CHAPTER XX
Development of Procedures for Evacuation from Theaters to the Zone ofInterior
Before the patient load (described in the last chapter) couldbe transferred from theaters to general hospitals in the United States, policiesand procedures to govern the entire operation had to be developed. Thoseestablished early in the war remained effective with minor modifications to itsend.
Procedures for Sea Evacuation
SOS directives charged ports of embarkation, operatingdirectly under the Chief of Transportation, with responsibility for theevacuation of patients from overseas areas to which they supplied war materiel.A basic prerequisite to the discharge of this responsibility was informationabout the kind and number of patients to be evacuated. Accordingly, in August1942 SOS headquarters announced that patients would be classified fortransportation purposes as mental, hospital, or troop class.1The next month these classes were increased to four by splitting thehospital class in two: hospital litter and hospital ambulant. Mental, or ClassI, patients were those who required security accommodations aboard ships ortrains to prevent them from injuring or destroying themselves. Hospital litter,or Class II, patients were those whose physical condition required them toremain in bed and be cared for entirely by others. Hospital ambulant, or ClassIII, patients were those who required medical care and service, even though theydid not have to remain in bed at all times. Troop class, or Class IV, patientswere those who needed little medical care en route and were able to care forthemselves even in emergencies.2
In 1944 subdivisions were established for Class I, or mentalpatients. They were actually of three groups: those who were seriously disturbedand needed locked-ward accommodations in hospitals as well as on ships; thosewho were borderline cases and might or might not require locked-ward care onland but did require it aboard ships; and those who were only mildly disturbedand did not need to be
1Memo,CG SOS (init by Lt Col J[ohn] C. Fitzpatrick) for SG, 21 Aug 42, sub: Est of Reqmt for Sea Evac. SG: 560.-2.
2Ltr SPOPH 322.15, CG SOS to CGs and COs of SvCs and PEs and to SG, 15 Sep 42, sub: Mil Hosp and Eva? Oprs. AG: 370.05.
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placed under restraint in any event. Patients of the lasttype suffered from being quartered with the more serious mental cases and, ifplaced in locked wards, took up space needed for the latter. Yet, under existingregulations and classifications, transport surgeons and medical officers incharge of patients on hospital ships often treated all mental patients alike,regardless of the degree of their disability. To remedy this situation the WarDepartment in June 1944 broke the classification for mental patients (Class I)into three parts-Class I A, Class I B, and Class I C-to conform with thethree groupings just stated.3 TheChief of Transportation then ordered hospital ship commanders and transportsurgeons not to place Class I C patients in restrictive quarters but to evacuatethem instead in accommodations used for troop class (Class IV) patients.4
To furnish ports in the United States with information aboutthe number of patients of each type to be returned to the zone of interior, SOSheadquarters in September 1942 devised a system of reports of "essentialinformation concerning evacuation of sick and wounded from overseas."Offices of both The Surgeon General and the Chief of Transportation concurred inits establishment. Each overseas commander was required to report monthly to theport commander serving his area the following information: (1) the total numberof patients awaiting evacuation, (2) the number in each of the four classeslisted above who were awaiting evacuation at each port within the theater, and(3) the number in each class who were expected to require evacuation at thebeginning of the following month. Upon embarkation of patients for the UnitedStates, each theater commander was required to report by air mail to portcommanders in the United States the name of the ship upon which patientsembarked, the number of patients of each class aboard the ship, and the expecteddate and port of arrival in the United States. Receipt of such information wouldsupply a basis for the Transportation Corps to use in providing transportationand for the Medical Department to use in assuring the availability of sufficientnumbers of vacant beds for patients being evacuated.5
Early in 1943 this system was slightly modified. In some instancesembarkation reports failed to reach ports in the United States before thearrival of ships carrying patients. In others, theaters failed to submit suchreports. In still others, they submitted incorrect reports. For example, on 9December 1942, 788 patients arrived from the European theater at the port ofHalifax in Canada. Although the theater had reported them all as ambulatory, itwas discovered upon arrival that seven were litter and 104 mental patients whorequired attendants. Because of the erroneous report, insufficient medicalpersonnel had been sent to Halifax to care for the patients received and theirdebarka-
3Ltr AG 704.11 (3 Jun 44) OB-S-E-SPMOT-M, TAG to CGs AAF, AGF, ASF, Base Comds, and TofOpns, 8 Jun 44, sub: Procedure for Evac of Pnts by Water or Air from Overseas Comds. SG: 705.-1.
4(1) Ltr, Hq ComZ ETO to CofT, 10 Jul 44, sub: Accommodations for Class I A Pnts on Trp Trans. TC: 569.6. (2) Telg, CofT (Mvmt Div) to CPE, 28 Jul 44. SG: 560.2. (3) Telg, CofT (Mvmt Div) to CGs PEs, 2 Sep 44. SG: 705. (4) Ltr, CofT (Mvmt Div) to PEs, 21 Sep 44, sub: Sea Evac of Mental Pnts. SG: 560.2.
5(1) Memo, CG SOS for ACofS OPD WDGS, 3 Sep 42, sub: Essential Inf Conc Evac of Sick and Wounded from Overseas. OPD: 370.05. (2) Ltr AG 370.05 (9-15-42) MS-SPOPH-M, TAG to CGs Def Comds, TofOpns, and Base Comds, 16 Sep 42, same sub. SG: 705.-1.
