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Korean War veterans used to say, "I don’t know what the next war will be like, but the one after that will be fought with clubs and spears.” Vietnam, the next war, has c°®e and gone and, in field hospitals, upper Photograph, and on such hospital ships as rhe Repose, there was much to take pride in and be grateful for. But two questions Persist: What will the next war be like, and what kind of combat casualty care will be
required?
of the Medical Corps must share with our line colleagues the classic opprobrium that historically we P an and start the action of a new war exactly as we ended the last. This has been particularly true when °ne is on the winning side. It appears that this also aPplies in the case of a military draw—which seems 0 he the accepted script in the mid and late 20th Century.
The threat of poor long-range casualty planning pangs over the Medical Corps after a decade-long war. ‘rst’ the surgical care rendered combat casualties in e opening months of a new war never approaches ^ expertise rendered the wounded on the last day the previous war. Second, almost a generation of ^hitary medical officers matured professionally—and Perhaps hardened mentally—under the highly abnormal ctical situation in Vietnam, th HlSt0ry w'h probably judge the surgical care given 363,000 U. S. casualties in the Vietnam decade as e halcyon days of American military medicine. This sa'’ not set easily with the 3,400 medical officers who ^ e<a> suffered, and supported the Navy, Marines, Va^’ 2n<^ h°rce in Southeast Asia, but, from the tage of the military planner, it seems unlikely that ysicians will have it so good again.
Physicians habitually analyze our clinical complications and it is now time to reflect on the lessons learned in our second profession—military medicine. As such we work at the interface of two fast growing specialties. Medical knowledge doubles about once every ten years. I presume the craft of war grows at an equivalent rate. Our deliberations and conclusions cannot be dismissed by our line colleagues as something they can simply relegate to the staff, for the priceless commodity with which we deal is the combat Marine, soldier, and sailor, and his military effectiveness—a logistic item fundamental to every commander. Indeed, future war games should include realistic involvement of senior medical officers.
Three scenarios are available for the next war: a Big One, i.e., nuclear; a Little One, i.e., like Vietnam; or a Medium Sized One, big in size but without nuclear weapons. The medical plan must be sufficiently flexible to meet each—a difficult compromise but one not unique to the Medical Corps.
Americans at last have learned the bitter Clause- witzian message that war is simply an extension of politics and not a Holy Crusade. Politics and our own national interests will determine which scenario we will be handed next time. This discussion deals only with a war fought with conventional weapons—for here is where we as physicians are in danger of blindly planning along the lines of our Vietnam experience when, in fact, casualty care may more closely resemble that of Korea or World War II.
People have a way of accepting luxury so quickly they soon believe it their due. So it was in Vietnam for the line officers, the medical officers, the combat casualty, and the citizenry we served. Those in the field mostly knew no other system and accepted the battlefield availability of immediate evacuation, quick transport, and superb facilities as their due. This in turn reflects the affluent and permissive society from which we all now spring; we do not suffer kindly any material
compromise. As military medical planners, we cannot afford to rely on this comfortable assumption of largesse, for there are identifiable military tactical reasons why the remarkable medical record we established in Vietnam will not recur in a future war.
Combat casualty care can be broken down into 1) initial first aid and resuscitation, 2) evacuation from the site of wounding, 3) transport to a hospital, 4) care in the hospital, 5) evacuation to the United States and 6) care in the continental U. S. hospital system.
Predictable tactical changes in a future war will alter every act and each scene of the Vietnam combat casualty management scenario.
Let us enumerate and examine both the unique tactical features that occurred in Vietnam and their effect on casualty management.
First aid at the site of wounding. With occasional exceptions a Marine or soldier injured in Vietnam combat was en route to a hospital within an hour following being hit. The unit corpsman or aidman had little required of him except to stop hemorrhage, provide a clear airway, and apply some sort of a temporary dressing. The casualty was away before much could be accomplished in the form of resuscitation. The incredible feat of immediate evacuation of a combat casualty from the point of injury depended on six factors.
