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By Major E. J. Green, USMC
Desert Storm was the largest military operation since the Vietnam War, one of whose noteworthy achievements was the rapid evacuation of casualties from the battlefield. It was fortunate that massive number of friendly casualties did not occur in the desert of Kuwait, because the evacuation of those relatively few wounded Marines was not nearly as efficient as during the Vietnam War. However, medical care was superior—once the Marines arrived in an advanced- care facility. The difficulty lay in the forward-based units not having the equipment and coordination procedures necessary to transport patients quickly.
Corpsmen and doctors provided superb medical support to Marines during the conflict.
These sailors worked diligently to ensure that they were ready to treat a large volume of casualties. The U.S. Navy medical establishment constructed field hospitals, manned battalion and regimental aid stations and casualty clearing companies, and Mobilized hospital ships for deployment into the region.
Throughout the months lead- lr|g up to the ground offensive,
corpsmen and surgeons were trained to provide the best possible care. Transporting wounded Marines assigned to a mechanized task force was rehearsed time and again, and the rapid displacement of aid stations and control procedures was incorporated into unit training.
► Transportation: Each battalion motor pool is provided two Ml035 high-mobility multipurpose wheeled vehicle (HMMWV) ambulances on its table of equipment (T/E) to support its battalion aid station (BAS). The Ml035 is a canvas- covered, low-backed vehicle capable of transporting two stretchers, and its major function is to transport casualties from front-line units to the BAS for initial treatment. It provides no protection from fragmentation, an obvious disadvantage when the vehicle must move through areas under hostile fire to extract injured Marines.
In addition, corpsmen sitting in the seats do not have access to the lower extremities of the patient without stopping the HMMWV, lowering the tailgate, and removing the litter from the vehicle racks. Since casualties
are stacked, the low-back canvas allows only minimal clearance between the upper and lower stretchers.
One of the units replaced the Ml035 by designating one LVTP-7 as an ambulance. This was the “chase” P-7, moving with the command section. The vehicle was configured with a stretcher kit capable of carrying six wounded Marines in litters, and it gave corpsmen room to provide care while the vehicle was mobile. This ambulance’s light armored protection enhanced its ability to move closer to the front, where casualties would have been most common.
Infantry battalions lack the internal capability to displace the BAS. The infantry battalion’s T/E is devoid of any kind of medium lift. The BAS alone requires two M923 five-ton trucks with trailers to move the authorized medical allowance lists (AMALs) and support equipment. Because of additional truck support by the 1st Marine Division, each infantry battalion in the mechanized task forces received six M923s. This allowed each BAS to remain mobile and displace with its par-
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ed soon after initial stabilizing surgery.
J? this hospital before long-distance evacuation to the rear, hose deemed nontransportable because of uncontrolled eeding, persisting and unremitting shock, or progressive eterioration of vital organs, were operated upon. The Vision to operate was made after these realities were ejghed against the estimated time and type of travel re- Mttired to bring the casualties to an operating room within re Central hospitals in Israel. Only 3% of all casualties e9uired immediate emergency surgery. c cixed-wing air subsequently evacuated 4,000 stable f^S|Uahies from the Sinai to central Israel within 12 hours owing injury. All survived the four-to-six-hour evacu- ^*°n without incident and received their definitive surgery e gin central Israel. The IDF repeated this procedure with 0^Ua* success during 1982 operations in Lebanon. Obvi- ■ {y> then, long-distance evacuation can be accom-
Ways to Implement Selectivity
Two types of combat-zone hospitals are required: one to handle those who will return to duty and the other to provide emergency surgery for only those whose condition renders them nontransportable (the physiologically unstable and those suffering from severe head, chest, and abdominal wounds—the bulk of the emergency surgery load). Some emergency surgery to facilitate transportability may be done by the surgical element projected forward at the clearing station level, as was done at Inchon.