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tion was delayed.6 Toprevent similar occurrences, as well as the arrival of patients without priorarrangements for their reception, theaters were directed in January 1943 toexercise more care in making reports of embarkation and to transmit them byradio rather than by air mail.7
Another modification in the reporting system occurred as aresult of increasing participation during 1942 of agencies other than the ArmyTransportation Corps in the evacuation of patients. Some were returned onBritish ships; others, by the Air Transport Command and the U. S. Navy. Forexample, by the end of 1942 most patients evacuated from the South Pacific areawere returned by the Navy; and from Central Africa, by the Air TransportCommand. Commanders of those areas considered it unnecessary to submit reportsof patients awaiting evacuation, since they did not normally use Army ships.While failure to receive such reports did not interfere with the Chief ofTransportation's efforts to supply sufficient transport lift for patientsawaiting evacuation by sea, it did hamper planning for the reception of patientsin the United States and for their further transportation, usually by rail, tohospitals of definitive treatment. Therefore, on 13 January 1943 the WarDepartment directed theater commanders to report monthly, in addition toinformation already required, the number of patients awaiting evacuation by air,by Navy ships, and by any other means, as well as the number in each categorywho were expected to need evacuation at the end of the following 30 days.8
Further changes were made later in the war. Toward the end of1944 the return of able-bodied men and officers on "rotation"complicated the problem of evaluating the adequacy of patient lift because suchpersons sometimes took up space on transports which the Medical Regulating Unithad considered available for patients. In August 1944, therefore, the WarDepartment directed theater commanders to add to reports of patients all othermilitary personnel awaiting transportation to the zone of interior.9Early in 1945, as the patient load mounted toward its peak, the Surgeon General'sResources Analysis Division requested additional information for planningpurposes. As a result, the War Department directed theaters in March 1945 toreport not only the patients awaiting evacuation and those expected to needevacuation at the end of the following month but also those that were expectedto need evacuation at the end of the second and third months after the date ofthe report.10
To assure proper use of the information submitted bytheaters, the SOS Hospitalization and Evacuation Branch prepared a directive inOctober 1942 for the Chief
6(1) Memo, Lt Col J. C. Fitzpatrick for Chief Hosp and Evac Br Plans Div Oprs SOS, 21 Dec 42, sub: Rpt on Temp Duty, Hq 2d SvC and Hq NYPE. HD: 705 (MRO, Fitzpatrick Daybook, Aug 42-Jun 43). (2) Memo, CG SOS for CofT, 3 Jan 43, sub: Reception of Pnts Evac by Sea from Overseas Comds. Same file.
7(1) Memo, CG SOS for TAG, 2 Jan 43, sub: Compliance with Directive. AG: 704 (1-2-43). (2) Rad CM-OUT- 1128, AGWAR to ETOUSA, 3 Jan 43, HD: Wilson files, "Book III, 1 Jan 43-15 Mar 43."
8Ltr, TAG to CGs Def Comds, Depts, and Base Comds, 13 Jan 43, sub: Essential Info Conc Evac of Sick and Wounded from Overseas. AG: 370.05.
9OCM form, with message prepared by OCT for dispatch to CGs Def Comds, TofOpns, and PEs, 30 Aug 44, and with Memo for Record. TC: 370.05.
10(1) Memos, SG (Resources Anal Div) for ASF (Plans and Oprs), 21 and 27 Feb 45, sub: Rpt for Overseas Theaters. SG: 705. (2) Rad CM-OUT-55158, WD to all Overseas Comds, 17 Mar 45. TC: 370.05 (Monthly Rpt of Reqmts).
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of Transportation to issue to port commanders.11It required them to transmit information received from theaters to the Office ofthe Chief of Transportation, to other interested port commanders, and to thecommanding generals of service commands in which ports were located. Also, portcommanders were to compare the number and types of patients to be evacuatedduring the following month with accommodations aboard transports scheduled tocall at theater ports. If it appeared that there would be insufficient"lift"- that is, too few ships returning from theaters or unsuitableaccommodations on available ships for different classes of patients-portcommanders were to report this fact to the Chief of Transportation in order thatadditional lift might be provided. Finally, port commanders were to useinformation received in embarkation reports to plan transportation from ports inthe United States to hospitals of definitive treatment.12
In the final months of 1942 transports arriving at overseasports sometimes found more patients ready for evacuation than theaters hadreported and hence had insufficient accommodations for all of them. Thissituation resulted from the temporary and sudden accumulation of patients,particularly of Class I (mental), after reports had been sent in, and from thepreemption of all space on a transport by its first port of call to thedetriment of ports of later call. Measures were taken to avoid such occurrences.Port commanders were required to submit their comparisons of evacuationrequirements with scheduled sailings of transports to the Office of the Chief ofTransportation for review. When that Office found that accommodations ontransports scheduled for return trips from theaters were insufficient forpatients needing to be evacuated, it directed port commanders to determinethrough direct communication with theater commanders what additional evacuationspace was really necessary. The Chief of Transportation was then responsible forcomplying insofar as possible with desires of the theater commander. Inaddition, when transports sailed for a theater with several ports of call, portcommanders in the United States were required to inform theater commanders oftheir capacities and theater commanders in turn were required to suballocatereported space among the several ports under their jurisdiction.13
Later in the war, the Medical Regulating Unit usedinformation submitted in reports of patients being embarked and awaitingevacuation to plan the most effective use of all available evacuationfacilities. Its Water Evacuation Section maintained at all times current recordsof patients needing transportation from different ports in the several theaters.Comparisons of such records with space for patients aboard scheduled transportsrevealed whether or not anticipated lift for a particular port or theater wouldbe adequate. If not, the Medical Regulating Officer recommended steps to supplythe required lift such as changes in the schedules of transports, increases inthe number
11Memo, CG SOS (Hosp and Evac Br) for CofT, 10 Oct 42, sub: Sea and Port Evac Oprs. SG: 705.-1.
12Ltr SPTSM 370.05, CofT (Mvt Div) to CGs PEs, 23 Oct 42, sub: Sea and Port Evac Oprs, with incl. SG: 704.-1.
13(1) Ltr, Surg NOPE to CG SOS (Plans Div), 10 Feb 43, sub: Overseas Evac Plan Ships' Hosp Space Almt, with 5 inds. HD: 705 (MRO, Fitzpatrick Daybook, Aug 42-Jun 43). (2) Memo, Chief Hosp and Evac Sec Plans Div ASF for Col [Frank A.] Heileman, 22 Apr 43, sub: Sea Evac Oprs. HD: Wilson files, "Day File." (3) Memos, ACofS for Oprs ASF for SG and CofT, 9 May 43, sub: Hosp and Evac Oprs. Same file.