The first was overwhelming fire superiority at the site of wounding so that there was no interference with immediate medical aid and start of transportation to the rear.
The second was uninterrupted radio communication. The third was total air superiority so that even the highly vulnerable helicopter could be used for medical evacuation. The fourth factor was that the enemy lacked shoulder-fired homing missiles. With the availability of this simple and reasonably cheap weapon, an unlettered soldier can reliably knock out a low flying hovering helicopter. He lacked it in Vietnam. Fifth was such a plethora of helicopters that these expensive craft and their expensive drivers could be dedicated solely for medical evacuation. The final factor was a low volume of casualties insufficient to overload the sophisticated and vulnerable casualty transportation system.
Short en route evacuation time from wounding site to a hospital. The dramatic speed and efficiency of medical evacuation by helicopter from the site of injury to a well-equipped hospital was the medical hallmark of the Vietnam war. It represented a quantum change and was a constant source of wonder to those of us who were surgically weaned and teethed in the cracker- box and ambulance-jeep era. Surgically it permitted operation on casualties that under classic wartime transport would have died before reaching primary definitive surgical care.
Each of the factors already listed was important in allowing fast casualty pick-up but total unchallenged air superiority was absolutely essential for the luxury of vulnerable med-evacuation coming and going into a combat zone. Unless such protection for the slow and defenseless ambulance chopper can again be assured, the entire pattern of casualty care will regress to that of earlier wars.
Superbly equipped and staffed hospitals immediately adjacent to the battle zone. The Vietnam battle casualty' characteristically was deposited within half-an-houf flight time to a helipad of a superbly equipped and staffed military hospital comparable or more often surpassing the best civilian hospital trauma centers. Nothing was spared. Even picayune equipment or personnel discrepancies elicited outraged howls from the pampered medical staff who, in their zeal to provide impeccable care to the wounded, were unwilling and unaccustomed to compromise their civilian standard of patient care. And, of course, under the unusual tactical conditions existing in Vietnam they were correct- Spoiled beyond historic reason—but correct.
There was logistic extravagance provided the Medical Corps and the combat casualty in Vietnam^ surprising though this might be to those who were experiencing their first war.
Those of us who had experienced casualty care in more Spartan wars or seen management of battle casualties by other countries were sometimes amazed to b£ the recipients of so much attention and largesse in Vietnam. Indeed, I often asked myself whether such logistic extravagance was universally defensible from t cost-effectiveness standpoint.
Huge expenditure in personnel, equipment, time, money, and diversion of tactical line missions were frequently made for the fatally injured or hopelessly maimed. Several lives were often lost to save one- Almost for the first time in a major war, the civilian philosophy of casualty triage was assumed whereby major effort was first directed to the most seriously injured. Classic military medical doctrine of course concentrates priority surgical care on the lightly injured who can quickly be returned to duty, even when A means less than ideal care for the seriously injured.
Particularly, during the later years of this unpopular war, I wondered whether such near illogical devotion of our resources to casualty care somehow did not reflect the emotional turmoil of our populace about this dirty little war. Was it a salve to our national conscience in unusual emphasis on the one identifiable morally justifiable and humanitarian facet of our mill' tary adventure?
Such attention and priority was flattering to the military medical officer, but let us not be beguiled into
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thinking it our due or birthright in a future conflict est we be unnecessarily depressed when we surgeons will once again probably be given our logistic comeuppance.
One reflection of the high national priority given casualty care was the unlimited availability of medical personnel. An essential part of first-class primary care °f the casualty in Vietnam was, of course, immediate availability of well-trained physicians and surgeons. uch were available in awesome numbers.
