Surgeons to the Front: Twentieth-Century Warfare and the Metamorphosis of Battlefield Surgery

Thomas S. Helling and W. Sanders Marble

This is a reprint of Chapter 10 from The Last 100 Yards: The Crucible of Close Combat in Large-Scale Combat Operations, part of The Large-Scale Combat Operations Series.

It had begun with Dominique Jean Larrey more than 100 years before. That magnificent surgeon of Napoleon Bonaparte's Grande Armee had once lamented that "Serious disasters afflict my soul and plunge me into the deepest grief," addressing the plight of wounded soldiers at the front.¹ Unable to leave, they languished on the battlefield as comrades-in-arms fought around them--and over them--their wounds, mangled limbs, and torn flesh offering no solace but unremitting pain.² Dominique Larrey had changed all that. His ambulance volante--literally, "flying" medical units--speeding to the edge of combat to aid and comfort fallen troops, even as muskets cracked overhead.³ This would initiate the metamorphosis of battlefield medicine from the safe confines of field hospitals placed outside the range of artillery to the very frontline trenches, firing pits, and encampments of modern warfare.

Yet at the dawn of the twentieth century, collecting combat wounded was the primary task of stretcher-bearers, medics, and physicians in the front lines--in "close combat." A modicum of care could be provided--morphine for pain, splinting of fractures, bandaging of bleeding wounds--but little else. At the time, most academicians felt nothing more ambitious should be done. Gunshot wounds from military firearms were thought clean, producing punched-out holes and tracts that nature would, by and large, take care of. The prevailing opinion, one shared by distinguished members of l'Academie de Chirurgie, was that these wounds "heal very quickly."⁴ Deeper injuries-- those violations of body cavities--produced such mischief that surely one could not meddle, not in the heat of battle with all the dust, dirt, and danger. "Capital" operations, indeed, "ought not to take place on the field or in the ambulances" because personnel and material are not available, there is not the necessary time, and the patient, so "exhausted from pain, fatigue, the journey, and loss of blood" is in no condition to bear surgery so soon, observed a British surgeon attached to the French Army during the Franco-Prussian War.⁵ French medecin inspecteur Edmond Delorme argued into 1914: "In principle, immediate laparotomy [abdominal surgery] is to be rejected. The most recent wars, those of Transvaal, Manchuria, Balkans, affirmed its harmfulness."⁶ Surgeons were urged to be "stingy" in their frontline surgery and focus on l'empaquetage-evacuation, packaging, and evacuation.⁷ Reserve any major operations for field hospitals where, out of range of artillery and danger from enemy intrusion, delicate surgical procedures could be completed at leisure.

The Great War

August 1914 would dramatically alter the paradigm of casualty care. Gigantic cannon, high explosives, and the machine gun soon invalidated all pre-war suppositions and strategy. More than eighty percent of wounds were due to shell fragments, which caused multiple, shredding injuries. "[T]here were battles which were almost nothing but artillery duels," a chagrined Edmond Delorme observed.⁸ Mud and manured fields took care of the rest. Devitalized tissue was quickly occupied by Clostridia pathogens, and gas gangrene became a deadly consequence. Delays in wound debridement, prompted by standard military practice, caused astounding lethality. Some claimed more than fifty percent of deaths were due to negligent care.⁹ And the numbers of casualties were staggering. More than 200,000 wounded in the first months alone: far too many for the outdated system of triage and evacuation envisioned just years before. American observer Doctor Edmund Gros visited the battlefield in 1914:

If [a soldier] is wounded in the open, he falls on the firing line and tries to drag himself to some place of safety. Sometimes the fire of the enemy is so severe that he cannot move a step. Sometimes, he seeks refuge behind a haystack or in some hollow or behind some knoll. . . . Under the cover of darkness, those who can do so walk with or without help to the Poste de Secours. . . . Stretcher-bearers are sent out to collect the severely wounded . . . peasants' carts and wagons [are used] . . . the wounded are placed on straw spread on the bottom of these carts without springs, and thus they are conveyed during five or six hours before they reach the sanitary train or temporary field hospital. What torture many of them must endure, especially those with multiple fractures!¹⁰

It was in this climate that an obscure Parisian military surgeon by the name of Maurice Marcille surfaced with his outlandish idea of a motorized surgical team capable of traveling to the front and operating on soldiers in need of urgent attention. His colleague Paul Hallopeau provided proof of concept, operating under a canvas tent hung from the side of a truck just behind the trenches in the fall of 1914. Seventy-five patients passed through his "surgical suite," limited only by the fatigue of the surgeon. Mortality remained substantial but almost certainly would have been higher without immediate treatment.¹¹

Thus was born the forward surgical unit. The French would argue and modify but maintained the basic format, now calling Marcille's concoction the ambulance chirurgicale automobile, or "auto-chir" for short. The units would become a mainstay of the battlefield, equally useful in static trench warfare and in the war of movement which characterized the closing year of the conflict. The American Expeditionary Forces adopted the French model and fielded five mobile surgical hospitals before the Armistice of November 1918.¹²