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of patients to be evacuated by air, or the redeployment ofhospital ships.14
While directives issued during 1942 charged the Chief ofTransportation and port commanders under his control with evacuation fromtheaters of operations, they contained no demarcation of areas of responsibilityof overseas commanders and the Chief of Transportation for transfer of patientsfrom control of the former to the latter. To insure co-ordination between atheater and the zone of interior, such demarcation was necessary. Hence, earlyin 1943 the SOS Hospitalization and Evacuation Branch prepared a directive on"sea evacuation operations" which the War Department issued on 25January 1943.15 This directive detailedspecifically for the first time the respective responsibilities of the Chief ofTransportation, port commanders, and theater commanders.
The Chief of Transportation was charged with the care,treatment, and safety of patients after their ships had left overseas ports. Upto that point theater commanders were responsible. These commanders were chargedwith selecting patients to be evacuated, with concentrating them at or nearports of embarkation, and, in co-ordination with overseas port officials, withplacing them on ships bound for the United States. They were responsible forinsuring that patients were not placed on ships lacking suitable accommodations.For example, a theater commander was not to permit mental (Class I) patients tobe embarked in excess of a ship's capacity for patients of that type.Furthermore, he was to prevent the loading of ships with more patients thancould be "reasonably expected to be evacuated to lifeboats should it becomenecessary to abandon ship." This left the decision as to suitability ofaccommodations up to theaters. Eventually, though, they were forced tosubstitute the War Department's opinion of suitable accommodations for theirown. As transportation and medical officials of ports in the zone of interiorcompleted surveys of transports during 1944, theaters were expected to useofficially announced capacities for patients of all classes.16
Theater commanders were also responsible for providingadequate medical personnel for patients embarked and for furnishing anyadditional medical supplies requested by transport surgeons. Personnel whom theyplaced on ships normally belonged to the Chief of Transportation and weresupplied to theaters on an "attached" basis. Medical hospital shipplatoons of various sizes were attached to United States ports by the Chief ofTransportation. Port commanders then ordered them to temporary duty in theatersof operations. Only when such platoons were not available were theatercommanders required to supply medical troops of their own. As with personnel,theater commanders were expected to furnish additional medical supplies totransports only in unusual or emergency circumstances. Normally port commandersin the United States placed aboard each transport enough medical supplies tocare for all troops on its outbound voyage and for patients, on the inboundvoyage,
14Examples of the records kept may be found in "Estimate of Evac Reqmts [Weekly]," Books 1 thru 8, 31 Jan 44-27 May 46, and "Evac Reqmts-Monthly Rpt," Books 1 and 2, Nov 43-May 46. SG: 705. Also see Study of Pnts Evac. HD: 705 (Evac).
15Ltr AG 370.05 (1-19-43) OB-S-SPOPH-M, TAG to CGs Theaters, Depts, Base Comds and Task Forces, and COs Base Comds and Task Forces, 25 Jan 43, sub: Sea Evac Oprs. AG: 704 (1-19-43).
16See above, p. 327.
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equal in number to one fourth of the transport's troopcapacity.
Theater commanders were given additional responsibilities inconnection with sea evacuation operations in the latter part of the war. Toreduce the medical personnel who would be needed for assignment to regularlyorganized medical hospital ship platoons, they were required after 8 June 1944to form Medical Department officers, nurses, and enlisted men being returned tothe United States on "rotation," into provisional medical hospitalship platoons. Regularly organized platoons were saved for use only whenprovisional platoons could not be formed. In the same month, theater commanderswere directed to furnish transport surgeons and hospital ship commanders notonly with evacuation orders but also with lists of patients showing diagnosis,transportation classification, and type of accommodation needed for each.Similar lists had formerly been prepared by transport surgeons and hospital shipcommanders for submission to zone of interior port officials for use indebarkation activities. Now, their preparation by theaters saved time formedical officers aboard ships and assisted them in placing patients in suitableaccommodations. Theater officials were expected, in addition, to assemblecomplete sets of records for each patient and to deliver them, along withpatients' baggage and valuables, to ships upon which patients were embarked.When records were missing, theater commanders either had new ones prepared orsubmitted to ships' officers certified statements of those missing and of thereasons for their absence.17 Nearthe end of the war an additional duty was placed on theater personnel. Up tothat time debarkation tags containing information similar to that found onembarkation lists were prepared and attached to patients aboard ship.18In July 1945 a War Department circular required theater hospitals toprepare and attach identification tags to each patient before his embarkation.These tags were made of four perforated sections. The first three could bedetached to serve theater ports, ships, and United States ports as records ofpatients handled. The last section, containing information about a patient'sdiagnosis, could be used by debarkation hospitals in assigning patients towards.19
The directives just discussed served as a basis forco-ordination of activities of theaters and the zone of interior in theevacuation of patients by sea. A further step-the co-ordination of activitiesof transport surgeons with those of the ports of debarkation in the UnitedStates-was taken in 1943. In the spring the New York Port issued instructionsfor transport surgeons. In addition to describing the manifold duties andresponsibilities of transport surgeons for sanitation aboard transports, for thecare of outbound troops, and for the care and treatment of inbound patients,these instructions covered the duties of transport surgeons in the transfer ofpatients from ships to ports. Upon arrival at a zone of interior port, eachtransport surgeon was required to submit to a port surgeon's representative alist of all Army patients, showing for each a
17(1) Ltr AG 704.11 (3 Jun 44) OB-S-E-SPMOT-M, TAG to CGs AAF, AGF, ASF, Base Comds, and TofOpns, 8 Jun 44, sub: Procedure for Evac of Pnts by Water or Air from Overseas Comds. SG: 705.-1. (2) Ltr, CofT to CG NATOUSA, 13 Nov 43, sub: Embarkation of pnts. HD: 705 (MRO, Fitzpatrick Stayback, 493). (3) Ltr, Stark Gen Hosp to CG CPE, 10 Jan 44, sub: Pnt Lists for Hosp Ships, with 4 inds. SG: 705.-1. (BB).
