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 COLONELDOUGLAS LINDSEY, MC
Any discussion on the implications of experience in the Korean war mustbe undertaken in an atmosphere of conscious, continued caution. In spiteof 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 espisodefor historical analysis. This is not to say that generalizations cannotbe made; they should be. We must continually develop, revise and supersedeour policies, plans and procedures. But conclusions must be drawn onlyafter sober, skeptical, philosophical reflection. Generalizations foundedon the Korean war stand on a narrow base, and if the process of broadeningand projection is not carefully done, the whole structure will topple underthe 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 settingthe pattern for the future, or to ignore all of our experience there asinvalid for future planning on the basis that it was so unusual or specializedas to be generally inapplicable.
I would like to quote just a few examples of hasty conclusions thathave been drawn from experiences in the Korean war. At one time, a greatdifference between cold injury rates between two successive winters wasquoted widely as heralding the effect of improved clothing and equipment,and improved leadership and discipline. Yes, these factors did vastly improvebetween the two winters, but no mention was made of the overpoweringeffect of the vastly different tactical situations: in the first winterwe were fighting desperately, and moving often. In the second winter thelines were stable, the fighting much less severe, and shelter was moreplentiful and better developed. This patent error was made in the faceof the fact that a similarly fallacious conclusion was made in World WarII, in comparing the rates for successive months of the winter of 1944-45in Europe, and that error was later openly disclosed. Incidentally, thehue and cry over the rigors of the Korean winter obscures the fact thatthe 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 andthat at the Yalu is no more severe than that of Montana.
I have seen the statement made, with relation to the difficult terrainand lack of communications in Korea, that the problems which we faced inKorea were different from those encountered in any previous operation.It is clear that the author of this statement is enthusiastic, and soundlyimpressed by his Korean experience, but just as clear that he did not participatein the campaigns in Burma, New Guinea or Italy, nor has he maneuvered inAlaska or trained in the Rockies.
I repeatedly hear officers returning from a limited tour of duty ina limited assignment in Korea extolling the virtues of "the way wedid it in Korea" along with heated discussion and forceful proposalsto the effect that this is the best way to do it, and the way itshall be done henceforth-all this without realization that the particularinterval organization, or mission, or function, or equipment for the unitin question was designed by the responsible planners to fit particularcircumstances, or was a frank expedient and improvisation, reluctantlyaccepted by higher headquarters to make the best of the limitations ofa 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, splintsand plasma. Since frequent moving tends to shake a unit down and immobilitytends to promote a buildup of supplies, this is an entirely logical conclusionin theory. Typical illustrative photographs of aid stations appear to lendimpressive support to this thesis. Further, if the author of the statementhad interviewed a number of battalion surgeons their testimony would havewholly supported him. But actually the aid stations were not carryingan excess and were even dangerously low in the basic supplies needed forsupport of battle casualties. At that same time I was concerned enoughabout the ability of the forward installations to support the initial phasesof 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 notknow what their basic authorizations and requirements were, andI did not find a single installation whose supply of splints, dressingsand plasma came up to the basic load, much less exceeded it. The staticperiod promoted the acquisition or fabrication of fancy equipment and frills,but the low flow of casualties during most of the war promoted the acceptanceof 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 reinforcementin personnel, send in an immediate emergency requisition for supplies andemphasize the moving out of patients as
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rapidly as possible, an emphasis on transportation at a certainexpense to treatment.
The point of this last example is that whenever the factor under considerationis subject to objective comparison or quantitative measurement, such comparisonor measurement should be made. When the matter is one of opinion, one shouldget as many separate opinions as possible.
Much of what I have to say will be prefaced by "I feel," "Ithink," or "I believe," since I alone stand responsiblefor the conclusions, estimates, and recommendations I present, and sincedeterminations of degree of success or fortune and recommendations as towhat things might have been done better, or how, are often matters of opinion.However, this presentation is based in great part on material developedfor formal staff studies in Headquarters, Eighth Army. Most of it has beenincluded in various official reports from that headquarters. It representsmuch careful, objective consideration. I feel that it meets The SurgeonGeneral's injunction to all of us speakers that we offer thoughtful, documentedanalyses.
In exercising your caution and skepticism in appraising even my ownmaterial I ask you to remember-and I will remind you of it frequently-thatduring most of the Korean war the front was geographically stable. Duringthat same period United States casualties were relatively light, with sporadicperiods of heavy casualty flow, limited in time and limited in the sectorand units involved. We were able to settle down, smooth out the rough spotsand, generally speaking, offer custom-made, personalized professional serviceto every serious casualty. We will not be able to do this to the same degreein a moving situation, or in a situation with a sustained heavy casualtyflow.
In particular, I feel that much of the specific medical research thatproduced the technical data which are to be presented to you in this symposiumwas vastly facilitated by the peculiarly favorable circumstances that existedin the latter 2 years of the war. Research, in all the branches of theMilitary, is following hotly on the heels of the combat troops, and someof the operations research actually goes on out in the combat squad area.The accomplishment of Army medical research teams was phenomenal. I amtoo conservative a pessimist to state that they could not have done asmuch in the face of heavy fighting and a moving front, but it would havetaken a great deal more effort, inconvenience and administrative and logisticsupport to do so. In such a situation I think the pattern and orientationof research will change.
No matter how hot the battle and how rapid the maneuver, there is roomfor 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 ofit) in which the laboratory element was minor. We need some of this researcheven farther forward: a number of men with broad surgical background, maturejudgment, sincere interest and staunch heart-to go up and work with battalionsurgeons, or as battalion surgeons, for extensive periods, then reflectand recommend on what they see.
If the surgical hospital is moving 2 or 3 times a week, 8 to 10 milesper move, I think you will find it rather difficult to carry out thereany intensive technical research involving the more complicated laboratorydeterminations. If it is deemed essential to do so, the mission can beaccomplished by reinforcing the host hospital with transportation, personneland other support facilities. It would appear more feasible, however, toarrive at the same result by giving the team a permanent base more to therear, feeding to it by air the patients, specimens or data collected andselected 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 medicalsoldier-the company aidman-accompanies the infantry platoon into combat.He administers emergency treatment on the field of battle and places thewounded man in a sheltered location, if possible, for somebody else tocome and pick him up. He cannot linger long; he must keep up with his advancingunit. Casualties in the engagement may number 2 or 40 and the last of thenumber may be the one who needs him worst, or with the least delay.
Usually, the conditions of fire and terrain are such that the casualtyis moved initially by the backbreaking method of litter carry, possiblywith relay by surface vehicle. At the battalion aid station he is seenfor the first time by a doctor, on whose professional skill the lives ofthe seriously wounded depend. No surgical hospital or general hospitalcan 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 thecasualty is moved-practically always by a mechanical means of transportation,surface or air-through one or more field-type installations before reachinga true hospital. At the hospital he receives definitive surgical treatmentand becomes more a "patient" than a "casualty." Inthis and successive hospitals the patient receives surgical care entirelycomparable in quality and scope to that administered in civil hospitals,though slightly different in technic. The major difference is that hishospital care involves several separate hospital staffs in several successivelocations. Some of the hospitals in the casualty evacuation system dealcustomarily only with strict surgical emer-
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gencies. Others, though dealing with traumatic surgery, which in civillife is usually regarded as an emergency regardless of degree, receivepatients of a deferred or lesser priority.
