Commanders must think creatively to provide casualty care in the dynamic environment of combat.
After the Cold War, changes in international relations shifted the Navy's focus from countering a global threat on the high seas to influencing world events in coastal waters and inland areas vulnerable to the striking power of sea-based forces. Included in this strategy is an increased emphasis on joint, combined, and special operations adjacent to the littorals. Based on prior experiences during amphibious assault warfare, we can anticipate sudden and massive generation of casualties.
Operational orientation in contemporary peacetime training evolutions concentrates on offensive tactics. All too frequently, the sustaining elements of combat operations, such as casualty care, are given a subordinate role or forgotten. Scripted scenarios might never challenge Navy and Marine Corps operational commanders to contend with the formidable degradation of personnel assets through combat injury, sickness, and a host of non-battle injuries typically experienced during amphibious operations. As Winston Churchill noted in The River War:
Victory is the beautiful, bright colored flower. Transport is the stem without which it could have never blossomed. Yet even the military student, in his zeal to master the fascinating combinations of the actual conflict, often forgets the far more intricate complications of supply.
During combat operations, that facet of logistical support dedicated to maintaining the physical integrity of a commander's greatest asset—the flesh-and-blood elements of his operational forces, the rational element of his weapon systems—has challenged adaptability and sustainability. General P. X. Kelley, former Commandant of the Marine Corps, argued that issues such as fleet medical support "are often overlooked when novices discuss amphibious operations; the professional knows how easily an operation can founder without these naval support elements."
The constitution and use of services to support the combat injured and infirmed cannot be wholly predicted or planned for, yet they may be pivotal in determining a commander's success or failure. Situationally unique challenges to established doctrine demand mature and innovative command responses. It thus behooves senior operational line commanders to elicit creative and adaptive solutions to problems relating to conservation of their human assets.
For modern littoral warfare, which emphasizes operational maneuver from the sea without immediate lodgment ashore, old doctrinal mechanisms for medical support will require revisions, implemented by those on-site, supported by equally pragmatic and visionary leadership. Innovative thinking will be necessary, with little time for deliberate planning or theoretical modeling. Medical prescience ultimately will depend on an understanding of both the exigencies of expeditionary warfare in the littorals and modern advances in medical care, underwritten by an appreciation for lessons learned in adapting casualty care to prevailing combat environments.
A few historical examples demonstrate innovative operational leadership in accommodating health care in the combat environment. Though they do not provide ready-made solutions for future conflicts, they show a creative mind-set adaptive to unexpected circumstances, unfettered by theoretical doctrine or by standard operating practices from previous conflicts.
Solutions through Innovation
The Seventh Amphibious Force. Vice Admiral Daniel Barbey, discussing medical capabilities among his ships in the Pacific theater during World War II, noted:
Even before battle casualties started coming in, the staffs of the amphibious ships in Milne Bay were unequal to the task of caring for those stricken with tropical diseases. There was doubt that a hospital ship would be assigned to the Seventh Amphibious Force . . . but as a partial substitute we thought we might be able to convert an LST into a "first aid" ship if we could spare one and if the Navy Department had no objections. . . . Anyhow, an official request was sent to Washington outlining our reasons and needs. Then, to "save time," we went ahead with the LST conversion plan on the assumption it would be approved. . . . The LST 464 was chosen because she would arrive in Sydney within a few days where the shipyards could do the work. Two days after her arrival, the conversion job was under way and her character changed from a fighting ship to a ship of mercy. . . . Assembling [her] equipment in the States would not have been a matter of consequence, but getting it in war short Australia required a lot of priorities. The ship's medical staff . . . were obtained by "thinning out" other ships and shore bases.
Subsequently, LST-464 became the main reliance for medical service in the Seventh Amphibious Force. In early operations, she was stationed at advanced bases to receive casualties from other amphibious craft and then transport them to hospitals in Milne Bay. As other ships joined the Seventh, and operations became larger, additional ships were converted into "casualty ships." Surgical teams were embarked for the emergency handling of the wounded, which were then evacuated to LST(H)s.