The Second World War

World War II caused further iterations of forward surgical care. American forces in the Pacific were challenged by enormous distances from battlefield to hospital care. Frontline surgery would be of the essence. Col. Percy Carroll, in charge of medical support for Army operations in New Guinea, witnessed it firsthand:

I was up there and saw these boys, sometimes abdominal wounds, chest wounds, legs almost shot off, and hemorrhage and so on, in shock--in which they had to depend just upon company aid people to take care of them. . . . I said [to Gen. George Marshall, Chief of Staff of the Army] I want surgery in the front lines. . . . I want surgery where it's needed.¹³

Indeed, bring the surgeons to the patient. Large, ponderous hospitals would be totally impractical. Something much lighter and more portable would be necessary to surmount the rugged geography and small-unit actions of the South Pacific. Carroll would call his compact units "portable surgical hospitals." Two surgeons--four doctors total--and twenty-five enlisted would form the core of his groups; these young vigorous men were able to literally carry the entire hospital on their backs. Once established, each would house up to twenty-five patients. The entire effort had a singular purpose in Carroll's mind: "This [portable surgical] hospital . . . was designed for one purpose and one purpose alone in combat and that is to perform lifesaving operations on patients who, if evacuated without such skilled attention, would probably die en route."¹⁴

Carroll's portable hospitals were indispensable during the Buna campaign in northeastern New Guinea at the end of 1942 into 1943. These men worked under conditions as hostile as those of the common infantryman, in jungles soaked with daily downpours, baked in stifling heat, dripping with relentless humidity, and inhabited by the small denizens of wilderness fauna. Surgery was often done bare-chested, covered only by rubber aprons; gloves were cleaned after each case in bichloride of mercury and used again. And all within hundreds of yards of Japanese positions. It was not unusual to see canvas riddled by bullet holes. Major George Marks's 5th Portable Surgical Hospital saw 389 battle wounds during nineteen days of combat. Two hundred required surgery, including a dozen with chest injuries and seven who needed exploratory abdominal surgery.¹⁵ All together the twelve portable hospitals deployed around Buna handled 1,800 combat casualties and an additional 5,500 medical problems. Their amazing work was highlighted by Col. Augustus Thorndike from the Surgeon General's Office who reported: "Perhaps the most valuable development in military medicine in this theater [Southwest Pacific] concerning the care of the sick and wounded was the organization, development, and operation of the portable surgical hospital. . . . The patients . . . received the best housing and the best medical and nursing care available within hundreds of miles."¹⁶

General Douglas MacArthur embraced them. They accompanied his troops along the northern coast of New Guinea as he leap-frogged in a series of amphibious landings. They proved ideal for loading and deploying in small landing craft, even remaining afloat to service the wounded. And when MacArthur invaded Leyte Island in the Philippines in October 1944, thirteen portable hospitals accompanied him; the portable hospital teams set off into the primitive wilds and tropical rainforests as they had done in New Guinea, even on occasion toting supplies on their backs. It had to be so. Roads and weather were atrocious. Ambulances bogged down, up to their wheel wells in mud. Wounded often arrived by native carts or carabao harnessed to travois reminiscent of the Indian wars of the American West. The 7th Portable Surgical Hospital functioned as the only medical unit supporting the 21st Infantry Regiment when it landed seventy miles to the south of the main force on A-Day and again when the regiment was re-directed to the northern coast at Capoocan. Again completely isolated, the portable hospital managed numbers of wounded soldiers, many of whom suffered ghastly injuries and had lain for hours in rain-drenched foxholes.¹⁷ In blinding storms, surgeons efficiently cleaned, debrided, and dressed contaminated open wounds and pumped blood and plasma into shocked victims.

More traditional land warfare unfolded in the Mediterranean and European theaters. Of course, that perennial small unit resource, the battalion aid station, was available and generally accessible. But these were notoriously spartan affairs. Often not much more than a shell crater, gully, or bombed-out dwelling, the battle aid station was at least shelter for wounded men. Battalion surgeons could be seen bent over, crouched, kneeling and all the while poking, prodding, splinting--usually bare-handed. Their medics held plasma, shone flashlights, pulled pulped tissue out of the way. And then the plight of the critical, determined efforts to shove in an airway, slice through a throat, or maybe clamp off a femoral artery lent a surreal aura to this makeshift infirmary. At the ready were plasma bottles--no blood available--of which there were plenty. It was not unusual to give as much as 200 units in a three-week period of combat. The surgeons had only arm and leg splints for fractures, bandages of various sizes and shapes, and a limited supply of surgical instruments. And syrettes loaded with a hefty dose of thirty-two milligrams of morphine--used quite liberally--were a mainstay of treatment, of incalculable benefit for the wounded. Waystations only, these posts would collect wounded and send the more serious cases farther back. Intense surgical attention was simply not possible this far forward.