18TC Cir 50-31, 30 May 44, sub: Use of Debarkation Tag (Manual for Trans Surg); (Revised 17 Jul 44). TC: 710.
19WD Cir 218, 20 Jul 45.
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brief diagnosis, a classification (neuropsychiatric, medical,or surgical), and whether litter or ambulatory, along with records accompanyingeach patient. Each transport surgeon was required to submit a list of thebaggage of patients and a list of patients' money and valuables in the surgeon'spossession. Finally, he was to complete all entries on a debarkation tag foreach patient and was to insure the attachment of such tags to the clothing ofall except those who were neuropsychiatric. Tags for the latter were to bedelivered to debarkation officers. These actions were designed to assist portsin planning the transfer of patients to general hospitals and to assist thesehospitals in assigning them to proper wards.20
As experience accumulated and the evacuation load grewheavier, the Transportation Corps, assisted by the Medical Regulating Officer,supplied transport surgeons and hospital ship commanders with more specificinstructions than formerly. Toward the end of 1943 the guide for transportsurgeons which the New York Port had issued earlier was sent to other ports fortransmission to the surgeons of transports which called at them.21About the same time, general regulations covering the sailing of hospital shipswere published. Later, as the number of hospital ships in service increased, theCharleston Port, which had been designated as the home port for Army hospitalships serving the European and Mediterranean theaters, issued a sixty-one pagemanual of instructions for their commanders. It covered such subjects as reportsand records, procedures in case of death, regulations for sanitation andhygiene, quarantine procedures, suggestions for the care of patients at sea,supplies and equipment, and the like.22 Instructionsissued to transport surgeons and hospital ship commanders also includedprocedures to be followed in preparing for debarkations at ports in the UnitedStates, but gradually many of their duties in this connection were transferred,as already described, to theater officials. As that happened medical officers onships became responsible for checking for accuracy and completeness theembarkation lists and identification tags prepared in theaters.
Procedures for Air Evacuation
Though few patients were transported by air from theaters tothe United States in the first year and a half of the war, such demands for airevacuation as were made resulted in the establishment during 1942 of a basicsystem of air evacuation.
Earliest requests for the evacuation of patients by air fromoutlying areas came particularly from the Alaska Defense Command. Before the warthat Command had asked for airplane-ambulance service to the United States; inthe first half of 1942 it renewed its requests, pointing out then and later thatevacuation by sea was uncertain, delaying the movement of patients in some casesfrom two to four weeks and subject at all times to interruption by enemyactivities.23 To the demands ofAlaska were added in July
20(1) Instructions for Transport Surgeons, Off Port Surg, NYPE, 26 May 43. HD: 560 (NYPE), (2) ARs 55-350, 14 Sep 42; 55-415, 11 Dec 42.
21Ltr, CofT (Mvmt Div) to CGs PEs, 9 Dec 43, sub: Guide for Trans Surgs. HD: 705 (MRO, Fitzpatrick Stayback, 583).
22(1) AR 55-530, 30 Dec 43. (2) CPE, Instructions (Med) to Hosp Ship Comdrs, 30 Aug 44. HD: 560 (CPE). (3) TCP 16, 4 Apr 45, US Army Hosp Ship Guide. HD: 560.
23(1) Gordon H. McNeil, History of the Medical Department in Alaska in World War II (1946), pp. 167-192. HD. (2) Ltrs, CG Alaska Def Comd to CG Western Def Comd and Fourth Army, 14 Jul and 6 Oct 42, sub: Aircraft Amb for Alaska. AG: 452. The 14 July 1942 letter cites earlier letters on the same subject dated 10 November 1941 and 6 April 1942.
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1942 a request of the Newfoundland Base Command for airevacuation to New York. The Surgeon General's Office and SOS headquartersapproved this request and passed it on to the Army Air Forces, which in June hadbeen charged with responsibility for the development and operation of airevacuation.24
The Air Surgeon saw in these demands an opportunity todevelop an air evacuation system,25 butbasic decisions had to be made first as to (1) who within the Army Air Forceswould be responsible for planning and operating this system, (2) whether or notspecial airplane ambulances would be provided, and (3) the extent to which airevacuation would be encouraged or permitted. On 25 August 1942 the Air Surgeonforeshadowed the answer to the second question when he stated that"airplanes have not been produced in sufficient quantity to allot planessolely for ambulance use. . . ."26 On thesame day he recommended that the Air Transport Command be charged with planning,developing, and operating a system of air evacuation from outlying bases to theUnited States.27
Three days later the Air Staff announced its decisions.Special planes would not be provided for the evacuation of patients fromoverseas bases and theaters; but air evacuation would be carried out inconnection with the routine operation of air transports. Since the Air TransportCommand operated such transports, it would operate the air evacuation system.The Air Surgeon-not the Air Transport Command-would be responsible forplanning and establishing policies for this system.28To discharge this responsibility, the Air Surgeon expanded his Office,assigning to it in September and October two officers-Maj. (later Col.)Richard L. Meiling and Col. Wood S. Woolford-who had already demonstrated aninterest in air evacuation.29
Meanwhile the Air Surgeon had drafted a policy governing theextent of air evacuation. After approval by the Air and General Staffs it wasannounced to theaters by the Chief of Staff of the Army on 25 September 1942.Air evacuation would be accomplished "upon call" on the Air TransportCommand, but such calls would be kept "to [a] minimum." Theatercommanders would classify patients for air evacuation according to the followingorder of precedence: first, emergency cases for whom essential medical treatmentwas not available locally; second, cases for whom air evacuation was a"military necessity"; and third, cases-except psychotics-whorequired prolonged hospitalization and rehabilitation.30
24(1) Ltr, CG Eastern Def Comd and First Army to CG AAF, 31 Jul 42, sub: Air Amb Evac of Pnts from Newfoundland Base Comd, with 3 inds. SG: 705.-1 (Newfoundland)F.