The Battle of Leyte Gulf in 1944 demonstrated the benefit of beaching surgical LSTs after unloading their embarked troops and equipment. Planners saw the value of holding one or two of them in reserve, to be committed to beaches overwhelmed with casualties or without medical facilities. As noted by Admiral Barbey, "Since Army hospitals ashore could not be set up as rapidly as anticipated because of heavy rains, LST 464 remained in the harbor, and became the most important medical facility afloat or ashore for several days."
During the operation at Lingayen Gulf in 1945, six LST(H)s with embarked surgical teams were beached to provide casualty care. At Normandy, all LSTs were equipped to handle returning casualties, and 54 were outfitted to perform surgery. Others were subsequently equipped to serve as casualty control ships, regulating the retrograde flow of the wounded to rear facilities. One even was made a floating blood bank. Such hospital LSTs, able to provide sophisticated surgical care in a relatively safe environment close to shore, performed even under fire at Iwo Jima and Okinawa. Admiral Barbey concluded:
Our first aid ship did a magnificent job throughout the war. Ironically, nine months after her conversion, and after she had handled some thousands of sick and wounded, a letter was received from the Bureau of Ships regretfully turning down our conversion request: "It is desired that all LSTs continue to operate in the manner for which they were designed." . . . The letter was placed in those files most likely to be lost in combat, and the LST 464 continued to operate, if not in the manner for which designed, at least in the way we most needed her.
The Hospital Ships. After U.S. entry into World War II, Army Transport Services assumed responsibility for evacuating Army sick and wounded, carrying them in the hospitals of troop transports. The troopships' facilities provided neither comfort nor sufficient care and offered no guarantee against enemy attack. Consequently, command policy was modified to use Geneva Convention-protected ships whenever possible, to evacuate those who needed considerable medical care en route and would be unable to abandon ship without assistance in an emergency. By early 1944, the Comfort (AH-6), Mercy (AH-8), and Hope (AH-7) had been converted and placed in service with civilian operating crews and Army medical staffs. Ultimately, the number increased to 26 Army ships, the majority converted passenger liners or troopships.
During the final phases of the Pacific campaign, tactical doctrine for employment for Navy vessels also changed, allowing them to function as mobile, definitive care combat hospitals. Two Navy hospital ships were in commission in 1941, three were added in 1944, and seven more in 1945. Specially designed Haven (AH-12)-class ships also were built to support this concept, which continues today.
The Falklands. In 1982, in anticipation of casualties at the inception of the campaign to retake the Falkland Islands, the Royal Navy requisitioned two cruise ships, the Canberra and Uganda, and refitted them for casualty care.
The Uganda was converted to a hospital ship in Gibraltar within 60 hours, painted white with red crosses. A helicopter pad was titled, and a ramp was installed to allow rapid transfer of patients to the main hospital on the promenade deck. Other sections of the ship were converted to an operating room suite, an intensive care ward, and a high-dependency skilled nursing unit, among others. A burn unit was established in the ship's original hospital.
At Britain's suggestion, and without any special agreement in writing, the parties to the conflict established a 20-by-20-nautical-mile neutral zone on the high seas known as the "Red Cross Box." Without hampering military operations, this zone enabled hospital ships of both belligerents to hold position and exchange wounded prisoners of war via helicopter, under the supervision of the International Red Cross.
In addition, three ocean survey vessels, converted by the Royal Navy to Red Cross-identified ambulance ferry ships, evacuated casualties from the Uganda to a neutral Red Cross-supervised aeromedical staging site in Montevideo, Uruguay, for air evacuation to Britain.
The luxury liner Canberra was converted to a troop carrier, with a major surgical facility. Original plans called for her to receive casualties, although she did not qualify for Geneva Convention neutrality by virtue of having conveyed troops and combat equipment to the theater. This lack of protected neutrality originally was felt to be an advantage, because troops treated successfully could be returned to the field directly, something the Geneva Convention prohibited from "protected" hospital ships. Unfortunately, after fierce aerial attacks on the fleet supporting the landing force, the British removed the Canberra from the operational area and elements of her medical organization were put ashore hurriedly at Ajax Bay.