The accelerated flow of the non-return-to duty casualties through hospitals hinges on rapid long-distance aero- medical evacuation, in the postoperative period after emergency surgery, to an offshore general hospital or hospital ship. (After further treatment and stabilization in this general hospital, they are moved to U.S. bases when their
G. KIEFFER/FOTO CONSORTIUM ent organization.
Each unit was responsible for evacuating wounded at least as far as the BAS. Once a patient was received at a BAS. further evacuation to advanced-care facilities was based on the severity of the wound, and CH-46 helicopters were designated to transport urgent medevac patients.
Priority and routine medevacs used ground transport to the casualty clearing companies run by the Force Service Support Group (FSSG). Once the Marines were stabilized at the BAS, the combat service support detachment (CSSD) in direct support to the task force provided evacuation to advanced-care facilities. The CSSD delivered necessary resupply, while routine and priority casualties were loaded on the empty beds of offloaded trucks for transportation to the rear. At the direct-support CSSD, a transfer was made to the general-support CSSD, which had a casualty-clearing company. To evacuate mass casualties, the latter was provided buses driven by Marines. These were outfitted with stretcher kits to increase lift capacity.
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The BAS could not cope with the need to receive a large number of casualties as forward elements continued to advance; displacement of the BAS and simultaneous transport of casualties was impossible with the limited number of trucks.
► Command and Control: Helicopters were requested from the direct air support center (DASC). This required that the BAS have a high-frequency (HF) radio available, because of the extreme distances. To reduce the burden on the air officer in the combat operations center, an HF radio was located in the task force logistics trains to identify possible landing zones for the DASC. Battalions notified the task force logistics train of a landing zone and the DASC was informed by the task force logistics officer, over an uncovered HF radio using checkpoints as map references.
Units were provided with global positioning systems (GPS) and the position location reporting system (PFRS); both provided an operator with an accurate current location or could be used to guide a driver to a
Contending with sand and heat, Desert Storm casualty evacuations were still rapid, without heavy reliance on helicopters.
known location. These systems were excellent.
Periodically, however, the task force outran the PLRS envelope and the GPS would go “out off net” when satellites went over the horizon. A second difficulty was the limited quantity available. Each S-4 had either one or the other to transmit an accurate location of operational BASs—but when the navigation system was down, units reverted to maps, compasses, and odometers. To identify exact locations of an aid station within logistics trains, a large white flag with a red cross and red crescent was flown. Unit movement was so swift that the logistics trains and the CSSD basically chased forward elements through Kuwait.
To preclude logistics trains becoming bogged down, individual battalions were designated responsibility for casualty collection at places on the battlefield. This meant that a battalion would lose direct control of its BAS for an indeterminate amount of time, but allowed the remainder of the task force to continue the attack. As the CSSD “caught up” to the designated BAS, the consolidated pri-
surges in casualties from the Chinese counteroffensive an other periods of intense combat flushed many of the sic
condition permits.) Experience has shown that the safety of casualties is not compromised if long-distance aero- medical evacuation is defined by time—four to six hours bed to bed, not all the way to the continental United States. It has indeed been done, and can be done again in the future.
What Happens in the Absence of Selectivity___________
There are several major examples in U.S. military history where there was no medical selectivity, which led to overevacuation and not enough return to duty:
In France and Belgium in the fall of 1944, the lightly wounded were air-shuttled to England while the seriously wounded filled the mobile hospital beds. The lightly wounded had a low rate of return to duty. This was a significant factor as General Omar Bradley searched for
replacements during the battle of Ardennes in December.
In contrast, the German Army’s medical system in the Soviet Union in 1941 was designed to evacuate the seriously wounded well to the rear and care for the lightly wounded in forward positions. This required only half as many forward-located medical personnel and achieved a higher return-to-duty rate of the lightly wounded. (One can only speculate, however, about whether the protracted transportation requirements added to the death rates of the seriously wounded.)
In Korea in 1951, we learned to treat combat-fatigue casualties forward of the hospital with very high return-to duty rates, and the Army had some forward-located mobile army surgical hospitals (MASH units) for emergent surgery. None of this proved optimal, however, since
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ority and routine medevacs were to be turned over by the established BAS. The logistics train was then free to move in support of its parent unit. Logistics requirements for battalions whose logistics trains were delayed were covered by crosssupport from adjacent units; this was possible because of the narrow frontages.