Professional considerations are vitally important throughout every stageof this process of moving casualties to the rear and treating them at thesame time. However, based on the invitation of Colonel Stone, I have selectedfor emphasis certain specific points of direct professional interest. Theseare:
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 initialtreatment on the battlefield. What the wounded soldier does in his ownbehalf, or what his infantry colleagues do for him; and what the companyaidman does for a traumatic amputation or gaping wound of the chest, inthe thick of battle, in dust and heat or in blowing snow-on these simpleprocedures depend life and death.
Major Mallory and Dr. Scott have already mentioned these things. I wishonly to add my own emphasis and indicate that they are matters for professionalconcern. A slight improvement in the skill and judgment of the companyaidman will save us more human lives than will the attainment of 100 percentperfection in the surgical hospital.
But this development of the company aidman and changes in the standardprocedures for infantry first aid must be founded on professional considerations,and the stimulus will have to be provided by professional people. The lineare generally satisfied with, or proud of, their aidmen. They extol theirhardihood and sacrifice, and other rugged and simple virtues, but expressrather little concern over their technical competence.
There are differences of opinion regarding the aidman, even regardinghis basic position in the military scheme. Some feel that this man is aninfantryman 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 isadequate 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 memberof the Army Medical Corps. Even in our own United States Army Medical Servicemany feel that he is an inferior being in the medical enlisted field. Thisshould not be. I can take any clever meatcutter, carpenter,or mechanic and develop him into a highly competent surgical operativeassistant. Something more than that is needed in the company aidman. Ittakes 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 theArmy Medical Service realize their importance and support a degree of precedencefor the selection, training, and assignment of them.
A word about the litter bearer, who links the company aidman with thebattalion surgeon. He is still with us. He was not replaced in Korea bythe helicopter, the tramway or the Korean Service Corps. In Korea the helicopterrarely operated forward of the battalion aid station. And even later, whenthe machine is plentiful, it will not customarily operate on the actualbattlefield unless the character of battle has so changed that the infantrymanis no longer on foot, nor in an armored vehicle. That time is not nearlyat hand.
We tend occasionally to count the short time lag between the battalionaid station and the surgical hospital operating table, and to be smuglypleased without thinking of the time spent forward of the aid station.In a stable, permanently developed sector with tramway or jeep road tothe top of the company hill this time is not greatly significant. Withoutthese improvements, and depending on litter haul, the time span is tremendouslyincreased, and the initial treatment, treatment en route and treatmentin the battalion aid station are commensurately increased in importance.In virgin terrain in Korea a litter squad could be expected to make approximately100 to 300 meters per hour in horizontal distance. Thus an aid station500 meters away from the company on the hill is 2 to 4 hours distant. Inspecial circumstances this time distance increases even more. In a nightoutpost action, a man wounded before midnight often will not reach theaid station until 1000 the next morning, and I know of one outpost in Koreathat required (I am told) a litter haul that was 36 hours round trip. Iaccept this staggering figure as true, since I personally verified thefact that the litter haul from the main battle positions of eachof the three battalions of the regiment was not less than 8 hours. Thesedifficulties were not peculiar to Korea, and we will have the same problemsin 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 operationsforward of the battalion aid station are not readily apparent to the outsideobserver, but the problems in the aid station itself are more orthodoxand more familiar to you.
Here we have a graduate M. D., and we have equipped him well to performprofessional resuscitation. Some of his professional capabilities havebeen outlined by Major Mallory and Dr. Scott. The physical appearance ofhis 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 thoracentesisas on any university hospital pediatric or surgical ward. We can cut downon a vein and give blood under pressure. The distribution of blood to forwardstations is something we did not have in World War II. It is an improvementin service we can keep up in the future, and is not to be considered aluxury made possible by the static situation in Korea, to be lost in theevent of moving warfare.
In spite of these facilities, professional resuscitation wasoften neglected. And a lot of us are to blame. Through two World Wars andKorea we have passively sustained, or actively contributed to the discouragingmisconception that the battalion surgeon is nothing more than a commissionedaidman. Many of these men believe that, and when they do believe it, theyact it. With that attitude and the availability of the helicopter theybecome transportation agents and their activities there seldom exceed thechanging or reinforcing of the dressing, the starting of one bottle ofblood or dextran, and moving the patient out as rapidly as possible, almostfirst come first served. One too rarely sees a casualty retained in theaid station for intensive therapy to insure that he will stand the tripto 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 mustshow a near perfection of surgical judgment under the most adverse conditions.Surgical judgment is that indefinable but essential attribute compiledof just the right mixture of a stable nervous system, past surgical experience,common sense, and an ever-ready diagnostic ability." I am sure weall agree. Yet we persist in labeling the position one for MOS 3100: MedicalOfficer, General Duty. The people who hold this MOS are typically eitherlieutenants fresh out of internship, without advanced training, or generalpractitioners, also-too often-without graduate training. We persist inthis even
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in the face of a great scarcity of men of this MOS, and a great surplusof specialists of various sorts, who are better suited for the job.
By far the best battalion surgeons we had in Korea were the specialistswho went into those jobs by reason of that scarcity and surplus. Of thebattalion surgeons I knew well, the three best were a board-qualified surgeon,a board-certified internist, and a board-qualified obstetrician. We canuse the untrained and inexperienced men in hospitals in the rear, wherethey can work and learn under supervision. The battalion surgeon standson 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 surplusof residency trained men, we must provide the battalion surgeon with specializedmilitary professional training to qualify him for this job.
One professional problem in battalion medical service that we have notsquarely met is the question of just what is the function of the Lieutenant,Medical Service Corps, who is assistant to the battalion surgeon. Are weoffering him as a "stand-in" substitute for the battalion medicalofficer? Surely not, with the limited training and experience that he has.When a battalion surgeon is killed or wounded or goes on leave the MSCofficer does not succeed him; a medical officer replacement comes fromthe collecting platoon or the medical battalion. Is the MSC officer thereas an administrative or managerial or tactical assistant? Surely not. Thisis a travesty against sound principles of management, a farce in the faceof need for personnel economy, duplicating the functions of the platoonsergeant, and an insult to the everyday business judgment of the averagepractitioner of medicine.