The civilian physician community and our medical education system could and did provide physicians and SUrge°ns from the Reserve to the military for two- year terms with a minimum of dislocation or objec- tlon. Despite U. S. losses of 60,392 combat dead and ^03,640 wounded, the intensity of the decade-long war Just barely allowed tolerance of this doctor-draft system.
edically) the civilian population had both its guns and lts butter—the best of both worlds. Slightly higher casualty rates or a few less available doctors will, in a
ture war, demand a more realistic medical personnel Policy.
with highly skilled personnel, so it was with ^cdical equipment in Vietnam. There was—after the . at year—almost no limit to equipment provided. The th UStf^ cornucopia of America and the efficiency of medical industrial firms expanded to satisfy the Chilian and military needs simultaneously. No greater etion of our affluence was needed than to see disposable catheters, oxygen masks, and chest tubes being Se<a on rubbish heaps in a South Vietnamese jungle! Such can only be again anticipated if our affluence t°ntinues, if we are willing to be so extravagant, and casualty load is small. Regardless of riches and high Pri°rity assigned the Medical Corps, casualty loads the e of the first six hours of the Somme, Stalingrad, letam, or Cannae will preclude such future logistic judical expenditure. Regardless of assigned priority,
, fe are more compelling military tactical conditions ^ 1 will alter the combat casualty program in a future r- For the sake of clarity they can be enumerated, ph ,Xt<* warfare- Guerilla, irregular or whatever eu- mtsm is used for a Vietnam-type of war dictates at the major power remain primarily in static de- Se- This military posture is frustrating to offensively oed line officers, but static tactical defense has pro- nd medical benefits. It permits construction of es- tially permanent hospital buildings. After a few bd.asy months in Vietnam when we couldn’t quite ^Ve r^at our hospitals wouldn’t have to be kept 0 he, we relaxed, dug in, "hardened” the floors, and
^ase hospital. Allegedly mobile surgical units and some medical batallions soon resembled stateside
community hospitals in their permanence.
This was a natural adaptation of medical corps personnel to achieve the better patient care possible in a semi-permanent facility and to improve their own personal comfort.
In a future irregular war we may once again find our hospitals in semi-fixed defense enclaves. It would, however, be unwise to count on such luxury or on the highly unpopular and frustrating type of defensive tactical warfare upon which such hospital construction depends.
Absence of enemy air or artillery. Immediately adjacent to combat zones in Vietnam stood tented or semipermanent hospital buildings above ground, unprotected, and aglow at night with lights. It was an unreal military world. Medical personnel and patients moved unimpeded. Generators, radio transmitters, sterilizers, laundry, x-ray, and kitchen equipment stood less protected than would have been necessary if adjacent to hospitals in downtown Cleveland or Watts. Only an occasional sandbag remained to comfort the constantly uneasy veteran of previous wars who instinctively continued to keep an ear cocked for "incoming” and an eye on the nearest foxhole.
Such stateside security may again occur during a war, but let future medical military planners—most of whom know no else—not rest on this happy but dangerous assumption. Light, cheap, and simple recoilless rockets will quickly drive future forward medical officers into underground hospitals just as it made moles of their grandfathers. In all likelihood only the generation of their lucky fathers will have enjoyed the luxury of unprotected above-ground day and night activity beneath the tropic skies—in Vietnam.
Unthreatened seaborne logistic support. None of the professional luxuries of the Vietnam hospitals would have been possible if we had not controlled the seas. Ninety-eight percent of Vietnam supplies came by sea. Even the fuel required to return cargo airplanes carrying personnel or supplies to Vietnam had to be brought to Southeast Asia by surface tankers.
Not by chance alone did we choose to have this confrontation in a country with a long coastline with several suitable harbors. Medical logistics will be vastly more complex if in the future we draw a line for our enemy with our foot in dust far from the coast rather than in the sand on a beach adjacent to the sea—a sea controlled by our Navy.
Unchallenged sea and air superiority. The Vietnam war provided an ideal scenario for hospital ships—intermittent, low level warfare with combat zone adjacent to the sea in a long lean country with a generous coastline. In addition, we had the helicopter—the ideal medical evacuation system for hospital ships. The enemy lacked, or restrained from using, artillery or rockets to interdict our red cross-marked hospital ships that roamed at will immediately offshore, immune from hostile activity. Such an ideal scenario for hospital ships would have been considered unrealistic in a pre-1962 war game. It certainly will be unwise to rely on such assumptions in future medical planning.