Traffic control at minefields was determined by the operations officer of the task force.
An initial breach of four northbound lanes was specified in the operation order. After their completion, the engineers breached an additional four lanes from north to south, for a total of eight. The outermost lanes (a total of two) were designated as return lanes for casualty evacuation and the return of empty logistics vehicles. This system worked well.
The main function of medical command and control is to keep units continually appraised of the location of all operational aid stations. Information regarding opening and closing of the casualty clearing companies was slow in getting down to forward units, but improved with experience. One patient with a gunshot vvound was directed to be taken to a casualty clearing company that had no surgeons. The Marine was later evacuated by helicopter, but the poor initial coordination was frustrating.
► Supply Support: Units arriving into Southwest Asia were provided with AMALs by the medical logistics (MedLog) company of the FSSG. The AMALs were stocked with a designated amount of medical supplies and were a good starting point for battalion surgeons. Individual medical officers could also express preferences for items they wanted to retain and others that would be left in the rear. The containers were a good means for transporting the supplies but had to be reconfigured for ease of use while moving around in five-ton trucks.
There were significant difficulties in obtaining individual line items from MedLog. A BAS could return empty containers and receive a new AMAL, but could not order a specific item within the medical list. Requests by battalion commanders for additional bandages were denied. There may have been a problem with supplies having a shelf life, but this should not have been the case with an item like a bandage. To receive the individual bandages, empty AMAL containers were turned in and fully stocked AMALs were then drawn. The additional medical equipment not desired was then returned to MedLog. The inflexibility on the part of this support organization
U S. NAVY (P. HATZAKOS)
M1035 HMMWVs should be replaced with the larger, better- protected M997s (next page). Wounded Marines (above, en route to Fleet Hospital 5) were stacked in the smaller ambulances, making in-transit care nearly impossible.
was irritating to medical officers in the battalions.
Stretcher replacement was another difficulty that the CSSD solved. As a casualty was evacuated on a litter, the unit would lose the stretcher unless it was immediately replaced. This was to be overcome by a one-for-one exchange as the CSSD evacuated the patient.
► Recommendations: Medical logistics provided adequate support during Desert Storm because of the limited number of casualties sustained. Improvements needed include:
Replace the M1035 HMMWV ambulance with the M997 HMMWV at the regimental and battalion levels. The M997 is a highback with a temperature-
a°d lightly wounded through the field medical system into ^aPan and far beyond—even back to the United States, because of the 13-month tour, returns to duty were low °nce a casualty was evacuated offshore.
Vietnam was the epitome of high-tech medicine in fixed a°spitals. Emphasis was placed on the care of the trauma Patient with multiple injuries. Virtually all in-country sur- §lcal care focused upon the seriously wounded. Little evince, however, points to any attention being paid to the c°ncept of selective management. In-country bed occuPancy averaged 50% to 60%, yet so many sick and lightly founded were evacuated far offshore that three and a half rmy general hospitals were put into Japan in 1966.
Perhaps the most dramatic example of overevacuation insufficient return to duty occurred during the Tet Of- *-nsive in 1968. The lightly wounded again poured r°ugh the system far to the rear. Some casualties still
wearing bloody camouflaged uniforms arrived in hospitals in the United States within 96 hours after wounding; they were the ones who could best tolerate the evacuation. Returns to duty were negligible in this group.
Israel, after fighting brief, highly successful conflicts with low casualties in 1956 and 1967, entered the 1973 war with a field medical service similar to ours. They faced intense combat with high casualty rates and were well prepared to handle the seriously wounded. An abundance of air-evacuation assets overwhelmed selective management, however, and they repeated our mistakes, as combat fatigue and lightly wounded comingled with the seriously wounded and rapidly filled rear hospitals.
Will We Heed the Lessons of History?
A field medical system that lacks emphasis on far-
controlled shell capable of transporting four litters. It has ballistic protection and enough room for corpsmen to assist patients while in transit.