25The chief of the SOS Hospitalization and Evacuation Branch gained this impression after conferring with representatives of the Air Surgeon. Diary, Hosp and Evac Br SOS, 12 Nov 42. HD: Wilson files, "Diary."
264th ind, CG AAF (Air Surg) to SG, 25 Aug 42, on Ltr, CG Eastern Def Comd and First Army to CG AAF, 31 Jul 42, sub: Air Amb Evac of Pnts from Newfoundland Base Comd. SG: 705.-1 (Newfoundland)F.
27Ltr, Air Surg to ACofAir Staff A-4, 25 Aug 42, sub: Evac of Casualties by Air. AAF: 370.05.
28(1) Memo, CG AAF (ACofAir Staff A-4) for CG ATC, 28 Aug 42, sub: Evac of Casualties by Air. (2) 1st ind, Same to Air Surg, 28 Aug 42, on Ltr Air Surg to ACofAir Staff A-4, 25 Aug 42, same sub. Both in AAF: 370.05.
29(1) An Rpt, FY 1943, Oprs Div ASO. USAF: SGO Hist Br. (2) Medical History, I Troop Carrier Command From 30 April 1942 to 31 December 1944, pp. 49-50. Same file. (3) Ltr, Dr. Richard L. Meiling to Col Calvin H. Goddard, 30 Jun 52. HD: 314 (Correspondence on MS) XI.
30(1) Rad CM-OUT-8628 thru 8637, Marshall to CGs Bases, Def Comds, and Theaters, 25 Sep 42. OPD: 704.1. These messages were all identical. (2) Memo, Lt Col Milton W. Arnold, AC, for Lt Col M. T. Stallter, 9 Sep 42, sub: Evac of Casualties by Air. AG: 580.-1.
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After basic decisions were made about air evacuation fromtheaters, representatives of the Air Surgeon's Office, the SOS Hospitalizationand Evacuation Branch, and the Air Transport Command collaborated inestablishing operational procedures and delineating responsibilities of variousparticipating commands. Whereas the Air Transport Command was responsible forequipment attached to planes, such as litter brackets, the Medical Departmentwas to furnish all medical supplies and equipment used in the care of patientsen route. Supplies such as litters and blankets were to be furnished bytheaters, but were to be returned by the Services of Supply after patientsarrived in the United States. Medical air evacuation transport squadrons,consisting of nurses and enlisted technicians, were to be assigned to the AirTransport Command to furnish attendants for patients aboard transport planes.Theater commanders were to transfer patients to points along regular ATC routes.They were also to co-ordinate plans for air evacuation to the United States withthe commanders of ATC wings serving their respective areas, reporting to thelatter daily the location and number of litter, hospital ambulant, and troopclass patients who should be picked up. Flight surgeons alone would determinethe suitability for flight of patients selected by theater commanders. Finally,the Air Transport Command would be responsible for the care and treatment ofpatients from the time it accepted them in theaters until it delivered them toSOS or AAF control in the United States.31
Although ATC medical officers alone could determine the finalsuitability of patients for flight, after the first half of 1944 theater medicalauthorities were responsible for establishing the general groups of patients tobe transported by air. They agreed that litter patients should take precedenceover the less serious cases. The chief surgeons of both the European andMediterranean theaters considered patients requiring neurosurgery, maxillofacialsurgery, and plastic surgery, as well as those who were blind, to be among thosewho should have priorities in air evacuation. Both believed that serious mentaldisturbances were a contraindication to transportation by air.32On the other hand, in the fall of 1944 the Southwest Pacific theaterincluded mental patients among the groups to be evacuated by air as a regularprocedure. Success in this practice resulted in the preparation in August 1945of a standing operating procedure for the air evacuation of psychiatricpatients.33
Early in 1943 the Air Priorities Division of the AirTransport Command determined the priority of patients designated for airtransportation as against priorities already established for passengers and
31(1) Rpt, Mins of Mtg, ATC, 13 Oct 43, Air Evac of Wounded. AAF: 370.05. (2) Memo, CG SOS for CG AAF, 9 Nov 42, sub: Evac Oprs. AG: 704 (17 Jun 42)(1). (3) Memo, CG SOS for CG AAF, 12 Nov 42, sub: Status of Hosp Cons and Evac Fac for Alaska Sta. AG: 632. (4) 2d ind, CofSA to CG Alaska Def Comd, 21 Nov 42, on unknown basic Ltr. AG: 632. (5) Ltr, CG AAF to Surg 11th AF, 13 Dec 42, sub: Recommended Plan of Air Evac. AAF: 370.05. (6) Diary, SOS Hosp and Evac Br, 17 Dec 42. HD: Wilson files, "Diary."
32(1) Logistical History of NATOUSA-MTOUSA, 30 November 1945 (Naples, Italy, 1945), pp. 328-29, HD: MTO, 314. (2) Off Chief Surg Hq ETO, Admin Memo 147, 2 Nov 44; Admin Memo 16, 23 Mar 45, and other correspondence dealing with selection of patients for air evacuation. HD: ETO, 370.05 (Evac Br Corresp 1944-45).
33History of the Medical Department, Air Transport Command, 1 January 1945-31 March 1946. HD: TAS. For a discussion of medical considerations involved in air evacuation, see Sidney Leibowitz, "Air Evacuation of Sick and Wounded," The Military Surgeon, vol. 99, No. 1 (July 1946), pp. 7-10.