By now it was common creed that the gravest danger to the critically wounded soldier was delay in treatment. Yet battlefield evacuation still took much too long. Hours if not days might elapse before the casualty actually saw a surgeon. Army Surgeon General James Magee had set up the Surgical Consultants Division to investigate, recommend, and improve wartime surgical care. Gen. Fred Rankin was chosen as the Chief Surgical Consultant. In turn, Rankin looked to Dr. Edward Churchill--already at forty-seven the John Homans Professor of Surgery at Harvard--as consultant to the newly formed North Africa Theater of Operations Command (NATOUSA), later to include all campaigns in the Mediterranean (MTOUSA). Churchill immediately understood that the greatest detriment to the wounded soldier was time. He referred to the time lag between injury and initial surgery as the "golden period." "[E]very hour added to the time-lag between injury and initial surgery increases the loss of life and limb," he wrote.¹⁸ Churchill had paid special attention to the work of New Zealand surgeon Dr. Douglas Jolly who, as a British volunteer, organized a twelve-man mobile surgical unit during the Spanish Civil War. "Even the most serious abdominal wounds rarely failed to reach the operating table and . . . almost half survived, whereas in the First World War only one third lived," Jolly wrote.¹⁹ His casualty organization was based on a "three-point forward system:" dressing station, mobile hospital, and then evacuation to a base hospital.²⁰

Churchill liked the idea of a mobile surgical hospital. The Army Medical Department had already included Auxiliary Surgical Groups (ASGs) in its Tables of Organization, modeled in some respects after the complementary surgical groups, the groupe complementaire de chirurgie, employed by the French Service de sante during World War I. In total, General Rankin and Colonel Churchill would field five large ASGs. Each ASG was actually a multi-specialty enterprise, comprising a number of surgical specialists organized into teams of two to four surgeons each. For example, Col. James Forsee's Second ASG had twenty-four general surgery teams, six thoracic teams, six maxillofacial teams, six "shock" teams, and six neurosurgery teams. In fact, elements of Forsee's ASG had sailed with the Eastern Task Force for Operation Torch, landing east of Algiers shortly after the main landings on 8 November 1942.²¹ Churchill had also seen the effectiveness of the British "advanced surgical centers" in North Africa (during Operation Torch) and felt the Auxiliary Surgical Group (ASG) was an ideal counterpart. His intent was to marry skilled surgeons, the existing holding capacity of field hospitals, and the influx of critical patients close to the point of wounding, at most only a few miles away.²² Key features would be mobility and quality. Surgeons were picked based on their training and reputation: at least three years of formal residency and certification by the new American Board of Surgery were required. To furnish hospital beds and limited convalescence, ASGs worked in clearing companies or field hospital platoons, close enough to the front to intercept non-transportable casualties. Churchill called these "first-priority hospitals." There would be no time for meatball surgery here. Skill would be the essence. He felt that for chest or abdominal trauma, "initial surgery cannot be carried on as a hasty, slap-dash and bloody spectacle;" he insisted that proper repair of these injuries might take hours--"reparative surgery," it would soon be called.²³ "Surgeons assigned the responsibility of caring for the wounded in a first-priority surgical hospital must be highly trained and experienced, as their tasks are the most exacting of military surgery," Churchill emphasized.²⁴

The most common teams in ASGs were general surgeons. "The general surgeon of modern warfare has become the surgical specialist of trauma," he claimed.²⁵ As many as four such "general" teams would be necessary at a busy field hospital in order to work around the clock. Other subspecialists like thoracic surgeons, neurosurgeons, plastic surgeons, maxillofacial surgeons, and orthopedic surgeons, would also be a part but probably not used far forward. More likely they would be put in evacuation hospitals farther away. Each ASG team was to have an anesthetist, a surgical nurse, and two enlisted personnel. Churchill also stressed accurate recordkeeping, for the expressed purpose of reviewing experiences and improving results--a prototype quality assessment program.

Despite some skepticism from battlefield commanders, the ASG concept worked flawlessly. After North Africa, the Second ASG landed at Anzio in early 1944 and Forsee's teams were portioned out to American and British field hospitals. General Surgery Team No. 18, for example, performed 270 operations on 184 critical patients, losing 22 to catastrophic injuries. ASGs accompanied American troops from the Normandy landings across France and Belgium. Near Bastogne, Belgium, in December 1944, men of General Surgery Team 20, 3rd ASG, moved in with the 326th Airborne Medical Company (101st Airborne Division) and were positioned in a supposedly safe area outside of the town at a crossroads location called Herbairmont. They were the only surgical element for the entire division. By the afternoon of their arrival, 19 December, the teams were busy operating on a number of casualties suffering grave head, chest, abdomen, and extremity trauma. That evening, still working, the group was surprised by a German column motoring down the Houffalize road. Burp guns erupted on the tents, and surgeons bolted for cover. Capt. Gordon Block remembered: "Machine guns opened up . . . tracers tore through the canvas. The wounded lying on stretchers groaned as some were hit a second time with fragments. I remember thinking, 'Son, you've had it now.'"²⁶

The entire team was taken captive and spent the rest of the war in prisoner of war camps in Germany.²⁷ Lack of surgical support for the embattled garrison in and around Bastogne would have heavy consequences on the morale, let alone health, of the troops. It was for that reason that surgeons and surgical supplies were flown in on two occasions. On Christmas Day, Maj. Howard "Buck" Serrell, one of the surgeons from the 4th Auxiliary Surgical Group, was flown to an empty field just outside of the town of Bastogne in a single-engine Stinson L-1 Vigilant piloted by Lt. Ancel "Gordon" Taflinger. He was whisked to safety by airborne troopers and began to sort through the hundreds of casualties piled up in the flimsy warehouse-like building at the back of Heintz Barracks in Bastogne, the location of the 101st Airborne command post. "It was a frightful and terrible sight" he wrote in his diary.²⁸ The scent of gangrene was unmistakable, of course.