There just is not enough administration in a battalion medical platoonto call for an officer to manage it and there are not technical or subprofessionalduties appropriate to officer grade. Warrant officer? Perhaps, as the toprung of the enlisted field medical career ladder. But officer-no. Thisposition appears wholly anomalous until we look to history for the explanationand 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 theinfantry battalion: a Battalion Surgeon, and an Assistant Battalion Surgeon.It was considered that our medical manpower resources, even on our lushstaffing of World War II, could not support both positions and one wasreluctantly dropped. It was not that the job did not exist, but we didnot have men to fill it. The Marines still have two doctors per battalionand I have not heard the incumbents of those positions complaining thattheir services were not needed, nor that one of them was primarily a platoonadministrator.
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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 learneda great deal about combat medicine from the second lieutenant, MAC, whowas on the ground when I came in to take over as an Infantry BattalionSurgeon. This is both a tribute to his own ability and a frank appraisalof 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 commissionedas officers in the expansion of the Army; and others of less military experience,commissioned in the medical branch on the basis of paramedical civilianbackground. They received intensive training in advanced first aid, andwent out with commendable enthusiasm to do their share in a major war.
These conditions do not pertain now, nor did they pertain during theKorean war. In the first few months in Korea, career Medical Service Corpsofficers-Adjutants, Registrars and Supply officers-went out from administrativepositions in the Far East Command and substituted for the Battalion Surgeonsand Regimental Surgeons that the Army did not have. As lieutenants, captainsand majors they actually assumed the responsibilities of Medical Corpsofficers and carried out professional functions.
During the latter part of the Korean war, our typical assistant BattalionSurgeon was an officer on his first field assignment, with a few weeksof medical service training, after a direct commission on the basis ofa bachelor's degree in anything from law to anthropology, or officer candidateschool training in infantry or artillery. The former group could not befully considered as officers, but only as commissioned technicians, andworking at the moment out of their technical field. The latter group couldbe 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 himfunction as an effective medical assistant, we are going to have littletime left out of a 3-year Reservist's career. Worse, we will be embarkingon the treacherous policy of giving some appearance of accepting a second-rateclass 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 subprofessionalservice that could not be performed immeasurably better by a good sergeantwith 6 years of experience in the Army Medical Service, and the latterwould be performing the obviously legitimate function of a nonprofessionaltechnical 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 dutiesof a senior dispensary clerk and a medical technician is not valuable preparationfor an ultimate position of great responsibility in the administrationof a hospital, or management of a medical depot.
The type and extent of medical care offered within the battalion aidstation has been admirably presented by Major Mallory. I have been askedby Colonel Stone to discuss the professional considerations involved inevacuation of patients from the battalion aid station. They canbe rather simply outlined:
1. The battalion aid station is no place to maintain a ward-the patientsshould 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 oftreatment which is available at the aid station:
a. Bleeding should have been stopped, unless stopping it requiresan actual operative procedure.
b. A patient in shock should be improving, or stabilized, unlessit appears clear that treatment beyond the facilities of the aid stationis the only means of improvement.
c. A major fracture of a long bone should have been adequatelysplinted.
d. The basic mechanics of respiration should be intact.
3. No patient should be evacuated unless be is in condition to survivethe journey under the specific conditions he faces; and, conversely, thesequence and means of evacuation should be a matter of specific priorityand individual selection.
These criteria admittedly seem trite. Let me assure you that they areviolated often enough to require continuing supervision to insure theirenforcement.
None of these considerations require elaboration except possibly thestatement that the battalion aid station has no holding ward. I reconcilethis with the accepted handling of a mild combat-induced anxiety stateby choosing to regard these men, held overnight for a little rest and reassurance,not as true patients. The further forward they are retained, the betterthe result. This principle does not hold so strongly in the case of minormedical illnesses, and a more appropriate place to hold these patientsfor treatment and recovery is the regimental collecting station.
A restriction against holding patients at the battalion aid stationin no way impedes the battalion surgeon in his mission of preventing theloss of military manpower of the battalion, or detracts from the importanceof that mission. He should be able to treat promptly,
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and immediately return to duty, a significant proportion of thewounded who reach this station. Not every little wound requires a formaldébridement, and rear hospitals see too many utterly trivial woundsfor which a band-aid would have been sufficient treatment. Occasionallywe may err, and cover with a dressing and dismiss with reassurance a trivialscratch which actually is a significant wound of entrance. Conscientiousdiagnosis and judicious followup will make our misses in this type of caseactually 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 stationby litter bearer was almost never required. Physical conditions usuallypermitted the 3/4-tonambulances of the division medical battalion to be used as far forwardas the battalion aid stations, but tactical considerations or formal policyof the division or regiment often precluded their use ahead of the regimentalcollecting station, in which event the surface vehicles utilized were thelitter-jeep ambulances of the regimental medical company. This vehicleis an abominable improvisation retained in service because of our failureto develop anything better. The six-wheeled, semienclosed jeep ambulanceproposed by General Shambora from Army Field Forces during World War IIwould have been the answer, but it was not accepted. The new 100-inch wheelbase,1/2-ton vehicle maybe the answer, but I have seen little come of it yet.
The 1/4-ton litter-jeepambulance has few flat limitations, but a number of relative drawbacks.It is awkward and uneconomical. In cover and comfort to the patient itis no better than a litter haul, but it moves somewhat faster and is mucheasier on the litter bearers.
The new 3/4-tonambulance (M37) is, on the whole, a good vehicle. It is heated and lightedand has space for an attendant to work. It takes a little finagling toload into it patients with large splints, but otherwise it has almost nolimitations, from a professional standpoint, for use in the forward areas.
The indications for helicopter evacuation expand in direct proportionto the availability of the machine. I doubt if we should ever considerusing 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 circumstancesof 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 aerialmeans, 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 beportioned out with 100 percent efficiency, and sometimes the machines weredown for maintenance, or off on less important missions, or the night wastoo dark to fly. Roughly speaking, something less than half of the truesurgical hospital group was moved by helicopter.
No formal establishment of priorities was necessary. When casualty flowwas heavy the unit surgeons selected the worst cases. When casualty flowwas light, unit surgeons made almost as many requests for helicopter missions,but were far more liberal in selection, and many of the second prioritygroup could then be taken care of. A tenfold difference in casualties betweentwo successive months would be marked by only a 20 percent difference inmissions flown.
Hemorrhagic fever patients, or reasonable suspects, were arbitrarilyaccorded first priority, and many of us felt that the rapid and smoothevacuation to a conscientious nursing staff contributed as much to thelower mortality as did the complex and intensive treatment after admission.I have, however, listed these patients in the second bracket, so that priority1 will serve also as the criteria of selection for evacuation from thebattalion aid station to the surgical hospital. Generally speaking, withthe helicopter lift that we had in Korea, any evacuation by helicopterfrom the battalion aid station habitually meant an admission to the supportinghospital, with the exception of the hemorrhagic fever patients who wereflown all the way back to the hemorrhagic fever center, or transferred(near the surgical hospital) to light fixed-wing aircraft for the longerrear lap. When a decrease in casualties made possible a broadening in selectionof patients for helicopter evacuation, the surgical hospitals took a widervariety of patients. Thus in a quiet period a casualty with a bullet woundthrough the thigh was flown to the surgical hospital and operated on there.When things started popping, he went by ambulance and rail and was operatedon in Seoul, or even Pusan.
