soldiers. Their only defensive perimeter was the border of the one acre schoolyard. A MASH doctor had been asking for a ride in a helicopter. Sebourn put him in the right seat and then flew to the coordinates of the request. After landing in the schoolyard, Sebourn shut down the helicopter. As soon as he and the doctor climbed out, a mortar round landed near the right side of the helicopter, damaging it but not injuring anyone. Both men ran into the schoolhouse, where the commander of the SAG unit explained that he had numerous casualties and wanted the helicopter to bring in ammunition on its return flights from the hospital. When Sebourn tried to restart his aircraft, he found that the battery was dead; he and the doctor stayed at the school overnight.
When Sebourn did not return to the 2d Detachment's base after several hours, Capt. Joseph W. Hely checked back through Eighth Army channels. The request had been quite old when the 2d Detachment received it: it had been routed through Tokyo. Eighth Army asked Hely whether he would fly ammunition out to the beleaguered force, and he assented. With ammunition in both his aircraft's litter pods, he tried to fly out, but heavy snowfall made him postpone the flight until the weather improved. Next morning, when he reached the area, he noticed tracers from enemy machine guns trying to shoot him down. He spiraled down into the schoolyard, unloaded the ammunition, gave the battery in Sebourn's helicopter a boost, and then
loaded two patients in his own craft. He spiraled out to escape the enemy fire again and Sebourn followed him.
Later that day two other 2d Detachment pilots joined Hely in two more flights to the schoolyard, carrying food and ammunition to the SAG unit and casualties back to the hospital. Enemy ground fire harassed each entry and exit at the schoolyard. On leaving the school for the last time just before darkness, Hely radioed an Air Force fighter and marked the perimeter for its strike. The next morning the 2d Detachment made a final evacuation from the schoolyard before the SAG unit withdrew. Captains Hely and Sebourn won Distinguished Flying Crosses for their work.
The communications net used to route and obtain approval of a ground commander's request for such a medevac mission was, laborious at best, especially early in the war. The request usually originated at a casualty collecting station in the field or at a battalion aid station. Then it was relayed by radio or telephone to the division surgeon, then to the corps surgeon, and finally to the Eighth Army Surgeon, who decided if the mission was valid. If he approved, the approval passed back down the ladder to the helicopter detachment attached to the hospital supporting the corps area. This process often delayed a mission for hours, and sometimes it led to a cancellation because the casualty had already died. Some procedures, though, helped speed the response time of the helicopters. Stationing a mobile surgical hospital and its helicopter detachment close to the front line, usually some ten to forty kilometers behind it, reduced the response time. Eventually the Eighth Army Surgeon ceded mission approval authority to the corps surgeons, who had direct communications with the mobile surgical hospitals, thereby eliminating one level in the three-tiered approval structure.
To improve the communications and speed the response, the helicopter detachments began the practice of siting their aircraft in the field at clearing stations near the tactical headquarters just behind the front lines. These one-aircraft field standbys ensured ready and rapid transportation of the critically wounded to mobile surgical hospitals. But this solution produced another problem. Since the helicopters themselves carried no radios, an aircraft that was field-sited with a combat unit that had a poor radio linkup with other combat units in the Corps zone could not respond rapidly to sudden fighting in other areas. The absence of radios in the aircraft also precluded any air-ground communication and made necessary the use of smoke signals and hand gestures to ensure the safe completion of a mission. In the first months of the war not even the detachment headquarters had radios. When available, they helped immensely by freeing the detachments from their dependence on Army switchboards and landlines.
Several times division commanders tried to obtain the assignment
of helicopters to specific combat units for evacuation missions (direct support). For instance, the 3d Infantry Division, with an indorsement from I Corps, requested its own air ambulance; I Corps wanted to give each division its own air ambulance. But EUSAK headquarters denied the request because there were not enough helicopters to provide such individualized coverage, and the current area and standby coverage was working adequately.