Regardless of whether the red cross is officially respected in a future war, the easy availability to individuals and small units of homing long-range shoulder- mounted weapons will tempt the harassed individual enemy soldier to take a shot at an enemy ship slowly cruising offshore regardless of the official military posture of his government concerning the red cross.
At a higher level of interdiction, long-range rockets, homing torpedoes, and the uncanny reach of sonar ship-detection, plus the surveillance capabilities of satellites, will make mock of the horizon. Hospital ships—the epitome of sea-borne Medical Corps’ concentration-will have to yield to the less efficient safety of dispersal.
Theater evacuation policy. Military exigencies and paucity of beds seldom determined casualty evacuation policy from Vietnam. Holding time at in-country hospitals characteristically was dictated neither by acute bed shortage nor its corollary overwhelming press of casualties. Rather, the decision for evacuation out of the theater usually was determined primarily by medical criteria. This luxury has usually been denied to combat casualties in past wars who had to accept the inevitable compromise in forward hospital care and the subsequent dangers of increased wound complication along the chain of evacuation.
Whether we will be able again to enjoy this luxury will depend on two factors—level of casualties and availability of in-country beds. It is predictable that, during the opening phases of a war outside the continental United States, there will be an acute in-country bed shortage and evacuation time will be dictated by military not medical principles. Whether such conditions persist throughout the war will be determined by the tactics of the war. It is unlikely to be as unhurried an environment as in Vietnam. Let us hope it is not also so lengthy.
An untouched continental United States. During the Vietnam decade, medical care and military activity within the continental United States was unhurried and unimpeded—except by our own occasional civilia*1 dissenters! Our medical logistics developed without interference by the enemy. Physician and medical equipment had no competing civilian demand. Imagine how this would change if even one missile a year fed in a civilian community in the United States. Evef though there were negligible casualties every other city
th°nS must he told to employ techniques used
eir Avis and Volkswagen accounts. Unjustified
°u d demand extensive medical coverage that would Uri-tPete with the needs of forward military surgical 0U-Purely this cheap and effective means of diluting to C°untry’s military medical effectiveness has occurred eneevery major power who looks at us as a potential y- Even a minor power can use this ploy.
atlc^ 15 easy either to criticize or to mimic past perform- b C' planner cannot afford these luxuries. He must j rtl°re positive and more imaginative. If our thesis correct that the scenario of a non-nuclear future war Yj rnore closely resemble World War II than it will p Ctn®m> then the planner must determine how to ase °ptimum surgical care to a combat casualty, Uj lnS reasonable technological changes both in ^■*ne and warfare.
sha •€ lmaSe °f surgical compromise. A first step in Pm • ^ °Uf trhhtary-medical future is to create an ap- tvho reahstic image in the minds of those to
arkj We will be responsible—our citizenry, legislators, Pans'me Collea&ues- Responsible pragmatists, not ex- relati'Ve must be put in charge of our public optimism or overselling the glories of medical care in a future war will have an inevitable and serious backlash when the awful moment of combat truth and wounding arrives.
With the American penchant for records and statistics, combat casualty care is equated with pick-up time, hours of surgery, and percent survival of those coming to operation. Only the experienced military surgeon who understands the tactical features that affect these statistics or the quality (not just the length) of the life of those who survive know the significance of these stark numbers. We must impress those who will listen that we won’t break records next time and we certainly won’t be as glamorous or efficient as our 1963-73 television image.
An important part of building a realistic image will involve the young physician about to enter a combat theater. With a regular Medical Corps predictably preshrunk during peacetime financial austerity, the overwhelming majority of those actually rendering combat casualty care will be from the civilian medical pool just as it was in Vietnam.