The group of patients who are not first priority surgical casesare right now of greater interest to me than those who are. They have notbeen so much publicized, their plight is not dramatic, success or failureof treatment is not as clearly portrayed as is an unequivocal change inmortality 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 sumtotal of time and effort in treatment in a theater of operations and theyoffer more prospect of salvage for further military service.
This is perhaps the time to bring in my own classification of woundsby relative severity. It has no recognized standing; the adjectives cannotbe held officially equivalent to any accepted military term; but it isvery handy for rhetorical purposes.
The "band-aid" wound is trivial or insignificant, ifthe physical and psychological makeup of the soldier is such that he dismissesit after a wipe with a dirty handkerchief. It is minimal if thesoldier insists on bringing it in to the medical officer, for an officialtag to make him eligible for the Purple Heart.
The slight wound that requires only débridement and delayed closureis minor if it can be treated at the division clearing station.The soldier definitely has been wounded. He can be treated and returnedto duty by the medical service of the combat division.
The soldier with the moderate wound cannot be restored to dutyfrom the division clearing station because of the time required for healingand convalescence, but the wound may be appropriately subject to débridementat the division clearing station with the patient being immediately movedto a rear hospital for further treatment, or the casualty with the moderatewound may be moved through the division clearing station to the evacuationhospital for operation there.
The major wound is the typical evacuation hospital case: secondpriority for helicopter evacuation beyond the surgical means of the clearingstation 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 forhelicopter evacuation.
The Role of the Clearing Station
The function of the clearing station in the surgical treatment of theminor, and certain of the moderate, wounds was somehow quietly forgottenbetween the end of World War II and the middle of the Korean war. It cameas a shock to the Surgeon of Eighth Army and his staff that the clearingstations supporting the several sharp actions in the fall of 1952 had degeneratedinto simple relay posts, where patients were logged out of the division,and transferred to ambulances of the field army medical service. Part ofthis was certainly due to the fact that the shortage of medical officersforced 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 notthe whole answer is proved by what the clearing stations were able to dowith a limited staff later in 1952 and in 1953.
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The doctors were unhappy, and justifiably so; their professional taskswere frankly menial. A tremendous technical and professional personnelpotential was going to waste, as were expensive equipment and facilitiescomparable 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 eachplatoon of the company. But the worst of it was the tremendous burden ofminor and moderate wounds that were thrown on the evacuation hospitals.Even with a normal allocation of evacuation hospitals this is not the besthandling of such cases, and with the extreme scarcity of evacuation hospitalbeds in Eighth Army the implications were serious. In an evacuation hospitaladmitting 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 higherprecedence accorded the more serious casualties who continue to come in.At the clearing station he is, by virtue of the lesser severity of hiswound, at the top of the list for operative treatment. After débridementhe can wait out evacuation, transfer and admission at various stages withoutharm.
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 clearingstation 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 beabsolutely certain, since even the most insignificant appearing punctureof the thigh may involve the abdomen, or a trivial laceration of the shouldermay involve the chest. This criticism is not wholly valid. We must notdiscredit clinical judgment in favor of wholesale x-ray and laboratoryexaminations. And, at the battalion aid station or clearing station, whenthe clinical diagnosis is that the wound of the thigh does not involvethe belly, the patient automatically is placed in a low priority and evacuatedby surface transportation to an evacuation hospital. If the initial clinicaldiagnosis is wrong, the proper diagnosis will then be made only after thelong delay of evacuation or after development of significant peritonealsymptoms en route. Surely this is not preferable to making the diagnosisat the clearing station by débridement and surgical explorationof the wound track.
The system received enthusiastic approval and support by the SurgicalConsultant to the Eighth Army Surgeon, whose criteria for operation atthe division clearing station have been published (2). Wounds
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involving the cranial, pleural, and peritoneal cavities, and woundswith fractures of long bones or associated vascular or peripheral nerveinjury were excluded.
The need for equipment and personnel to administer general anesthesiawas expressed by several divisions. On this subject there are mixed feelings.In one instance we furnished apparatus to a division which had a qualifiedmedical officer anesthetist assigned, and it was profitably used. As apolicy I am against it. In practically all cases that meet the spirit ofthe criteria for operation at the clearing station it can be done underlocal anesthesia.
X-ray equipment is another question. It is not particularly dangerousto use; at least mistakes are not so likely to be fatal in radiology asin anesthesiology. I fail to see that it is essential for the performanceof minor surgery of high professional quality, or for the selection ofpatients for operation. But I feel that it might be justified, on the basisof reduction of manpower loss from disease and nonbattle injury, providedthe situation were quiet, or the requirements for additional personnel,transportation and electric power in the division medical battalion wereclearly met. The Table of Equipment of the clearing company may be theplace 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 ignoredas useless and wanted no part of.
To summarize the role of the clearing station, and the professionalconsiderations in its operation:
Functions:
1. To serve as an infirmary for minor medical illnesses, and an emergencyward for wounded.
2. To treat and return to duty appropriate patients.
3. To log out from division records those casualties requiring treatmentby other installations, for whom replacement will be required.
4. To offer small-scale "medical center" services for thepractitioners in forward units: laboratory, pharmacy and consultation.
Professional considerations in evacuation from the clearing stationare:
1. Is further evacuation necessary; or can the patient be treated, heldand returned to duty without losing him from the division?
2. Is immediate major surgery necessary? If so, the patient will betransferred to the adjacent surgical hospital, which is also receivingpatients by helicopter direct from the battalion aid station.
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3. If the wound does not require immediate major surgery, is it properlyoperable at the clearing station? The patient will in either event be transferredto 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 surgicalhospital is supposed to do, and how. Some of the presentations are hastyor prejudiced; a few are contradictory; many are controversial. In spiteof the fact that the basic Table of Organization and Equipment was evolvedonly in 1945, and the only actual experience with the organization wasobtained 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 missionofficially proclaimed in the Training Circular, Field Manuals, and Tableof Organization and Equipment: to provide a mobile surgical facility forthe treatment of seriously wounded casualties within the division area.
You are all familiar with comparable units used in World War II: thePortable Surgical Hospital in the Pacific, and the Field Hospital platoon(reinforced with surgical teams) as originated in the Mediterranean andlater successfully used in Europe. These two organizations met the pressingneed for major surgical facilities located well forward. When the frontis moving, "well forward," of course, means truly mobile. Ourformer surgical hospital, which many of you may not remember, was a 400-bedunit, well equipped, but unwieldy.