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cargo in general. Three degrees of precedence for the lattertwo were announced in January. Persons whose movement was required by anemergency so acute that any delay would seriously and directly impair the wareffort were given a Class 1 priority. Passengers and cargo whose transportationby air was absolutely necessary for the accomplishment of a mission essential tothe prosecution of the war were given a Class 2 priority. Class 3 prioritieswere given to passengers and cargo whose transportation by air was vital to thewar effort but not of an extremely urgent nature.34In February 1943 ATC headquarters announced that patients would normallyhave Class 3 priorities but could not be displaced, or "bounced," oncethey were en route, except at the discretion of ATC flight surgeons at stopoverpoints. In effect, this gave patients a Class 3 priority for loading but a Class1 priority for the duration of flight. In emergencies, ATC announced, patientsmight be given initially the highest priority at a theater commander'sdisposal. Medical attendants were to travel under the same priorities aspatients during flights to the United States; to insure their prompt return totheaters which supplied them, they were then to be given a Class 2 priority.35
An important change in the system of determining prioritieswas made in 1944. Beginning in April the Air Transport Command allocatedtransport space on a tonnage basis to each theater commander, and theaterpriorities boards then determined the amount of space that would be set asidefor patients, for other personnel, and for cargo.36Among the obvious advantages of this system was the increased certainty withwhich both theater surgeons and Medical Regulating Officers in the United Statescould plan air evacuation.
The use of air evacuation necessitated a system by whichairports in the United States and air bases along Air Transport Command routescould be informed of the arrival of patients by plane. In October 1943 the AirTransport Command issued a regulation making ATC officers responsible for thenecessary reports. It required a base embarking patients for another to informit by the fastest means of communication available. It also required the pilotof a plane carrying patients to report his cargo to the operations officer ofthe next stopping point thirty minutes before arrival. After planes landed inthe United States, ports of aerial debarkation-using a code devised by the ASFMedical Regulating Unit-reported patients received to the Air ForcesRegulating Officer.37
Procedures for Debarkation
Patients transported from theaters to the zone of interior bythe Transportation Corps and the Air Transport Command had to be transferredsoon after arrival to service commands for definitive treatment. It wasnecessary, therefore, to determine the point where responsibility for theirtransportation and care devolved upon service commands, and to establishprocedures for their debarkation, their movement from ships and planes tonear-by
34Air Priorities Div, ATC, Directive No 5, Priorities for Air Trans, 9 Jan 43. AAF: 580 "Air Trans."
35(1) Ltr AFATC 580.1, CG ATC to CGs Overseas Comds, Wing Comdrs, 26 Feb 43, sub: Air Priorities Instruction No 4. AAF: 370.05. (2) WD Memo 95-6-43, 26 Feb 43. AG: 580.81 (1-10-43).
36(1) WD Cir 130, 4 Apr 44. (2) AAF Reg 25-6, 29 Apr 44.
37(1) ATC Reg 25-6, 15 Oct 43. (2) AAF Ltr, 4 Oct 44, sub: Rpt of Pnts for Trf. (3) Comments by Brig Gen Richard L. Meiling USAF, 30 Jun 52. HD: 314 (Correspondence on MS) XI.
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hospitals, and their reception and preparation for furthertransportation to hospitals of definitive treatment. Problems in this connectionwere not as great for air bases as for port commands because patients arrived byplane in smaller groups and fewer numbers than by ship.
In the early period of the war ports of embarkation wereresponsible for sending patients who arrived from theaters to general hospitalsfor further treatment.38 Thisresponsibility conflicted with a basic principle of Army evacuation, namely,that support was always from rear to front. According to it, responsibilities ofports for the movement of patients should have ended at their normal rearboundaries. Failure to observe this principle is perhaps accounted for by thelingering influence of peacetime practices. In peacetime the most commonmovement of patients in the United States was from station to general hospitalsand in such instances station commanders were responsible for issuing orders andarranging transportation. So long as the number of evacuees arriving at portswas small, it was perhaps logical that port commanders should perform thisservice for them as well as for patients from port complements.
The practice of considering commanders of ports ofembarkation responsible for transferring evacuees to general hospitals had to bepartially modified after patients began to return to the United States by air.Under current regulations theater commanders issued orders directing them toreport to commanders of seaports responsible for the supply and evacuation ofrespective theaters. As a result patients who traveled by air from theCaribbean, for example, landed in Florida with orders to report to the commanderof the New Orleans Port of Embarkation. In such instances they had to be sent byrail from Miami to New Orleans for subsequent transfer to a general hospital,rather than directly to the general hospital which was nearest Miami (LawsonGeneral Hospital, Atlanta, Ga.). This not only caused inconvenience to patientsand delayed their treatment, but also added unnecessary burdens totransportation facilities that were already overtaxed. In February 1943 SOSHeadquarters referred this problem to the Air Surgeon's Office. On therecommendation of the latter the War Department in May directed overseascommanders not to designate, in orders transferring patients to the UnitedStates, specific commanders to whom they were to report. At the same time airbases in the United States were granted authority to issue orders transferringpatients to general hospitals for definitive treatment.39
Unlike port commanders, commanders of air bases serving asdebarkation points operated debarkation hospitals or at least used stationhospitals located on such bases for debarkation processing of patients. Theywere responsible for removing patients from airplanes and transporting them andtheir baggage to such hospitals. To discharge this responsibility they wererequired by ATC regulations to supply a team of at least one medical officer andfour enlisted men to meet each plane bringing in patients. They did not assumethe additional responsibility and authority of arranging for the transportationof patients from air debarkation hospitals to
38(1) AR 40-1025, 12 Oct 40; C 1, 21 Aug 42; C 4, 5 Jul 43. (2) WD Cir 64, 1 Jun 42. (3) WD Cir 316, 6 Dec 43.
39(1) Ltr, CG Trinidad Sector and Base Comd to CG NOPE, 27 Jan 43, sub: Designation of Specific Hosp in Evac Orders with 5 inds. AAF: 370.05 (Evac). (2) WD Cirs 119, 11 May 43, and 137, 16 Jun 43.