Many other problems in this new system proved intractable. The most serious came from the constant need to repair the helicopter. The sluggishness of the Air Force, the Army's aviation procurement agency, in meeting Army aviation's supply needs created a backlog of requests for helicopter parts and components. just as American industry at the start of World War II was unable to fill all the Army's requests for airplanes, so at the start of the Korean War it was not geared for helicopter production. The fine tolerances required because of the many rotating and revolving parts in a helicopter, and the limited commercial potential for the craft, made American aircraft manufacturers reluctant to devote their resources to such a chancy investment. When production did increase, a serious problem arose in transporting the vast quantities of war materiel from the States to Korea. All of these problems adversely affected the supply of spare parts, fuel, and even aircraft. By late 1952 the eleven air ambulance helicopters in Korea had to compete with about 635 other Army nonmedical helicopters for whatever resources the American aircraft industry could provide.
Parts shortages in the field accounted for the loss of much valuable flying time in all Army aviation units in Korea, more so than any other problem. In a three month period in 1952 the 8193d Army Unit lost about one-third of its potential aircraft days because of parts shortages. This resulted in lives lost because the unit was unable to respond to all evacuation requests. The 8193d commander, Capt. Emil R. Day, requested that a fifth helicopter be assigned to each of the MASH helicopter detachments, but this was not done. In allocating parts the Air Force favored its own fighters and bombers over the Army helicopters. Supply personnel in the States seemed to have little awareness of the cost in human life of returning supply requests for editorial changes, explanations of excess requirements, and "proper" item descriptions. Harry S. Pack, in an evaluation of the problems of helicopter evacuation in Korea, aptly criticized the support system:
The basic concept of the employment of the helicopter in the Army... is its increased speed over other forms of transport currently in use in the movement of personnel and materiel. Therefore, it is only logical that the entire helicopter program, including maintenance and supply procedures, should follow the same philosophy of speed and mobility to ensure receiving maximum value from the helicopter.
The focal point of these supply problems was the Bell Aircraft Corporation' s H-13 Sioux helicopter, which performed almost all aeromedical evacuations in Korea. Powered by a Franklin engine, it sported a large plexiglass bubble over the top and front of the cockpit. It could transport a pilot and one passenger, and two patients on external litters. Although Bell Aircraft sent some of its test pilots to Korea to help the Army pilots obtain maximum performance from the H-13, the aircraft simply had not been designed for medical evacuations in mountainous terrain. The H-13's standard fuel capacity could not keep the aircraft aloft the two or more hours that many evacuation flights took. The pilots had to either fuel at the pickup site or carry extra fuel in five-gallon cans. The cans could be carried in the cockpit or, more safely, strapped to the litter pods and left at the pickup site. Also, since the battery in the H-13 was not powerful enough to guarantee restarting the aircraft without a boost, the pilots often practiced "hot refueling" in the field. Although dangerous, the practice seemed safer than being unable to restart the aircraft near the front line.
Because the H-13D's the pilots flew had no instrument or cockpit lights and no gyroscopic attitude indicators, most evacuation missions took place in daylight. But extreme emergencies sometimes prompted the pilots to complete a night mission by flying with a flashlight held between their legs to illuminate the flight instruments. The expedient barely worked, because the bouncing, flickering beam of the flashlight often produced a blinding glare.
When the first Army aeromedical unit in Korea, the 2d Helicopter Detachment, arrived at the end of 1950 and put its equipment in working order, it still could not declare itself operational, because the H-13D's lacked litter platforms, attaching points on the helicopters, or even litters. The unit quickly received permission to fit platforms on the skid assemblies so that litters could be mounted on either side of the fuselage. When the EUSAK Aviation Section failed to obtain litters for the detachment, its commander, Captain Sebourn, turned to the Navy hospital ship in the Inchon Harbor. The Navy people gave him eight of their metal, basket-like Stokes litters. The detachment then had to find covers for them to protect the patients from the elements and secure them to the pod. Lt. Joseph L. Bowler took the litters to Taegu, found some heavy steel wire, and then had a welder at a maintenance company fashion a lid with a plexiglass window that could be attached to the litter, enclosing the patient's upper body. Next, both the lid and the litter were covered with aircraft fabric and several coats of dope. This laborious process required repeated painting and drying in the cold, sleet, and snow of the Korean winter.