In the early days of the Korean war the surgical hospitals were expandedinto 200-bed units comparable to half-scale evacuation hospitals. Theywere located well behind the division cleaning stations, on the line ofcommunications between the divisions and the so-called evacuation hospitals,which then in reality represented a combination between station hospitalsand communications zone general hospitals. The 200-bed unit received anyand all patients from the divisions, thus contributing indirectly to thedeterioration of the clearing stations.
The initial reasons for using the surgical hospitals in this mannerdid not long persist. It was found feasible and quite desirable to locatethe surgical hospitals well forward and to institute an effective selectionsystem in the clearing stations. Although it was not until February 1953that the 200-bed Table of Distribution surgical hospitals officially returnedto 60-bed Table of Organization status, they functioned as the latter throughout1952. They were not, however, located always directly adjacent to divisionclearing stations. Divisions on line were rotated frequently, and a UnitedStates division was often replaced by a division of the Republic of KoreaArmy. 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 investmentthey had in comfort and luxury construction, they were left slightly tothe rear of divisions, in central locations from which they could normallysupport any division sector within the corps. It was not that they couldnot operate forward, or could not keep up with a moving division. Eachof them proved, in realistic training exercises (in which the Communistshappened to cooperate unknowingly by throwing local attacks and producingcasualties), that they could leave behind their buildings and walkwaysand clubs and fancy quarters, load up the tentage, and go. They did beautifully.They proved the adequacy of the current personnel structure, equipmentlist and training doctrine.
Table of Organization and Equipment 8-571A (15 October 1952) is instrinsicallyadequate. It can and will be developed and improved upon, but right nowit provides for an organization that can turn out professional work ofa 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 dutiesamong the personnel now on the Table of Organization. It needs a moderateincrease in electric power, and a definite increase in tentage. About one-thirdof the tentage needed to set up a perfectly orthodox installation is notauthorized by the Table of Equipment, which provides nothing except puptents for personnel quarters, and no shelter for the mess except a kitchenfly. But any proposed change must be exhaustively considered on both clinicaland operational professional grounds. The restrictions on personnel availableto us in Korea, and likely to be available to us in the future, are painfullytight, and almost harshly inflexible. In ultimate principle the decisionwe may have to make with reference to a major addition will seem crudelyblunt: Will the sum of our military patients benefit more from a smallernumber of units that are a little better, or from wide distribution andclose support by the same or greater number of units that meet the thencurrent standards of best professional practice?
The surgical hospital is designed, equipped and staffed to perform-withthe highest professional standards-formidable initial surgery of all types.Its special characteristic in this respect, distinguishing it from evacuationhospitals, general hospitals and large station hospitals which can, technically,perform the same operative procedures, is that it is small enough, lightenough and flexible enough to offer this surgery in a physical locationwhich assures a reasonable minimum time distance from point of woundingto the operating table. Being small, its facilities should appropriatelybe reserved for the treatment of those patients for whom time lag is ofpressing importance. I
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offer the following as a loose list of wounds in order of anatomicaland 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 vasculardamage.
A detailed discussion of the treatment accorded these wounded is beyondthe scope of my presentation.
The professional considerations in arranging evacuation after treatment-selectionof the time, the means, and the channel or destination-are relative, dependingon just how fast business is at the moment and is expected to be in thenear future. I might illustrate this by presenting several of the criteriathat were utilized at various times for deciding the time of evacuationof patients with one particular type of wound-perforation of the largebowel. When things were unusually quiet in early 1952, our surgeons hadtime on their hands and hospitals had beds to spare. Some of the men werethen repairing the bowel and exteriorizing it for observation, or evenmaking primary repair and closing the abdomen, depending on private nursingand close surgical postoperative care to insure a successful result. Imention these choices to denounce them as inappropriate for general usein forward area military surgery, but a third method illustrates the detailedand extensive treatment that we could give during a slack period. In somecases a proper colostomy was performed, and the patient held at the surgicalhospital for final healing, and re-anastomosis of the bowel before he wasevacuated further.
When things are not quite that quiet, the patient was held untilthe colostomy was functioning well and he could help take care of it duringevacuation.
When the front was not calm, but tactical action was still sporadic,the patient might be held until the incision was clean and healing. Whenthings 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 followingoperation, and when the situation was frantic he might have to move outas soon as he recovered from anesthesia, to make room for someone in amore desperate situation.
The minimun requirement for evacuation of a patient with a neckor deep face wound is the cessation of bleeding, and adequate airwayand 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 attendantto work. Our present 3/4-ton ambulancemakes good provision for nursing care en route, in fact, far beyond thetechnical capacity of our ambulance drivers, who are usually medics ina very limited sense. For special cases, a qualified technician from thehospital can go along for the next lap.
For head cases I must give an equivocal answer. I am still toldby some that these patients travel better preoperatively than postoperatively,but I am not wholly convinced. The urgency of an untreated head wound isan overpowering stimulus to assume a manifest risk of transportation. Ifthey die en route, we have done our best and death is held to be primafacie indication that they were unsalvageable. Once they have reached thecare of the neurosurgeon, he is understandably loath to release them untilhe can confidently predict a safe journey. Like most general surgeons Iwill dodge neurosurgery and request to be relieved of the decision, butif I must state the criteria, as far as I am concerned the head wound patientcan be moved as soon as the surgery is over, the patient is in proper positionor on the proper apparatus, and his blood pressure is stable. These patientsdo require competent technical attendance en route. Their relatively smallnumber, their serious condition and their need for close attention warrantthe making of special evacuation arrangements. In Korea they were periodicallycollected by special helicopter lift (preferably by the larger H-19, withroom for an attendant) and flown to rear airfields to meet pre-scheduledaircraft for immediate evacuation to Japan. They ordinarily did not passthrough evacuation hospitals or intermediate holding facilities.
As for chest wounds, I feel that there is little excuse for evacuatingany man from a surgical hospital with a functionally open wound of thechest. Some sort of surgical or dressing closure can be effected. In spiteof their inherent appeal, I take a dim view of all sorts of tubes, fluttervalves, indwelling needles, or drainage systems. The chest patient shouldnot be evacuated until he is sufficiently stabilized that he can be caredfor by intermittent thoracentesis, at intervals that can reasonably bemet 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 totrauma is subsiding and the probable outcome from a circulatory standpointis no longer in doubt. If the adequacy is evident, the consideration isone of mechanical stability of the repair during movement by the meanscontemplated. If adequacy is yet in doubt, the patient should he held sothat he may have the benefit of all available measures to tide the limbover. If the circulation is patently inadequate, the extremity should bedressed 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 travelwell. 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 travelin a cast that is less than a day old: that day, of course, includes someclose observation. No patient should ever leave the surgical hospital ina cast unless the cast is split.