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general hospitals. Instead they normally called upon servicecommands to perform this function, but in extreme emergencies might arrangelocally, or apply to the Air Surgeon, for air transport.40
Early in the war commanders of ports of embarkation wereresponsible for removing patients from ships and also for transporting them todebarkation hospitals operated by service commands. By the middle of 1943several developed "SOP" (Standing Operating Procedures) for thisoperation. The SOP for the New York Port, for example, explained procedures forthe transfer of patients from transports to near-by hospitals. Upon arrival of aship, a party from the port went aboard to verify the reported number andclassification of patients and to receive from the transport surgeon his list ofpatients classified according to diagnosis (medical, surgical, orneuropsychiatric). This list was sent immediately to Halloran General Hospital,so that room in appropriate wards could be prepared. Ambulatory patients, thefirst to be debarked, were dispatched to Halloran in commercial buses in groupsof ten, with two enlisted men as medical attendants for each group. Litterpatients were placed in ambulances, each carrying four patients and oneattendant. Finally, mental patients were consigned to ambulances, with necessaryattendants. After patients were removed from a ship, their valuables were turnedover to the boarding officer for transmission to the receiving hospital. Baggageof small groups was sent by the port direct to the hospital, while that of largegroups was handled by the baggagemaster's section of the Army TransportService or, later, the port's water division. Patients' records were put inproper order and transmitted to Halloran General Hospital. The port surgeon'soffice then sent reports of debarkation to the Chief of Transportation, TheSurgeon General, the commander of the New York Port of Embarkation, and thesurgeon of the Second Service Command.41
For debarking patients from ships and transporting them togeneral hospitals port commanders normally used personnel and vehicles belongingto installations under their control. For example, the Charleston Port trainedas litter bearers enlisted men belonging to its own medical detachment and toport and service battalions in training or on duty in the area. It also used itsown ambulances, trucks, and passenger cars to carry patients to Stark GeneralHospital, which was located near by.42 Thisprocedure sufficed when the number of patients received was small. Whenlarge-scale operations were expected, other arrangements had to be made. In thefall of 1942, for instance, to assist in the reception of casualties from theNorth African invasion the New York Port called upon the Second Service Commandfor both personnel and vehicles and used, in addition, an ambulance section of aGround Forces medical regiment.43 In
40(1) Memo, Air Surg for ACofAir Staff A-4, 24 Feb 43, sub: Air Evac Casualties, with draft of directive to all air commands in the United States. AAF: 370.05. (2) ATC Reg 25-6, 15 Oct 43 and 29 Apr 44; AAF Reg 25-17, 6 June 44; AAF Ltr 25-10, 11 Jul 44 and 9 Dec 44.
41Ltr, Surgs Br NYPE to Port Surg NYPE, 12 Jul 43, sub: SOP of Trans and Evac Off, with inds. HD: 370.05.
42(1) Ltr, Surg CPE to CofT, 19 Nov 42, sub: Overseas Evac Plans. SG: 705.-1. (2) An Rpt, 1943, Med Dept CPE. HD.
43(1) Mins, Conf on Evac of Mil Pers, 26 Oct 42. TC: 370.05. (2) Ltr, Surg NYPE to Col H. D. Offutt, SGO, 12 Nov 42, with incls. SG: 705 (NYPE). (3) Memo for Record, on 1st ind SPOPH 370.05 (11-24-42) Hosp and Evac Br SOS to CofT, 26 Nov 42, on unknown basic Ltr. HD: 705 (MRO, Fitzpatrick Daybook, Aug 42-Jun 43).
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such instances ports actually controlled the movement tohospitals of only small numbers of patients, while they continued to beresponsible for the larger groups moved in service command vehicles by servicecommand personnel.
Early in 1944 this procedure was changed. To provide aclear-cut line of demarcation between responsibilities of ports and servicecommands and to simplify operations by having only one agency furnish vehiclesand personnel for transportation from ports to hospitals, the Second ServiceCommand proposed, and the commanding general of the Service Forces approved, achange in the transfer point.44 After11 April 1944 it was normally at shipside rather than in trains or hospitals.45In the case of New York this proved advantageous. The Second ServiceCommand controlled a number of nearby medical installations upon which it couldcall for ambulances and personnel to move large shipments of patients toHalloran and Mason General Hospitals. In other instances this change introducedthe very situation it was designed to correct. The Ninth Service Command, forexample, had to call upon the San Francisco Port for twenty buses each capableof carrying thirty-seven ambulatory patients to assist in transporting patientsfrom docks to the Letterman General Hospital. In any event the removal ofpatients from ships to debarkation hospitals required close co-operation betweenport and service command officials.46
For the transportation of patients from docks to hospitals,service commands used ambulances, buses, and trains, depending upon the physicalcondition of patients and the distances to be traveled. The Second ServiceCommand, for example, transferred patients from piers located in Brooklyn,Staten Island, New Jersey, and the North River to service command debarkationhospitals by ambulance, government bus, commercial bus, and hospital train.During 1944 this Command called upon as many as twenty of its installations tosupply vehicles and personnel for such movements. In a single day, it reported,more than 200 ambulances and 55 buses were used to move 3,000 patients receivedin one convoy. The First Service Command normally used trains to move patientsfrom ships in the Boston harbor to Camp Edwards and Camp Myles Standishhospitals. The Fourth Service Command used motor vehicles almost exclusively totransport patients from the Charleston port to Stark General Hospital. In theNinth Service Command patients were transported from the San Francisco port toLetterman General Hospital in buses and ambulances, but they were moved from theSeattle port to Madigan General Hospital in small groups by ambulance and inlarge groups by rail.47
Ports continued to be responsible for debarking patients fromships. Normally they used their own men, including specially trained port andsanitary companies, as litter bearers, but in some instances they
44(1) Rpt, Conf CGs of SvCs, Dallas, Tex, 17-19 Feb 44. HD: 337. (2) Memo, CG ASF (Control Div) for CofSA thru SG and CofT, 26 Feb 44, sub: Control of Med Serv at PE, with 3 inds. SG: 705. (3) Rpt, Conf to Discuss Proposed Changes in AR 170-10 and Cir 316, 6 Mar 44. SG: 337.-1. (4) Memo, Opns Div ASF for Planning Div ASF, 10 Mar 44, sub: Evac of Returning Casualties from Ports. TC: 370.05 (Evac of Pnts).
45ASF Cir 99, see IV, pt 2, 11 Apr 44.
46An Rpts, 1944, Letterman Gen Hosp; NYPE; and 1st, 2d, 4th, and 9th SvCs. HD.