A small chamber adjoining the riding stable, unheated, with only one dangling light bulb would serve as Serrell's operating suite. He operated through the night, choosing those wounds most in danger of developing gangrenous infections.²⁹ The following day a plywood glider landed in that same field filled with more 4th ASG surgeons, headed by Harvard-trained Lamar Souter and packed with 600 pounds of supplies. Surgeons were ferried to Heinz Barracks where they met a blood-stained Buck Serrell and the tell-tale smell of sweat and pus. According to Serrell, some of the wounded had lingered there for days. One surgeon commented that it looked like a pitiful Civil War encampment for the infirm.³⁰ Within twenty-four hours, the group had completed more than fifty operations with only a handful of deaths. By 27 December, Patton's Third Army had broken through and relieved the besieged garrison. Nevertheless, Serrell, Souter, and the three other surgeons who accompanied them saved life and limb of more than a few bloodied and maimed troopers--and did immeasurable benefit for the morale of a collection of abandoned and anxious wounded.

With the resounding success of Carroll's portable surgical hospitals and ASGs, it was clear, by the end of the war, that forward surgical units were not only feasible, but practical, and effective. Skilled, experienced surgeons were placed where they were needed the most--at the front. Innumerable critically wounded benefitted from urgent, expert care with minimum delays. Third Army Surgeon Charles Odom summed up the indisputable evidence for these teams: "Early, skilled care of the wounded, as near the front as possible, conclusively proved its worth. Such care can best be provided by proper triage, with diversion of non-transportable casualties to the platoon of a field hospital staffed by trained surgical teams and located in close proximity to the clearing station."³¹

But what did the future look like? Were these skilled surgeons to be part of a designated mobile hospital unit--such as Carroll's portable surgical hospitals--or complementary teams attached to regular field hospitals as Churchill had advocated? Brig. Gen. Frederick Blesse, surgeon of the predecessor of Forces Command, was convinced of the benefits of forward surgical care and set about designing a mobile surgical hospital with organic surgeons and allied personnel. Churchill and colleague Col. Michael DeBakey also championed the idea but proposed independent surgical teams to be attached rather than assigned; they thought this would give greater flexibility to the unit. However, Blesse won out, and a sixty-bed surgical hospital was created, soon to be known as a Mobile Army Surgical Hospital, or MASH.³² Fourteen physicians (including five surgeons), twelve nurses, and ninety-seven enlisted were allotted and assigned to staff a mobile sixty-bed unit, totally self-sufficient with tentage and operating space. General assumptions were that these units would support division-size formations and become the Army's de facto forward surgical unit.³³

The Korean Conflict

It was in Korea that they were first tested. Three--the 8055, the 8063, and the 8076 MASH--were quickly dispatched to Korea in the summer of 1950 as sparse American infantry were being hammered south of Seoul. Lt. Col. Kryder Van Buskirk, a urologist by trade, assumed command of the 8076 and found that of the ten doctors assigned to his unit, seven had completed only an internship. Only one had finished a surgical residency. Buskirk, as a urologist, would be the second "general surgeon," somewhat shy of his allotted five surgeons. On their first day of operation, five abdominal wounds rolled through the doors; three died on the operating table. Thirty-five patients were admitted that day, seventy-five the next. The nurse anesthetist, Lt. Katherine Wilson, was so busy administering ether that she was "nearly anesthetized from the fumes."³⁴

Following the Pusan breakout, MASH units shadowed the troops. Col. Frank Neuman's 8063 MASH dashed up the peninsula, passing the 8055 MASH and motored on toward the Yalu River. On 27 October, they arrived at Anju on the south bank of the Chongch'on River, a mere forty miles from the Manchurian border. Then disaster struck. Communist Chinese troops flooded the battlefield, ambushing US troops near the town of Unsan, Just in time, Neuman found a schoolhouse to set up their hospital, but extra space was needed. Tents were erected outside as well, and just in time. The hospital was "overwhelmed" with victims of the Unsan ambush. In a thirty-six-hour period, doctors treated more than 700 patients. But in their zeal to keep up with the infantry, Neuman's outfit found itself way out in front of the troopers, more like a reconnaissance unit than a field hospital. A few injured Chinese prisoners of war even filtered in, amazed so it seemed, that they were fighting Americans.