Line officers, who themselves had years of preparation or are accustomed to receiving recruits with a
minimum of many months of boot camp and specialist schools, are characteristically confounded by the lack of military preparedness of medical officers entering a combat theater. Little thought is given as to the reason why the limited military time of such skilled and expensive technicians must be used productively, devoting an absolute minimum to indoctrination.
The military surgeon picks up his indoctrination largely during his first weeks in a combat zone on an on-the-job-training basis.
Future civilian-physicians in a new uniform about to enter a war zone will predictably have a few days of indoctrination in some variant of Field Medical Service School. But with a predicted jealous use of their time in uniform, the basic elements of survival will predominate in the compressed curriculum. For important military reasons, however, their briefing prior to entering a war zone must emphasize the necessity for compromise and improvisation. Even in the comparative luxury of the Vietnam War many medical officers were shocked by the occasional need to change the pattern of patient care from that which they practiced in civilian life. Physicians are a rigid, compulsive tribe and, in many cases, the cultural, professional, and emotional shock of having to compromise patient care actually immobilized or rendered unfit the physician suddenly placed in a combat zone. This had nothing to do with personal fear. It was far more complex: it struck at the ingrained compulsion of the highly trained physician to provide optimal care to everyone of his patients and to accept no compromise. During the Vietnam War this very appropriate civilian goal could, miraculously, at least be approximated. Next time such luxury will be extremely unlikely. The impact on the physician will be multiplied and it will be important to indoctrinate such physicians realistically to achieve their most efficient function when faced with a flood of seriously injured young men.
Personnel. Volume of casualties, the tactical military scenario, and of course the possible use of nuclear weapons all will influence the pattern of medical and paramedical personnel call-up and assignments.
Physicians. Shamefully, the Medical Corps Reserve remained uncalled during the Vietnam decade while unenthused civilian physicians were drafted. Illogical political reasons dictated this inefficient and grossly unfair policy. Its effect is now decimating the Medical Corps Reserve which, for lack of purpose, is withering even beyond the historic confines of peacetime shrivel. If not on first call behind the regulars in time of war, what is its purpose? Without a purpose, why should busy civilian physicians give of their time? Or why should the country foot the bill for maintaining a Medical Corps Reserve? The Medical Corps Reserve
must be on first call in a future war.
Paramedical personnel. More efficient training and use of paramedical personnel is currently undergoing major study and trial in both the civilian and military community. In neither can we afford lavish expenditure of expensive physicians. The military medical planner and his line counterpart must consider the possibilities and implications. Of one thing we can be certain—it is time for a change. Assignment of every physician or highly trained corpsman in a future war will have to be scrutinized on a cost and casualty effectiveness basis. Blind mimic of the Civil War pattern when it took an entire day to get a casualty back to Regimental or Divisional Hospitals is unacceptable in the 20th much less the 21st century. Neither should the piteous wails of battalion or air-minded unit commanders for physicians be heeded solely on the basis of some unlikely emergency or because they want "their own Doctor!” The nation simply won’t be able to afford such luxury.
Fortunately, advances in communications, transportation, training of paramedical personnel, and telemetering will help provide an efficient solution in the combat setting just as it is now evolving in the civilian community.
When, in a future war, helicopters no longer can roam unfettered, we will lose the ability to evacuate the casualty immediately upon wounding. Immediate care will then once again evolve upon the casualty’s combat comrade and on the accompanying aid man- This scenario is an old one and we had better be prepared for a re-run. Immobilized forward, the corps- man will be forced to care for chest and belly wounds and to be responsible for initial resuscitation. Although he will have to be better trained for independent duty and, specifically, for resuscitation, there will be a higher battlefield mortality and fewer chest or large-bloodvessel injuries will reach a hospital alive.
This gloomy picture of an immobilized casualty given less than optimal battlefield care must challenge imaginative thinking. In civilian practice we now dispatch mobile emergency room ambulances staffed and equipped for resuscitating the injured. The Soviets, incidentally are a decade or two ahead of us in this practice. Perhaps we could evolve an armored mobile emergency room, a tank with a red cross that could bring professional care to the injured—lacking the potential for his airborne evacuation.