The choice of mechanical means of transportation is based more on theseverity of the wound (or rather, the general condition of the patient)than on the anatomical location or type of wound. The ambulance train offersthe best facilities for care en route, and gives the smoothest ride; theseadvantages are balanced against the longer time. The cargo aircraft issecond best, except that the shorter time in transit is a partial compensation.The large H-19 helicopter and the 3/4-tonambulance are comparable to each other in facilities for patient care,though vastly different in speed, comfort and cost. In respect to careen route the small H-13 helicopter does not even come up to the standardsof the litter jeep, but its versatility and speed make it an exceedinglyvaluable machine. Having weighed these various considerations in selectionof the means we then come up against the one that is overriding: whichone is available at the time?
The traditional means of evacuation from the division clearing stationor surgical hospital to the evacuation hospital is by ambulances from separateambulance companies of the field army medical service. This held true inKorea, but only for the initial stage of the trip to the rear. Patientswere transferred from ambulances at the earliest possible point, to makethe greater portion of the rearward journey by air or rail. This transferwas 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 thetemporary holding of patients is mandatory. At airheads the requirementis based in part on the irregular and unpredictable nature of air transportation.At railheads this factor is less prominent, but then there is the additionalrequirement for holding patients during the period of buildup of the trainloadbefore the scheduled loading time, even if the rail system is consideredabsolutely dependable. Our holding facilities in Korea were kept adequatein number and distribution, even when this meant subordinating or shorteningother medical support operations.
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The holding unit has never been regarded as glamorous, and thereis a tendency to forget the importance of its position in the provisionof uninterrupted medical care of the wounded. The stress of an ambulanceride of 1 to 3 hours, from the surgical hospital to a tent on an airstripor a rail siding, is not insignificant. Added to this is the period ofwaiting 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 forany patient who is still in the process of resuscitation, but it accumulatespatients of all grades of helplessness, with wounds of all locations andall degrees of severity, and in various stages of treatment. These addup to a requirement for a professional operation of some extent.
Our holding units in Korea were adequate in capacity, physical facilitiesand equipment, but I was never particularly proud of the caliber of theirprofessional work. The screening and rescreening of patients, interim medicalcare and nursing-even in the simple arts of bedding down and feeding thelitter patients-left a great deal to be desired. There is nothing wrongwith the "system" that requires that this be so. On-the-job training,repeated indoctrination of personnel, and continued interest and supervisionby 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 wasrequired. I make this blunt statement with confidence that I can supportit both on theoretical and practical grounds. I will mention it furtherin my later discussion on Evacuation and Specialty Centers. But you mayask now: How can it be said that we had only half enough when we obviouslydid well enough with what we had? We were able to operate an admirableevacuation service only as a result of the following special blessings:
1. The availability of common carrier (rail and air) transportationin 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 abilityof 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 upfrom the south to a point just over the combat zone boundary and angledover to connect with the main western line at Seoul. In the forward portionof the combat zone there were four major valleys or plains, each with anairfield located not more than 11/2 to2 hours away from the usual location of division clearing stations andsurgical
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hospitals during the latter half of the war. Holding units at the airfieldsassembled the loads of patients of all types (toothaches, backaches andconsultations included), logged them in and out, and prepared the flightmanifest before the aircraft arrived. And, of course, they held and caredfor the patients during the process. The typical length of stay for patientswas 3 or 4 hours, sometimes overnight for those with minor injuries evacuateddirect from division clearing stations, sometimes only a few minutes forseriously 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 13days, 10 of them in distressing direct succession. At such times we necessarilyused ambulance transportation, at a minimum of 11 hours per round trip.Under those circumstances we simply could not have supported a divisionattack against determined resistance, without evacuating the less seriouslywounded on ammunition and supply trucks returning to the rear over thesame long haul. In general, we could not have operated an efficient medicalevacuation system in the eastern sector without the help of the Air Force.We are deeply grateful for the favor. It is not a statutory functionof the Air Force to provide air evacuation within the field armyarea, but only from the combat zone to the communications zone.This is an assigned function of Army aviation, but diversion of all ofthe aviation in Eighth Army to purely medical missions could not have donethe job, nor will Army aviation ever be able to do it with aircraft ofthe present type.With the exception of the H-19 helicopter, no Army aircraftin current use is an adequate patient-carrying vehicle. And the H-19 isfar too expensive and complex a vehicle to use for routine hauling.
It may be heresy to suggest it, but Army aviation, or more specificallyArmy Medical Service aviation, should include aircraft comparable in capacityto 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 movementof patients entirely within the army area, and there is no more basis instatute or logic that it be operated by the Air Force than that the Navytake over from Army engineers the operation of river-crossing rafts. Aflight of six C-122's could have been economically employed by Eighth Armyeven during its quietest periods, and a squadron of 18 would have beenbarely sufficient during the most active times.
My only criticism of air evacuation in Korea was in the mechanism ofcontrol. Once the aircraft was allocated and scheduled, the service bythe air crews and medical crews was superb. But getting the aircraft wasa constant struggle, at least during the latter half of the war. We hadto 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 EighthArmy. We were required to substantiate our request with the actual numbersof litter patients and ambulatory patients to be moved. We naturally tookto the crystal ball rnethod of making such computations, since many ofour patients to be lifted tomorrow have not yet been shot today. When ourforecasts were badly off, or even initially when we made any unusual orostensibly odd request for air lift, we were criticized by the people inthe 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, withoutbreaching security, an explanation which, I sincerely believe, is of nolegitimate concern to the Air Force except as a matter of historical information.If air evacuation is going to be useful and dependable, our allocationof lift capacity should be definite, and the answer at the other end ofthe telephone should be positive: "Yes, we can do it," or "No,we cannot do it" (the lift is technically not feasible, or aircraftare not available), or "We can do only so much of it, or we can doit at another time," never a negative and indecisive "Whydo you want it done?"
We did not have the same problem with rail evacuation, which supportedour medical units on the western half of the front. The hospital ward carsand the medical crews belonged to a unit of the Army Medical Service; therailroading was in the hands of units of the Transportation Corps. Boththese units functioned under the communications zone organization whichsupported Eighth Army, but with respect to the service they rendered andthe channels of request and control, they might as well have been integralelements of the office of the Army Surgeon.
The usage of rail evacuation in Korea was prominent at all stages ofthe war. In the Pusan perimeter the rail system was well developed. Inthe fluid phases there were many examples of effective utilization of variousshort stretches of track and all sorts of odd rolling stock. During thelatter half of the war there were two preeminent features: first, the extensiveuse of rail transportation-there was even a baggage express system up toseveral of the division areas, and we belatedly started moving some ofour blood shipments by rail-and second, the proximity of rail operationsto the frontline. Some of the major and long-used railheads were withinrange 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 medicsestablished a holding facility at a lonesome terminus only 9,000 metersfrom the frontline. This installation was frankly invaluable in supportof the Triangle Hill and Whitehorse Mountain operations.
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Except in periods of consistently active battle it was unnecessary torun ambulance trains more often than once daily; the two to four divisionssupported by that rail line generated a one-train patient load each day.The hub of our rail operations was Seoul. There the seriously wounded patientswere off-loaded for air transportation to Japan. Less seriously woundedmen-those who could be expected to recover within the time period of thecurrent evacuation policy-went on down the line to hospitals in the communicationszone.