For the duration of the conflict, MASH units served, for the most part, as stationary field hospitals. Enlarged to 200 beds, they now more closely resembled small evacuation-type hospitals. Their mobility had been seriously curtailed, but then the battle front for those stagnant years of 1951-53 remained stationary as well. Yet, because of helicopter evacuation, their mission was unchanged: urgent treatment of unstable, "non-transportable" casualties. The place of forward surgical care seemed firmly cemented in battlefield medical doctrine. What was different, however, was the speed of evacuation. The utility of helicopter transfer from points close to front lines--mostly battalion aid station or nearby collecting points--to MASH units was fully realized in Korea, cutting time to surgical care and obviating--in many cases--the need and imperative of any more sophisticated surgical care in proximity to battalion aid stations.

The French War in Indochina

Further confirmation of this was seen in Indochina. At the same time as the Korean conflict, French expeditionary forces were battling Ho Chi Minh's revolutionary government. In the wilds of central Annam and northern Tonkin (the names formerly assigned to what is now central and northern Vietnam), small unit forays into the mountains and remote sanctuaries of the Viet Minh necessitated highly mobile and compact French medical units sturdy enough to accompany infantry and endure lengthy periods of isolated sustained activity. The French had further modified their auto-chir formations developed during World War I into advanced surgical posts. Now referred to as surgical "antennes" (antennes chirurgicale), these teams comprised a sole physician, usually someone with at least a modicum of surgical training; a chief nurse; five specialized nurses--an anesthetist, a scrub nurse, a sterilizer, and operative assistant; and a "reanimateur," a resuscitator. The unit carried tents, instruments, cots, stretchers, operating tables, sterilizer, medicines, and dressings weighing four tons and could be loaded onto trucks or flown in on two C-47 "Dakota" aircraft. Even lighter units accompanied paratrooper formations, called antenne chirurgicale parachutiste (parachute surgical antennes). Like ground surgical units, the parachute teams had a single physician-surgeon and a number of nurse assistants. Their equipment was packed in thirty-two bundles (some wicker-framed to better absorb landing impact), totaling almost two tons. They had a holding capacity of thirty to sixty beds and could easily perform ten or twelve operations before resupplying, a situation that uncommonly occurred.³⁵ Their directive was clear: evaluate (triage), resuscitate, evacuate. Only rarely, with critically unstable patients, would they perform any extensive surgery, and then often under the direst of conditions and circumstances. These teams were truly the leanest surgical units conceived. They would locate with battalion-sized combat formations in the most hostile of situations; burrow into the earth, often sandbagged and timber-reinforced; and care for the wounded, even under artillery and small arms fire. They needed access, of course, to air evacuation, the only practical mode of transport in the mountains of northern Tonkin, so placement near airstrips was imperative. Here, too, helicopters were introduced as evacuation craft. At first, the flimsy looking Hiller 360--piloted by a lone officer--would carry two litter patients strapped to either side. Neurosurgeon Valerie Andre attained notoriety by becoming one of the first two helicopter pilots, often flying right to the front lines to pick up wounded on the battlefield. By 1953, large bulbous Sikorsky choppers had arrived, capable of carrying up to six litter patients and an accompanying medical attendant.

The antennes achieved greatest notoriety from their work during the siege of Dien Bien Phu in early 1954. Four were deployed to the base aeroterrestre in northwest Tonkin, near the border with Laos. Under brutal conditions, including almost daily heavy bombardment, the physicians performed amazing feats of resuscitation and stabilization of all types of wounds. Disaster struck when Viet Minh antiaircraft artillery was able to completely shut down incoming and outgoing flights, condemning the wounded to the underground dungeons of antenne hospitals. Yet, the value of having onsite medical support provided some degree of comfort and aided the morale of the beleaguered garrison.

The American Vietnam War

The US Navy more or less adopted the French idea of close-in surgical support in America's Vietnam War a decade later. Marine medical battalions (run by the Navy), organic to each Marine division, were split into component companies, each to support a Marine regiment. The medical companies could operate a seventy-bed facility, including some surgical support. These collecting and clearing units, as they were called, were staffed by physicians whose expressed function was "triaging, sorting, transporting, and temporary hospitalization and evacuation after first aid and emergency surgical measures have been performed."³⁶ These were portable surgical hospitals capable of rapid repositioning to keep up with their maneuver regiments. In Vietnam, because of the nature of combat, these units most often resided in nearby military encampments that would also afford some degree of security. Doctors were qualified to perform minor and major surgical procedures--whatever was needed to salvage life or limb. In fact, oftentimes two or three operating rooms would be used for resuscitative procedures, including complex chest or abdominal procedures. They were more like Korean-era MASH units. However, small detachments could be deployed, much like the French antennes.