The improvised pods and litters proved far from ideal. Loading and unloading the patient was an awkward process, since he had to be taken from the standard Army field litter, lifted onto a blanket, and then placed
into the Stokes litter. Some patients with certain types of casts, splints and dressings could not be moved by helicopter at all because of the confined space of the Stokes litter. The pilots and mechanics improvised heating for the inside of these litters by fabricating manifold shrouds and ducting warm air off the manifolds into the litters. Even so, the patients had to be covered with mountain sleeping bags or plastic bags. If the manifold heat were used on one litter only, excess warm air escaped near the hose connection; but if heat were turned on both litters, there was not enough for either. The problem partly stemmed from the plastic cover; it lay directly on the patient and did not allow the heat to circulate properly So the detachments worked with a maintenance company and a Bell Aircraft technical representative, constructing a three-quarter length cover of fabric-covered tubing that could be joined to the original head cover. It served as a windbreak and gave space for the heat to circulate over the patient's lower body. In July 1951 a new litter mount, manufactured by Bell Aircraft for the H-13, reached Korea. These greatly improved mounts accommodated a standard Army field litter, eliminating the need to transfer a patient to a Stokes litter before placing him in the pod. Unfortunately the covers that Bell manufactured for the new mount were usually torn up by the slipstream after just thirty days of use. The detachments improvised a canvas cover from pup tent shelter halves; when used with the zipper and snaps from the Bell cover, it proved far superior to the original in that it had a long service life and kept water from seeping through onto the patient. The men of the detachments used their own money and Korean labor to produce an ample supply of covers.
Even with the improved pods, the external mounting and the absence of a medical corpsman on the aircraft produced another difficulty. Pilots began to notice that many of the casualties needed transfusions before being moved to a mobile surgical hospital. In cold weather an in-flight transfusion with the fluids stored outside the aircraft risked deepening the patient's shock as the fluid temperature dropped. At first the pilots would wait the thirty or forty-five minutes necessary for a transfusion before departing with a patient. Then Lt. Col. James M. Brown, commander of the 8063d Mobile Surgical Hospital, devised a method for en route transfusions of plasma or whole blood. A bottle of blood or plasma was attached to the inside wall of the cock it within reach of the pilot. Needles and plasma would be arranged before departure, and during flight the pilot could monitor the fluid flow through the tubes extending to the litter pods. A rubber bulb could be used to regulate pressure to the bottle. This modification was approved for all medical helicopters in the theater, and Bell Aircraft also incorporated it in all its D-model aircraft.
Since the Eighth Army possessed only thirty-two H-13's by May
1951, use of the valuable craft had to be closely monitored and restricted. A recurring problem was that ground commanders sometimes requested helicopters more as a convenience than as a necessity. To prevent this, the EUSAK Surgeon on 23 June 1951 disseminated a statement that the role of helicopter evacuation was only to provide immediate evacuation of nontransportable and critically ill or injured patients who needed surgical or medical care not available at forward medical facilities. This statement was given wider distribution than had Colonel Dubuy's in February and it noticeably reduced the number of unnecessary missions.
The detachments offered their service to all of the fighting units involved in the United Nations effort in Korea. At first glance it seemed that the language barrier would make many of these missions extremely difficult. But the lack of air-ground communications helped in this respect, for it precluded any attempt whatsoever at oral communication between pilots and ground commanders. Most pilots found that universal sign language usually sufficed to transmit any information necessary to complete an evacuation. In September 1951 one of the pilots received a request to pick up two wounded men from a Turkish brigade. The pilot recalled:
When I got to the spot designated I couldn't find anybody. I was circling around when a Turkish observation plane buzzed me. He led me to a wooded area on a mountain top where the Turks had dug in. The trees were too high to permit a landing. It looked pretty hopeless because I couldn't communicate with them. Finally, I went in close until the rotor blades of the helicopter brushed the tops of the trees. The Turks got the pitch. They chopped down enough of the trees so that I could land on a ridge. I sat down and the Chinese began tossing mortar shells at me. But I got the two wounded Turks out.