At a slightly less exposed area of medical care, the corpsman can be helped by radio, telemetering, and television contact with a physician who can with electronics help multiply his guidance of first aid care ovef a larger horizon. Blind assignment of one physician^ much less two—at battalion level under garrison o< static enclave conditions wisely ended in Vietnam with
not minutes as in Vietnam—most of the true
gencies will have expired by the time a helicopter tn corne to them for evacuation. The true emergencies wnh large vessel internal injuries, severe head injuries, uncompensated thoracic injuries will probably ala y have expired in the field before they can be vacuated by helicopter. Little can be done, even by y trained corpsmen, several hours after injury, that
appreciably affect casualty salvage.
p!oneering efforts made by the Army high command.
In the future, if the situation demands, the physician ^nh appropriate backup corpsmen can be dispatched y helicopter to the scene. Emotions to the contrary, c°st-effectiveness scrutiny will have to determine physi- ^lan and paramedical personnel placement just as it states use of other expensive, hard-to-get, hard- and software.
Paramedical personnel assignments to ambulances be ey seaborne, landborne, or airborne will require ^assessment. The current practice of placing highly 1 wd corpsmen on ambulance helicopters, though ^anaatic, will probably be less relevant in a future war.
a casualty is to remain at the wounding site for hours— emer; can
will
tio^ Wl^ Probably recluire the objectivity of a genera- y.n physician planners who were not involved in ‘“nam to assess properly the airborne ambulance ng pattern. The breed who were there already have P'nions, fantasies, and proprietary interest so fixed that
objectivity is, if not impossible, unlikely.
Medical support hardware. The scenario we have constructed implies decreased reliance on the ambulance helicopter because of improved enemy ground-to-air fire. Although no longer essentially unmolested, the vastly improved future choppers will undoubtedly remain an invaluable Medical Corps asset. Predictably, the chopper will be faster, cheaper, easier of maintenance, better able to withstand ground fire, and much better coordinated for dispatch of casualties once airborne to an appropriate forward hospital. We hope the era of the dedicated Red Cross medical evacuation helicopters—not merely an itinerant gunship—is here to stay.
Still to be perfected is a better system for determining the safety of calling in a helicopter for casualty evacuation from a combat landing zone. Frenetic, unjustified calls for ambulance helicopter pickup cannot be tolerated. The decision will not be left to the pilot who, in his zeal and desire to save the wounded, may use poor judgment in risking his life and that of his crew for a needless emergency pickup from a hot landing zone. The exact nature of the injuries will have to be assessed by qualified surgeons before risking the life of the helicopter crew and its expensive airborne ambulance. Despite the awesome appearance to laymen of most combat (or traffic) accident wounds, a very small fraction justify risking the life and limb of others in immediate transportation to a hospital. Trained corpsmen can usually do as much as physicians in primary casualty care.
Automobile ambulances will come back into use. Perhaps the springs of the cracker-box ambulance will be improved. If this breakthrough in modern medicine can be achieved, it will represent a great leap forward in combat casualty care.
New types of ambulances will emerge. In amphibious assault the five-knot casualty-bearing landing craft will give way to hydrofoil or air cushion vehicles traveling at a respectable 60 to 100 knots above the water. This will allow transport of casualties to dispersed medical facilities afloat 50 miles or more from the combat shore.
Vertical take-off and landing (VTOL) or short take-off and landing craft (STOL), when made more efficient,
The next war may not he at all like the last, Vietnam, in which both physician and casualty never had it so good; it may he more like our next-to-last war, Korea, where first-rate combat casualty care was available, but not always where and when needed.
will have a predictable role in casualty evacuation.
Hospital ships. Seaborne medical back-up will have to be dispersed. This necessary truth will be hard to accept for those of us with fond memories of past campaigns. Fortunately, advances in prefabricated hospital design makes instant hospitals a reality. The MUST hospital unit led the way in modular hospital design. The collapsible operating rooms, laboratories, and x-ray units are, with little change, adaptable to shipboard conversion. They can be erected within a few minutes after a tank, truck or pallet of beans has been offloaded from any amphibious or cargo ship lying off a combat shore, and 50 such instant floating hospitals can be purchased for the cost of a single $100,000,000 new hospital ship.