In fact, during the 1968 siege of Khe Sanh, a special "clearing platoon" of "C" (Charlie) Med of the Third Marine Division was sent to the combat base for medical support. Manned by a handful of doctors and hurriedly sandbagged in, the small detachment saw 372 patients in its underground operating space during the first ten days of the Vietnamese offensive.³⁷ Just like at Dien Bien Phu, evacuation was paramount. Doctors were concerned with stabilization only, often working under incoming artillery fire. Complete care could only take place at better-equipped hospitals. High explosives would rattle timber beams and surgeons' fingers. Vital was Khe Sanh's airstrip, the target of repeated Vietnamese attempts to isolate and strip the garrison of any hope of escape. "I can't tell you how important Charlie Med was to the morale of all of us at Khe Sanh," said combat engineer Lt. Bill Gay, himself a patient from a random artillery shell.³⁸ Simply the perception of medical care was enough to allay the fears of the combat Marine.

After Vietnam: Surgery then Hospitalization

"A fundamental determinant of mortality among the wounded is the speed with which they are given medical care, particularly first aid, resuscitation, and initial surgery," wrote Gilbert Beebe and Michael DeBakey in 1952.³⁹ What is the essence of combat casualty care? STOP THE BLEEDING. Most combat deaths are from exsanguination; a good number bleed to death very quickly--within ninety minutes--from horrible mutilative wounds. Almost two-thirds of battlefield deaths occur in this fashion. Hemorrhage, even in contemporaneous literature, is responsible for almost half of all combat mortality.⁴⁰ Yet, keep in mind that a minority of wounded will have life or limb-threatening injuries, perhaps ten to fifteen percent. Most wounded would survive despite the nearness of medical care. But for the direst wounds, the major factor in reversing this dismal picture of spiraling shock and demise is TIME: time to rescue and evacuation, time to medical attention, and time to surgical intervention. Someone, somewhere must stop the bleeding--and soon, within an hour is the oft-quoted time period, the "golden hour."

What can be done to shorten the time period? History is replete with those efforts to get medical providers to the patient sooner. Medics and corpsmen have been trained to recognize signs of hemorrhage and expedite evacuation. Physicians with some surgical (i.e. interventional) capabilities have been put closer and closer in proximity to the battlefield. But the closer one is to the lines of combat, the fewer treatment options become available. Major surgical procedures under fire are notoriously difficult and dangerous. To date, less invasive techniques are available to temporize internal bleeding such as "quick-clot" agents or REBOA (resuscitative endovascular balloon occlusion of the aorta) technology and could be activated at the level of battalion aid stations. Perhaps the future will see trained specialists--doctors and paramedics--at the front armed with devices that can control internal bleeding without the need for emergency entry into body cavities. But it all must happen fast. And evacuation from the battle area is still paramount. Today's air transport systems rapidly bring wounded to full-fledged surgical stations, but battlefield access is a function of enemy presence, terrain, and weather. And interference with evacuation capabilities, as witnessed by the French at Dien Bien Phu, can be crippling for the welfare of the troops and eventually for morale. Nevertheless, at some point, strictly resuscitative care may not be enough. At some point, just as the French realized in Indochina or the Marines at Khe Sanh, surgical capabilities must be a stone's throw away--embedded with combat units, however threatening the environment may become. In other words, the proper blend of mobility, capability, and sustainability will be necessary to provide life-supportive help, including surgical expertise, so close to the wounded as to fall within that Golden Hour of opportunity.

An Uncertain Future

Medical advances in the 1960s and 1970s saved lives. Helicopters moved severely wounded soldiers to the operating table, and intensive care units kept post-operative patients from dying. But these advances came at a logistical cost.⁴¹ In World War II, the medical system could function with .35 pounds of medical supplies/man/day; by the 1980s, that had risen to 1.55 pounds. The most mobile hospital, the MASH, became no more than 65-percent mobile with organic transportation and a lumbering footprint. It took twenty-seven aircraft to move a 250-personnel MASH. Recognizing the need for surgical support, and the problems of having a hospital forward, the Army experimented with getting surgical capability forward as a team, and moving a post-operative patient back by helicopter to a hospital ward. History had furnished the prototypes and the incentives.

For the Grenada intervention in 1982, the 5th MASH was too bulky, and a surgical team was improvised to deploy with a "slice" of the 307th Medical Battalion. ⁴² Line and unconventional units at Fort Bragg tested various teams that would fit in one C-130. The team could treat up to sixty patients without re-supply and could hold up to twelve critical casualties, but was only for a few hours--it was not a hospital, and relied on prompt evacuation.⁴³ For Operation JUST CAUSE, the December 1989 removal of Panamanian strongman Manuel Noriega, the 5th MASH and the 56th Medical Battalion set up two forward surgical teams (FSTs) at Howard Air Force Base in the Canal Zone. The FSTs took in 129 casualties and performed 73 operations, 22 of which were classified as major cases.⁴⁴

In Operation Desert Storm, forward surgical teams had limited operative experiences but were reasonably mobile. Meanwhile, conventional hospitals had been too heavy to move. Even the Army's highest-readiness hospital, the Fort Bragg-based 5th MASH, had been too slow on the battlefield in its full formation. Justifiably, the Army shifted to FSTs, trimmed to twenty medical staff and limited but adequate operative capabilities. They would work in the brigade rear, not the division rear; could move with only a few vehicles; and had very restricted holding capacity--basically, stabilize and evacuate (much like French antennes chirurgicales). But immediate access from the front lines is the true value of FSTs. Wounded could be taken from battalion aid stations directly--by ground transport--to FSTs. From the FSTs, though, there must be access out. Inability to remove critical patients to higher echelons of care would be the death knell of any forward surgical effort. Dien Bien Phu proved that. Air supremacy is key.