Enemy ground resistance to air ambulances in Korea never became a severe problem, as it did later in Vietnam. Few landing zones were subject to enemy small arms fire, but many were within range of enemy artillery and mortars. Although the pilots generally stayed out of landing zones under enemy fire, several had more than one encounter with Communist weapons. At one point early in the war a company of the 7th Infantry Division was fighting in the area known as the Iron Triangle. In assaulting an enemy-held slope, two of its soldiers were seriously wounded by the Chinese. A request for an air ambulance quickly made its way to the 4th Helicopter Detachment, stationed with the 8076th Mobile Surgical Hospital at Chunchon. CBS correspondent Robert Pierpoint was there and had received permission to fly with the detachment. Three minutes after the call came in, a pilot and Pierpoint flew north toward the pickup site. The men on the ground put out colored panels to mark a landing zone on a
nearby paddy, while others tried to bring the casualties down from the hill. Thirty minutes after the call went out, the helicopter landed at the marked position. The pilot and Pierpoint got out. just as the litter bearers made it down the hill, Chinese mortars from across the valley opened up on the paddy. A mortar round came in, hit about thirty feet from the helicopter tail, and sent the Americans scrambling up the hill. The company commander called an artillery battalion 6,000 yards to the rear, and had them knock out the Chinese mortar positions.
The pilots, Pierpoint, and the litter bearers returned to the helicopter and loaded the casualties. Not waiting to check for damage, the pilot climbed into the smoke-filled cockpit. He could hardly see the instruments, but, as soon as Pierpoint jumped in they made a maximum power takeoff. They landed at the hospital at 2120, reading their aircraft instruments with a flashlight one of the men at the paddy had given them.
In another respect, Korea was worse than Vietnam: the ambulance crews sometimes had to contend with enemy aircraft. Although the U.S. Air Force destroyed most of the North Korean aircraft early in the conflict, the entrance of the Chinese Communists into the war in December 1950 brought fast and powerful enemy jet fighters to Korea. A few medical helicopters did encounter fire from North Korean Yak fighters, but the Americans outmaneuvered the faster jets and escaped damage.
Apart from frontline evacuations, air ambulance detachments also flew a few other medical support missions. By the second year of the war they routinely transported whole blood to the mobile surgical hospitals. This proved valuable because the whole blood tended to break down prematurely or clot when carried by surface vehicles over the rough Korean roads. The faster means of transport also allowed blood storage and refrigeration to be centralized rather than dispersed close to the front. The helicopters backhauled some critical patients from the mobile surgical hospitals to airstrips for further evacuation to one of the general hospitals in Japan. Sometimes they even backhauled patients to hospital ships along the coast, such as the Navy's hospital ship Consolation and the Danish Jutlandia, which were equipped for helicopter landings. Since fixed-wing cargo planes flew all casualties bound for Japan, the hospital ships remained anchored as floating hospitals off Korea rather than act as ferries.
Most detachment pilots also tried to make the life of the frontline soldiers as tolerable as they could. Besides medical supplies and ammunition, the pilots often took beer, ice cream, and sodas to the front. The sight of the helicopter coming in for a landing in the blistering Korean summer with the pilot wearing only his boots, a red baseball cap, and swimming trunks, and then unloading these otherwise unobtainable luxuries, did much to boost the morale of the combat soldiers.
Apart from yielding a great deal of practical experience, the Korean War furthered aeromedical evacuation by convincing the Army that the helicopter ambulances deserved a permanent organization. When the war broke out, the Army Medical Service commanded neither helicopters nor pilots, and its leaders were not committed to furthering aeromedical evacuation. In Korea the Eighth Army soon acquired virtually complete operational control of the helicopter detachments charged with a mission of medical evacuation. But the Surgeon General wanted to have the detachments made organic to the Medical Service, to have an organization within the Office of the Surgeon General capable of directing and administering the aviation resources, and to have medical personnel rather than aviators from other branches of the Army piloting the aircraft.