If there is any place for hospital ships, they need bold thinking in redesign. Why not, for example, have submarine hospital ships? Huge submersibles are built for oil storage and transport. Why cannot similar hospital ship units be towed on the surface or submerged close to a hostile shore and sunk? Such a ship would remain immune from surface gunfire and airborne attack. Under a scenario where the red cross was not respected, such a submerged hospital would be inviolate from all but direct torpedo attack.
There remains the dilemma of surface to sub-surface casualty transfer. It seems only fair however to leave some problems such as this interface transport to occupy the military Ph.D.s and the GS-l6s.
Medical charts. Every feature of the existing military-medical sacred cow must be critically re-examined. This includes the hated hospital chart.
In an era all but dominated by computers and advanced communication technology, we use a military- medical chart system only slightly more advanced than the one probably employed by the Medical Department of Genghis Kahn. We have no method for retrieving our surgical results in Vietnam. No system exists for overall recall or follow-up short of pulling all charts under a given coded diagnosis. Benefits that would be achieved by applying known technology to combat casualty charting include: improved casualty care along the chain of evacuation; prompt and more detailed knowledge given the involved family; an enormous saving of manpower acting as liaison with congressmen as they seek up-to-date knowledge on their wounded constituents! Of added importance will be the ability of the forward surgeon to follow his case— and thus professionally benefit—even after the casualty has been started down the evacuation chain. At last we will also have an accurate means for gathering military-medical data. Future military-medical planning can then be based on a more solid statistical basis.
The technology for such computerized combat casualty charting is available. It only requires minimal conversion and application.
In-country hospitals. The medical evacuation helicopter and the unique military scenario played hell with the echeloned system military hospitals in Vietnam- The neat and orderly diagrams along which the casualty was supposed to flow were thrown into total disarray. Some of the more compulsive medical administrators never recovered from the impact. Supposedly-mobile mount-out Medical Battalion units within a year resembled base hospitals of earlier wars. Any pad marked with a red cross and a reputation for good public relations with chopper pilots received fresh casualties.
The problem for the future is how best to plan for such chaos. Flexibility will have to be the guiding principle. Bare bones potentially mobile hospitals and resuscitation units will have to have supplementary lists of personnel and equipment available to flesh them out if a static war develops.
Miniaturization and solid state development of medical equipment will help in making the equipment more easily transportable, but this will be more than countered by the enormous technical complexities of modern surgical and laboratory demands. Try as they may—and they will—Medical Service Corps officers will not be able to duplicate the hardware of a University Center Intensive Care Unit. Military surgeons in forward units will return to reliance on what they see, feel and hear—rather than relying on mechanical online read-outs of physiologic parameters. When all else fails, they will have to examine the patient! They wiU have to be clinicians and this in fact is the highest level of surgical sophistication.
The combat casualty care that evolved in Vietnatn provided almost ideal surgical care to the casualty but was fragile and militarily vulnerable at many critic^ points. For these reasons it would be irresponsible to rely on such utopian medical conditions in planning future combat casualty care.
We must not plan to fight the medical aspect o> a future war as we did the last. It is a twist of fatC that we will probably be better served if we becorfo more antediluvian and though including modern tech' nologic advances make our medical plans more lik* those of the war before-last!
It is doubtful that the combat casualty or we mil1' tary surgeons will ever again have it so good!
A 1939 graduate of Yale University and Harvard Medical School, Eiseman is now Professor of Surgery at the University of Colorado Med»c School in Denver. His various Navy assignments as a Reservist Surg^ since 1942 have been almost constantly with the Amphibious Forces the Marine Corps. In Vietnam he was the Surgeon General’s surg1 consultant in this military specialty on several occasions.