FSTs soon proved almost as popular as the MASH had been as the twenty-first century unfolded. In the maneuver phase of Operation Iraqi Freedom, FSTs performed as expected. They were mobile, operated, and stabilized wounded; then patients were flown to the rear. When a secure battlefront developed (and control of the air was maintained), combat support hospitals (CSHs) and MASH units took over, relaying patients directly from the front lines. Spoiled by their effectiveness, though, field commanders still wanted "their" FST attached even though stopping a medevac at a FST that had less capabilities than a CSH would be worse for the wounded.

And it all came down to that crucial issue--TIME--that elusive target: the "Golden Hour." Promoted by R. Adams Crowley in the 1970s as the span after which trauma patients would have much diminished chances of survival, it became a buzzword among trauma surgeons (actually surgeon Edward Churchill had alluded to it in the 1940s).⁴⁵ There is nothing magical about the Golden Hour. It merely signifies that time is of the essence. Obviously for hemorrhaging men and women, the sooner the bleeding stops, the better; there is little argument about that. The Golden Hour provides a realistic target in which to frame resuscitative care. As a result, Secretary of Defense Robert Gates directed in 2009 that US forces in Afghanistan and Iraq implement a Golden Hour policy: medical support must be organized so that potential casualties could receive surgical care within an hour.⁴⁶ Partly this mandate was met by deploying more air ambulance units, partly it was met by not operating in areas remote from bases, and at times it was met by moving very small surgical teams forward. These Golden Hour Offset Surgical Treatment Teams (GHOST-Ts) could move to a forward base, or even accompany an operational team. While the Golden Hour mandate did not apply to other areas, the Army tested expeditionary resuscitation surgical teams that could carry all their mission equipment in rucksacks, "backpack surgeons" harkening back to the portable surgical hospitals of World War II.⁴⁷

Yet all these efforts relied on prompt evacuation, both from the battlefield, and after surgery. With few enemy air defenses, such a system could work. Those happy circumstances may not be the norm, and more recently the military has been exploring the skills, equipment, and training required for prolonged field care, mainly applying before surgery. Medics may have to tend the wounded for hours or days, going back to the conditions before 1914, but with better equipment and training to sustain life before the wounded can be evacuated to surgery. But combat surgeons are wise to remember the now-popular maxim, retold by countless battlefield medics over the decades: STOP THE BLEEDING. And stop it as early as possible. This imperative, though, must be balanced against the hazards to physicians, medics, and patients rendering care far forward and within range of enemy fire.

 