47An Rpts from SvCs, Ports, and Gen Hosp (Halloran, Hammond, LaGarde, Letterman, Lovell, Madigan, McGuire, Stark) and Sta Hosps (Cp Edwards, Cp Myles Standish) for 1944 and 1945 explain debarkation procedures and reception of patients by hospitals. HD.
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still borrowed enlisted men from service command hospitals.To save personnel and speed operations the Boston Port used wheeled litters tomove patients on its piers. Ports differed in the order in which they unloadedpatients. Some unloaded mental patients first, and then ambulatory patients.Others reversed this order. Usually litter patients were debarked last becausesuch preparations as transferring them to litters could be made while otherpatients were being debarked. As ports gained experience in operations andimproved procedures, the time required to unload ships decreased. For example,the Charleston Port cut the time from five hours at the beginning of 1944 to twohours by the end of 1944 and then to one hour for a 600-patient hospital shipduring 1945. The Boston Port reported that on one occasion in 1945 as many as1,958 patients, among them 287 litter cases, were moved from a transport tonear-by trains in two hours and twenty minutes.48
The manner in which general hospitals received evacueesdiffered from one to another. In May 1943 The Surgeon General directed hospitalsreceiving large numbers of patients from either ships or trains to admit themdirectly to wards, without "processing" them through hospitalreceiving offices. The reason was to avoid delays in giving patients neededfood, rest, and treatment. Halloran General Hospital had developed a differentsystem, and on request of the hospital and the Second Service Command, TheSurgeon General approved its continued use. There, a receiving ward had beenestablished to care for a large number of patients. It contained a mess hall forthe prompt feeding of patients, space for the medical inspection of patients andfor the care of those needing immediate medical treatment, bathing facilities,and a clothing room in which patients received fresh hospital clothes and storedtheir own clothing. There was also space for a battery of typists brought in tocomplete all of the paper work required for the admission of patients. Theaverage length of time patients stayed in this building, before being admittedto wards, was reported to be 61 minutes.49
With the growth of the evacuee load in 1944 and 1945debarkation hospitals had to transfer evacuees to other hospitals as rapidly aspossible-normally within seventy-two hours-so as to keep enough beds vacantfor large groups of new patients arriving in quick succession. With such a shortperiod of time the medical and surgical care afforded evacuees had to belimited. They were given necessary medications and their dressings were changed,while a brief examination served to check the accuracy of the diagnosis carriedin medical records and to determine their ability to undertake further travel.Primary emphasis was upon administrative matters. Records required for use indebarkation hospitals had to be prepared; reports of patients received had to bemade to Washington; orders for their transfer to other hospitals had to beissued; patients had to be outfitted with complete
48(1) Files SG: 705 (ports or debarkation hospitals) contain correspondence dealing with debarkation difficulties and operational procedures; for example, Memo, CG 4th SvC for CG ASF, 13 Jun 44, sub: Evac of Overseas Casualties at Stark Gen Hosp. SG: 705 (Stark GH). (2) History of Stark General Hospital, Charleston, S. C., 1941-45. HD. (3) An Rpts, Boston, Charleston, Hampton Roads, New Orleans, New York, San Francisco, and Seattle PEs, 1944, 1945. HD.
49Ltr, Halloran Gen Hosp to SG, 19 May 43, sub: Admission of Pnts when Arriving in Convoy. SG: 705.1 (Halloran GH). (2) An Rpt, Halloran Gen Hosp, 1943. HD.
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uniforms and given partial payments;50and arrangements had to be made for their transportation. The paper work thusrequired was voluminous. Beginning in the latter part of 1944 attempts were madeto simplify it. Concurrently, it will be recalled, the Surgeon General'sOffice was engaged in a more general project to standardize and simplifyadministrative procedures in all hospitals. Changes that were made indebarkation procedures were of two types. In June 1944 the Control Divisions ofStark General Hospital and the Fourth Service Command proposed the eliminationof records required for patients admitted to hospitals for definitive treatmentbut not needed for those in transit and the simplification of entries in otherrecords. As a result, evacuees were not admitted to the registers of debarkationhospitals and their names were not entered on admission and disposition sheets.In addition, standard rubber stamp entries were authorized for use in patients'service and field medical records.51 During thewinter of 1944-45 another measure toward simplifying the work of debarkationhospitals was adopted: the installation of addressograph equipment. With thisequipment hospitals prepared plates for use in making rosters and in issuingorders and thus eliminated the necessity of typing each separately.52Though seemingly small when considered individually, the significance ofsuch measures can be judged more accurately if the total evacuation load ofdifferent hospitals is taken into account. Stark General Hospital, for example,admitted 44,003 patients in the nine-month period from 1 January 1945 to 30September 1945, while Halloran admitted about 69,500 and Letterman about 73,000during the entire year.53
50That is, partial payments of the pay and allowances due service men, made by the Army pending full settlement of their accounts.
51(1) Memo, CofT (Mvmt Div by Lt Col J. C. Fitzpatrick) for SG (Hosp Div), 23 May 44. TC: 370.05. (2) Memo, CG 4th SvC for CG ASF (Control Div), 13 Jun 44, sub: Evac of Overseas Casualties at Stark Gen Hosp, with inds. SG: 705 (Stark GH).
52(1) Memo, SG (Control Div) for QMG, 30 Aug 44, sub: Use of Addressograph and Embossing Equip in Debarkation Hosps. SG: 413.51. (2) Ltr, SG to CG 2d SvC, 20 Dec 44, sub: Admitting Off Procedure for Pnts Retd from Overseas. SG: 705 (2d SvC). (3) Memo, Hosp Div SGO for HD SGO, 18 Jun 45, sub: Add Mat for An Rpt for FY 1945. HD: 319.1-2. (4) Memo, NP Cons Div SGO for Hosp Div SGO, 14 May 45, sub: Procedure of Pnts Recd from Overseas thru Stark Gen Hosp. SG: 705 (Stark GH).
53An Rpts, Stark, Halloran, and Letterman Gen Hosps, 1945. HD.