Except for such patients as were flown by helicopter direct to hospitalships in the harbor at Inchon, the 1st Marine Division was supported byrail, from Munsan, through Seoul to Inchon. With the extreme tides thatoccur at Inchon it was necessary to schedule the trains for the port sidingat the time of a high or rising tide. Since hospital ship patients whowere evacuated from the ship to Japan also came in by rail from Inchonto the airfield, this was an operation that epitomized tri-service cooperation.
The function of the hospital ship in Korea is indicated by the factthat it retains that title yet, while the late "hospital" trainis now more aptly called an "ambulance" train. The hospital shipwas utilized as a floating hospital, primarily as an evacuation hospitalfor the 1st Marine Division. Its role in the transportation of patientswas only incidental. As ships were replaced and moved back to their basein Japan they might carry along a few special patients; the bulk of theirload 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), occasionallytwo-engine C-46's. The aircraft were obtained through the same channelsused in arranging intra-Korea evacuation. Requests were made to the AirForce medical evacuation squadron in Japan. These requests were initiatedby Eighth Army. Theater headquarters maintained the medical regulatingfunction by controlling the hospital of destination in Japan.
This link in evacuation worked well. It is an entirely normal functionof the Air Force. Aircraft were usually available in adequate quantityand there was less bickering involved. The extreme fluctuations in ourrequirements naturally inconvenienced Air Force and theater planning. Thisfluctuation was due to two factors: our inability in Korea to shift patientslaterally to the full extent desired, and the lack of any significant cushionof beds to absorb sharp increases in casualty load.
The Utilization of Evacuation Hospitals
The lateral redistribution of patients is a process of far greater importancethan is indicated by the little attention it has received.
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The essential time consideration in the initial evacuation of a woundedman is not how soon we can get him to a hospital, but how long it willtake to get him on the operating table. The nearest hospital becomes swampedfirst. The surgical backlog, expressed in hours of surgical lag from timeof admission to time of operation, becomes so high that even with conscientiousapplication of clinical priorities a critically wounded soldier will bemuch better off by going a longer distance to a hospital that is readyto treat him immediately. This principle was practiced in World War II,in the control by the Army Surgeons of the distribution of patients byambulance from divisions to the several supporting evacuation hospitalsto the rear. The development of the helicopter and intra-Army air evacuationmade possible the shifting of seriously wounded patients laterally (oreven forward) between the surgical hospitals located across the front.
In one of the actions on "Porkchop" the casualties quicklytied up the surgical hospital in direct support, overflowed to the nearbyNorwegian Surgical Hospital and loaded the facilities of the nearest neurosurgicaldetachment. The next patients with head wounds were then flown by Armyhelicopter to the hospital ship at Inchon. The less seriously wounded wereculled out and moved to the evacuation hospital near Seoul and the seriouslywounded were spread out to other surgical hospitals across the front. Finallyit was necessary to move several aircraft loads of those with minor woundsentirely 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, occurringentirely in the sector of one regiment of one United States division, filledevery operating table in Korea except those in the one surgical hospitalon the far right.
The impact of the seriously wounded on the surgical hospitals in thisinstance was less disrupting than the avalanche of lesser wounded on theevacuation hospitals. To make room for them it was necessary to dump wholesaleloads of common colds, consultations, and other trivia on the hospitalsin the communications zone, or in Japan, and even so the surgical lag atthe evacuation hospital for operation on some minor wounds rose to 30 to36 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 sustainedcasualty flow of major degree could not have been accommodated by the medicalsupport we had in Korea except with periods of stagnation aud significantlowering of fundamental professional standards.
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By the summer of 1952, successive reductions in the troop ceiling onmedical units in Eighth Army and the Far East Command, and the dwindlingof the replacement stream to the point that we could not staff the unitswe 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 havegiven effective mutual support in the event of movement forward or rear.They were kept busy most of the time with station-hospital-type patients-diseaseand nonbattle injury. Even with expansion of number of beds their abilityto absorb a sudden increase in admissions was limited to one full train-loadof patients, or eight C-46 aircraft loads. By the time the second liftcame in, arrangements had to be completed for the simultaneous transferof patients to Japan or the communications zone before the second groupcould be cared for.
Allocation of Medical Manpower Resources
These arrangements were made and were executed. The hospitalsin Japan supported the combat operations as if they were in Korea and wearingthe patch of Eighth Army. The medical service in the Far East did not just"get by"-it turned out superior work. The medical service wasnot unduly imposed upon by these successive reductions in troopstrength-the whole of Eighth Army was cut, and the whole war in Korea wasfought 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 overthe whole world.
I wish to give no implication of complaint, but of caution. Do not acceptthe troop basis in Korea as an optimum for planning. Do not accept it aseven an adequate minimum for Korea. The medical service in Korea functionedas well as it did by virtue of special circumstances that are not dependableassets to draw on in the future.
In particular I warn you not to accept the physician: troop ratio of1950-53 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 nonfightingfronts, and those in Korea favored by the special circumstances I havementioned. If we had met with reverses or sustained heavy action, and ifthe medical service had stagnated as it might have, I am sure that medicalmanpower resources would have been released to the Armed Forces on a moreliberal basis. I am alarmed to see a figrure of 3.5 per thousand bandiedabout with the implication that it is to set the standard for any futurewar, not just the period of uneasy peace. And I am amazed that outsideagencies take pride in having been instrumental in establishing such
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an arbitrary and restrictive allocation of medical manpower resourcesfor national defense.
I am confused by the continuous harping on the desirability for furthercurtailment of assignment of Medical Corps officers to nonprofessionalduties. In World War I there were approximately 6.5 physicians, and 0.5administrative officer per 1,000 troops. Now the total of 7 per thousandis split differently: approximately 3.5 Medical Corps officers and 3.5Medical Service Corps officers. A good part of the increase in MedicalService Corps positions is legitimately due to increasing complexity ofadministration and operating of ancillary services. But not in the lastdecade do I recall a single instance in which the reduction in proportionof Medical Corps officers was accomplished by replacement in ourmanning tables by officers of the Medical Service Corps.