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Notes

1. P. N. Skandalakis et al., "'To Afford the Wounded Speedy Assistance:' Dominique Jean Larrey and Napoleon," World Journal of Surgery 30 (August 2006): 1392-99.
2. Skandalakis et al.,1392-99.
3. One must keep in mind that the European definition of ambulance was that of a mobile ad hoc field hospital, not, as Americans are liable to think, of a medical vehicle.
4. R. Way, "1914: de l'offensive a outrance au desastre sanitaire," Medecine et Armees 44 (2016): 11-16.
5. Charles Alexander Gordon, Lessons on Hygiene and Surgery from the Franco-Prussian War (London: Bailliere, Tindall, & Cox, 1873), 115-16.
6. Edmond Delorme, Blessures de guerre, Conseils aux chirurgiens (Paris: Comptes Rendus, Des Seances de Academie des Sciences, Seance, 10 August 1914), 394-99.
7. F. Chauvin, L. P. Fischer, and J. J. Ferrandis, "L'evolution de la chirurgie des plaies de guerre des membres en 1914-1918," Histoires des Sciences Medicales 36 (2002): 157-73.
8. Francois Goursolas, "Chirurgie et chirurgiens d'une ambulance francaise en 1915," Societe francaise d'Histoire de la medecine (30 April 2016).
9. Eugene Louis Doyen, "Service de sante de notre armee: les reformes urgentes," Commission de l'Armee du Senat et la Commission d'HygiËne de la Chambre des Deputes, 7 July 1915.
10. E. L. Gros, "The Transportation of the Wounded," The Boston Medical and Surgical Journal 173 (1915): 1-7.
11. P. Hallopeau, "Fonctionnement complet d'un service chirurgical transportable et deplacable: destine a operer, a panser les blesses du front," Press Med (11 February 1915).
12. US Surgeon-General's Office, The Medical Department of the United States Army in the World War, vol. VIII, Field Operations (Washington, DC: US Government Printing Office, 1925), 189-91.
13. "Interview with BG Percy J. Carroll," Washington University School of Medicine Oral History Project, St. Louis, MO, 23 February 1981, accessed 11 March 2014, http://beckerexhibits.wustl.edu/oral/transcripts/carroll.html.
14. Colonel Carroll letter to W. J. Miehe, Surgeon I Corps, 21 December 1942.
15. G. A. Marks, "Portable surgical hospital at Buna," Bulletin of the US Army Medical Department 71 (1943): 43-54.
16. A. Thorndike, "Surgical experiences with the wounded of the Buna campaign," New England Journal of Medicine 231 (1944): 649-51.
17. Headquarters, "7th Portable Surgical Hospital, Quarterly Report, 1 Oct 1944 thru 31 Dec 1944," RG 112 (HUMEDS), Box 238, NARA, College Park, MD.
18. Edward D. Churchill, "The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the Fall of Rome," Annals of Surgery 120 (September 1944): 268-83.
19. Douglas W. Jolly, Field Surgery in Total War (London: Hamish Hamilton, 1940), 166.
20. Jolly, 166.
21. L. A. Brewer, "The Contributions of the Second Auxiliary Surgical Group to Military Surgery during World War II with Special Reference to Thoracic Surgery," Annals of Surgery 197 (1983): 318-26.
22. M.E. DeBakey, "History, the Torch that Illuminates: Lessons from Military Medicine," Military Medicine 161 (1996): 711-16.
23. Churchill, "The Surgical Management of the Wounded in the Mediterranean Theater," 268-83.
24. Churchill, 268-83.
25. Churchill, 268-83.
26. Letter to a Mr. Orton from Dr. Gordon Block, 19 May 1945," in George E. Koskimaki, The Battered Bastards of Bastogne (Philadelphia: Casemate, 2011), 115.
27. Surgeon, 101st Airborne Division, Annual Report, 1944, filed 31 January 1945, RG 112 (Records of the US Army Surgeon General, World War II), NARA, College Park, MD.
28. Maj. Howard Serrell diary courtesy of his son, Chip Serrell.
29. Serrell diary.
30. Jerome Corsi, No Greater Valor: The Siege of Bastogne and the Miracle that Sealed Allied Victory (Nashville: Nelson Books, 2014), 288.
31. Charles B. Odom, Medical Department United States Army in World War II, Third U.S. Army, Activities of the Surgical Consultants, vol. I (Washington, DC: US Government Printing Office, 1962), 331. "Non-transportable" casualties were those patients who were so badly injured that any attempt to transport could result in their demise. Emergency care and stabilization was mandatory first.
32. S. Marble, "Forward Surgery and Combat Hospitals: the Origins of the MASH," Journal of the History of Medicine and Allied Sciences 69 (2014): 68-100.
33. S. C. Woodard, "The Story of the Mobile Army Surgical Hospital," Military Medicine 168 (2003): 503-13.
34. L. B. Witt, A Defense Weapon Known to Be of Value (Lebanon, NH: University Press of New England, 2005), 185.
35. R. Forissier and E. Hantz, "Guerre d'Indochine," Revue Historique des Armees 4 (1984): 8-10.
36. Leon P. Eisman, "Brief History of 1st Hospital Company, 1st Medical Battalion, 3rd Medical Battalion in Republic of Vietnam," Bureau of Medicine and Surgery, Falls Church, VA, 1973.
37. Figures were provided by Rev. Ray W. Stubbe, Marine chaplain, recorded from his diary of numbers listed in Charlie Med's "green log book.".
38. Jan K. Herman, Navy Medicine in Vietnam: Oral Histories from Dien Bien Phu to the Fall of Saigon (Jefferson, NC: McFarland, 2009), 237-38.
39. Gilbert W. Beebe and Michael.E. De Bakey, Battle Casualties: Incidence, Mortality, and Logistic Considerations (Springfield, IL: Charles C. Thomas, 1952), 96.
40. R .F. Bellamy, "Epidemiology of Trauma: Military Experience," Annals of Emergency Medicine 15 (1986): 1384-88.
41. This section draws heavily on Sanders Marble, "The Evolution and Demise of the MASH, 1946-2006," Army History 92 (Summer 2014): 22-39.
42. T. E. Broyles, "A Comparative Analysis of the Medical Support in the Combat Operations in the Falklands Campaign and the Grenada Expedition" (master's thesis, US Army Command and General Staff College, 1987), 92-93.
43. M. T. Samecky, A Contemporary History of the U.S. Army Nurse Corps (Washington, DC: US Government Printing Office, 2010), 311.
44. R. V. N. Ginn, The History of the U.S. Army Medical Service Corps, CMH Pub 30-19-1 (Washington, DC: US Army Center of Military History, 1997), 426.
45. E. B. Lerner and R. M. Moscati, "The Golden Hour: Scientific Fact or Medical 'Urban Legend'?," Academic Emergency Medicine 8 (2001): 758-60.
46. R. S. Kotwal et al., "The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties," JAMA Surgery 151 (2016): 15-24.
47. M. D'Angelo et al., "Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings," Journal of Special Operations Medicine 17 (Winter 2017), 76-79.