The Surgeon General achieved his first goal with the publication on 20 August 1952 of TO&E 8-500A, which provided for an air ambulance detachment of seven officers, twenty-one enlisted men, and five utility helicopters. The first such unit was the 53d Medical Detachment (Helicopter Ambulance), activated at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas, on 15 October 1952. In Korea, meanwhile, the ambulance units were transferred from the administrative command of the Eighth Army Flight Detachment to that of the Eighth Army Surgeon.
By the end of the war the Surgeon General also succeeded in achieving his second goal of creating a special aviation section in his office. On 30 June 1952 the Chief of Staff of the Army directed the Chairman of the Materiel Review Board to evaluate the Army helicopter program. In accordance with the Board's recommendation, the Chief of Staff on 17 October 1952 directed the assistant chiefs of staff and the various Army branch chiefs to set up their own agencies to supervise and coordinate aviation within each office. The Surgeon General's Office was charged with coordination of all planning, operations, personnel staffing, and supply of Army aviation used in the Medical Service. On 6 November the office established the Army Aviation Section within the Hospitalization and Operations Branch, Medical Plans and Operations Division. On the advice of the new section, the Surgeon General recommended that "...all aircraft designed, developed, or accepted for the Army (regardless of its intended primary use) be chosen with a view toward potential use as air ambulances to accommodate a maximum number of standard litters." This advice was followed in 1955 when the Army held a design competition for a new multipurpose utility helicopter. The winner of the competition, the Bell Aircraft Corporation's prototype of the UH-1 Iroquois ("Huey"), eventually became the Army's standard ambulance helicopter in the Vietnam War.
During the Korean War the Surgeon General also tried to place
Medical Service Corps (MSC) pilots in the cockpits of the Army's air ambulances.2 But he did not succeed until shortly after the armistice in 1953. From early 1951 on, the Surgeon General had advocated training some MSC officers as aviators, and in the spring of 1952 the regulations governing Army aviation were amended to allow MSC personnel to become pilots. A quota of twenty-five MSC officers, mostly second lieutenants, was set for flight training in October. None of the current MSC officers had ever been helicopter pilots, although a few had had some aviation training. By early July, fifty-three applications for the slots had been received, but only seventeen applicants were qualified. Eight MSC officers began flight training in October, and one washed out before graduation. The other seven graduated on 28 February 1953. In September the Surgeon General's office requested and received a standing quota of ten MSC officers per month for attendance at the Army Aviation School at Fort Sill, Oklahoma. By 1 October the Medical Service had twenty-four officer pilots and soon received five more by transfer from other branches. None had flown in Korea before the armistice in July.
After the Korean War the Surgeon General's Office applied itself to assessing the potential of helicopter ambulances in future conflicts. In particular, Lt. Col. Spurgeon H. Neel, Jr., in a number of medical and aviation journals, publicized and promoted the Army's air ambulances. The Korean experience, he realized, could not serve as an infallible guide to the use of helicopters in other types of wars and different geographical regions, but it certainly showed that helicopters had made possible at least a modification of the first links in Letterman's chain of evacuation. A superior communications system would allow a well-equipped and well-staffed ambulance to land at or near the site of the wounding, making much ground evacuation unnecessary. If the patient's condition could be stabilized briefly, it might prove helpful to use the speed of the helicopter to evacuate the patient farther to the rear, to more complete medical facilities than those provided at a rudimentary division clearing station. Triage might be carried out better at a hospital than in the field. But the Korean War and the concurrent French struggle in Indochina had afforded only limited, imperfect tests of helicopter medical evacuation. The potential was obvious, but not fully proven.
2At this time the Army Medical Service consisted of six corps: Medical, Dental, Veterinary, Army Nurse, Women's Medical Specialists, and the Medical Service Corps, which provided a variety of administrative and technical services.