We have cut Medical Corps positions too far, and I flatly do not believea ratio of 3.5 doctors per thousand is right. We have, in too many instances,compounded and confused the administration by adding personnel who arenot really needed. I fail to see why a lieutenant is needed in additionto a sergeant to command a section (not a platoon, just a section) of ninelitter jeep ambulances, or a section of six litter squads. I cannot conceiveof a reason why a regimental medical company requires both a captain, administrativeofficer, and a lieutenant, mess, supply and motor officer. Nor can I imaginewhat keeps the administrative officer who is assistant platoon leader inthe clearing platoon profitably occupied. Eighth Army officially and voluntarilyoffered, through both command channels and technical channels, to giveup nearly 200 officer spaces for Medical Service Corps officers in tacticalunits, and this without hope or intent of increasing the number of ourscarce Medical Corps officers. In other words, that portion of the 3.5MSC's per thousand troops that these officer positions represented wasin no way contributing to the reduction of MC's to 3.5. They representin my opinion nonessential padding, and poor contributions to the prestigeand importance of the Medical Service Corps. The future of that Corps appearsto me to lie in its quality, not in its numbers. It is of interest to notethat 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 preferto call it a cry against "nonclinical" positions, exceptthat 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 battalionof a division; airborne division surgeon; operations officer for a fieldarmy surgeon and commander of a medical group. Yet all of these are positionswhich have been neglected in assignments; have been filled on occasionsby Medical Service Corps officers by default; and have been held, by some,in private conversations, as coming within the group of administrativeassignments 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 considerationsin evacuation with a listing of some essential features of a modern fieldmedical service, with comments as to where and why we succeeded, and where,what and how we might have done better:
Exceptional | 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 anevidence of prominence, not quality.
Division medical service in Korea was good, but most of thoseconnected with it will agree with me that it needs more medical officersthan we could supply from our resources in Korea and the Far East, andit needs more interest in the matter of selection, training and assignmentof officer and enlisted personnel. It deserves a great deal more attentionfrom the research people. And it stands to profit us more by such researchthan does any other field.
The value of helicopter evacuation from aid stations is apparentand has been widely discussed. The first trial in Korea was a great blazeof glory. The machine is here to stay; the program will coast into thefuture of its own momentum. If anything, we need to see that the machineis not oversold, and that sober attention is given to the relative costof the use of such an expensive means, the propriety of using commissionedofficers as ambulance drivers, and the development of a vehicle which istechnically adequate for the transportation of patients. Let me lay oneghost here: the helicopter is not vulnerable to enemy air, at least nomore so than the jeep or truck.
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Korea was the first trial of the surgical hospital, and its debutwas also brilliant. We do need further emphasis on the development anduse of this unit, particularly its role in close physical support of thedivision. This function will never rightly be lost to rear hospitals byvirtue of swifter and more capacious and more flexible air transport-atleast not while the infantry moves on the ground and is supported in mostpart by surface transportation.
The utilization of evacuation hospitals in Korea was prominentin a negative sense, as pertains to service to battle casualties, and ina positive sense only with respect to the great amount of work that wasdone for the nonbattle sick and injured. This applies, of course, to evacuationhospitals generally. As individuals, the two we had assumed a tremendousload as a result of the missing ones that we needed, and they did yeomanwork. The shortage of evacuation hospitals and the resulting inabilityto absorb sudden heavy casualty loads was the most disturbing singledeficiency in the organization of the medical service in Korea.
Although the military surgeon must be a true general surgeon, preparedto operate on anything between the scalp and the toenails, expert servicemust be provided in certain of the professional specialties. Wecannot hope to do this by apportioning the specialists so that each medicalunit has its across-the-board share. Some of the units will wind up withhalf a neurosurgeon. The specialist with limited training in his fieldworks better with and under guidance of his colleagues, and the answeris the concentration of certain specialists at designated centers. Thiswill be the subject of a separate presentation.
It may seem prosaic to you, but I wish to stress again the need foradequate surface transport for evacuation. So long as most of thefighting men are on the ground, and most of the tonnage of food and gasolineand ammunition to support them comes by pipeline, road and rail, we musthave an adequate surface evacuation system. The helicopter can, technically,eventually replace any of our standard cargo or evacuation vehicles. Andit will-for certain units, certain special functions and certain tacticaloperations. Fixed-wing aircraft and the convertiplanes that will come duringour term of service cannot replace any significant numbers or types ofstandard surface vehicles. They supplement and complement, and contributeto flexibility. They will save lives, but not units and personnel spaces.
The prominence of the use of rail transportation and evacuation inKorea is a feature that is not likely to disappear in the future. A railsystem and a determined field army engineer make a combination that isfar less susceptible to destruction by enemy action, by either conventionalor 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 WarII, and they ran into Hiroshima almost immediately after the bomb. Theymay not have run on time, or smoothly, but they hauled tonnages that wouldrequire 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 Forceto fulfill its first duty of attaining and maintaining air superiority.For the future we need a great deal of attention to developing a type ofaircraft for evacuation within the field army, and developing the organizationand control of the system.
Preventive medicine service was in Korea, and will be in thefuture, accomplished in keeping with the finest and deepest traditionsof 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 mobilewarfare. It will be altered slightly in orientation and methods, and ithas reached such proportions in personnel, service support and scope toindicate the need for formal organization and control.
You will note that I have not starred the final consideration of overallprofessional quality, either for Korea or for the future. Militarymedicine goes along with civilian medicine and leads it or follows it inall its aspects. The difference in our military practice between WorldWar II and Korea reflects the startling advances in medicine of the pastdecade. The Army is as interested in the standards of medical educationand medical practice as is any civilian agency. We draw our doctors fromAmerican medicine. From a healthy population we draw our soldiers and weare supported by a productive industry.
For this reason I am depressed to see statements made which indicatethat the Military is in competition with civilian medicine, in particularthe open implication that the requirements of the Military for medicalmanpower threaten the quality of medical care of our population as a whole.This is selfish foolishness. Medicine on the home front in World War IIdid not suffer in quality-only in sweat and inconvenience. And at thattime there was a vastly greater proportion of American medicine in uniform.
I arn certain that the Military deserves a more liberal access to anduse of medical manpower than the starvation level we have worked underfor the past few years. All of you who have had anything to do with assignmentor management of personnel in Korea, in Japan or in the United States knowfull well that we led a hand-to-mouth
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existence. Every transfer of a single individual overseas was followedby a fingernail-chewing suspense waiting for his replacement to return.Every loss of an individual from overseas-even on his return for emergencyleave or board examination-was keenly felt, and required all sorts of shufflingof people to cover the vacancy. Divisions in the United States, supposedlytraining or ready for a combat role, existed on one or two medical officersper division, with noncommissioned officers or Medical Service Corps officersrunning sick call.
As is the quality of American medicine as a whole, so will be the qualityof medicine in the Army. Although the process of evacuation of the woundedhas little counterpart in civilian medicine, it is a truly professionalendeavor-in its planning and management, and in balancing the administrativerequirements and limitations against the probable professional outcome.We must get more Medical Corps officers out of wards and clinics and intofield units. The quality of medical evacuation, including the medical careen route, will depend on the amount of professional interest andability that goes into it.
This is the prime of the "Professional Considerations ofPatient Evacuation."
References
1. Conn, H. R.: In speaking to the Field Medical ServiceSchool of the Marines.
2. Ginn, L. H., Jr., and Ziperman, H.: Surgery in Division Clearing Stations.Military Surgeon 113: 443, Deceniher 1953.