Provide each infantry regiment and battalion with M923 five-ton trucks and trailers. These are required not only for transportation of the BAS, but also for troop movements of motorized forces, resupply of food and water, ammunition, and expendables. Even in a low-intensity conflict, infantry units should have some internal medium-lift capacity. Truck support was a critical shortage faced by all logistics officers during Desert Storm.
Designate an HF medevac radio net. Urgent requests were relayed through the task force logistics net and were passed to the DASC. This worked, but could have been more efficient if a separate HF medevac request net had been available.
Helicopters designated for this mission were well to the rear of advancing forces; requests were sent to the DASC, which then directed the aircraft. Once the aircraft was in the general vicinity, the unit came up on a landing zone control net to provide terminal guidance. The entire procedure usually took three to four hours. The process was not exercised frequently, and it was not successful. The major difficulty lay in getting the pilots notified that evacuation was needed. When they were notified, they came.
Establish a medical evacuation cell within the G-4 section. Net control for the HF medevac net should reside with the G-4. All regiments, separate battalions, the FSSG, and the air combat element should be required to monitor. A medical logistics cell in the G-4 would maintain a status level on casualty clearing company locations, their ability to receive casualties, and patient levels at each location. It could also direct the movement of helicopters to transport urgent medevacs. This would relieve the DASC of trying to control close air support and casualty evacuation.
Continue procurement of navigation aids. PLRS and GPS were particularly useful for logisticians. During night resupply operations, the navigation aids assisted units in linking up with support echelons.
Place MedLog under control of the Marine Corps supply system. The AMAL concept is excellent for initial arrival, but is unwieldy for forward elements during resupply. Having to go through a separate supply system for medical supplies is unnecessary. MedLog could remain responsible for medications, vaccinations, and controlled items such as syringes, but units should order stretchers and expendables using the Supported Activity Supply System.
Train. Training requirements set by higher headquarters have become more restrictive, reducing a commander’s flexibility. Unit surgeons and logistics officers must become more aggressive in pursuing the application of casualty handling during training. Medevacs demand a good deal of support, and the loss of equipment and men must be accepted as an inherent part of unit training. Coordination of medevacs with the aircraft wing should be rehearsed, ensuring that a noncommissioned officer on patrol knows how to get a medevac bird.
Major Green is the battalion executive officer for 3d Battalion, 7th Marines. He participated as the GCE logistics officer for 7th Marine Expeditionary Brigade during Desert Shield and was the S-4 for Task Force Ripper during Desert Storm.
forward care must still rely heavily upon the helicopter, as in Vietnam, to “scoop and run,” depositing all gradations of sick and wounded at medically sophisticated facilities in the rear. Many modem military medical-support systems thus represent a paradox. Spawned in the Vietnam era, they still bear overtones reflective of peacetime medical practice—concentration upon the most seriously wounded, with high-technology, medically sophisticated, deployable (but not wholly mobile) medical systems being fielded worldwide. Through fiscal year 1988, the Navy spent $418.7 million on its deployable medical systems project. From 1989 to 1994 there is a planned outlay of an additional $640.2 million for these battlefield facilities.
One can legitimately question whether construction of this system will satisfy all of our flexible medical-support requirements in the future. High-visibility perfection in such matters as hospital care; command, control and logistics; readiness of professional and ancillary hospital personnel; and sophisticated advanced casualty management techniques may ultimately prove fruitless. As a major priority, focused attention must be directed toward the means by which discriminating judgment and stabilizing care are applied at the most far-forward and austere reaches of combat activity.
Colonel Llewellyn is professor and chairman of the Department of Mil1' tary Medicine, Uniformed Services University of the Health Sciences. He was group surgeon, 5th Special Forces Group (Airborne), Vietnam, from 1965 to 1967.
Captain Smith is professor of surgery (urology) at the Medical College <4 Georgia, Augusta. He is also clinical professor of surgery and military medicine at the Uniformed Services University of the Health Sciences >n Bethesda, Maryland.
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