Ajax Bay had a small pier and a deserted slaughter-house that offered a dry, vermin-free floor, a corrugated tin roof, and compressed cork walls with a skim coat of concrete. The Canberra's medical staff quickly converted these simple facilities for medical use, and inserted components of a casualty handling and treatment system.
Because of difficulties with logistics, transport, communications, terrain, and weather, the tactical advancement ashore of surgical facilities was advantageous, to provide care as close as possible to the point of wounding in terms of both time and distance. Two other medical groups joined the Canberra team, and created a composite Advanced Surgical Center, staffed by nearly 100 men and able to run four operating tables. Three weeks later, they had treated more than 650 battle casualties. On 8 June 1982, a "major casualty overload" occurred as a consequence of the Argentine bombing of the amphibious ship Sir Galahad, and 150 patients came through the door. Some ships took smaller numbers of flash-burn casualties. The 70 worst cases stayed at Ajax. The following day, the British transferred many of the casualties to the Uganda.
Not since Anzio in 1944 had surgical teams worked in isolated groups on a beachhead close to the fighting, functioning within a small advanced location surgical center provided with only basic equipment, with offshore ships functioning as base hospitals.
Desert Shield/Desert Storm. Royal Navy casualty projections in the Persian Gulf indicated the need for a minimum of 100 beds in an afloat facility able to admit mass casualties of all types, initiate their management, and hold them for six days. With no hospital ship available, the Royal Navy designated the air training ship Argus to be that platform. Her flight deck, with five helicopter landing spots and two aircraft elevators, was considered ideal for movement of casualties. The British drew plans to convert the forward hangar to a hospital in a "subcitadel" with airtight protection, leaving the other hangars for maintaining and operating aircraft. In three weeks, the hospital was designed, built, equipped, and staffed. Using modular construction the exoskeleton of the hospital was lifted to the flight deck in sections, then fitted together and moved into position.
The Argus arrived in the Gulf with a 100-bed hospital independent of the superstructure of the ship, including an intensive care unit, high-dependency skilled nursing unit, a low-dependency unit, plus four operating tables in two operating rooms with full support services, staffed by a medical team of 136 men and women. The hospital also was supported by the Argus's air department, with four designated casualty evacuation Sea King helicopters, as well as Royal Navy support and liaison personnel. Implementation of this afloat tactical medical support concept significantly shortened casualty transit time from frontline, at-risk maritime units, because the Argus could operate in forward areas with unrestricted communication (the latter capability is denied any ship registered with Geneva Convention neutrality protections).
In September 1990, a mobile surgical support team boarded the Royal Navy ammunition ship Fort Grange, to supply forward emergency stabilizing surgery to injured fleet personnel. Because the Fort Grange, with her hazardous cargo, could not be sent too far forward, this innovative surgical team was prepared to go forward by air drop, carrying its own gear. Its mission was to resuscitate and stabilize casualties on board a damaged ship, and then transfer them, acting also as escorts to undertake continuing care.
Responsive Care
During the World War II amphibious campaigns in the Mediterranean, small craft returning with casualties to transports or hospital ships transferred their patients either by litter hoist or by hoisting the ambulance boats themselves to the rail and then transferring the patients directly to the deck. The most expeditious method was to keep one boat, usually a disabled one, permanently rigged for hoisting, and to have the ambulance boats come alongside. In a similar vein, programs for management of casualties in a combat theater must be engineered not only to supply speed and flexibility, but above all to be responsive to changing tactical and strategic requirements.
Casualty management doctrine in the littorals must accommodate several highly variable realities—the unique nature of the tactical environment, including physical characteristics of the combat zone; the nature of weapon systems in the hands of potential adversaries; and the complexity and clinical requirements of the multiplicity of wounds encountered in the face of modern weaponry. With these operational requirements, many creative adaptations and adjustments in the means of delivery of medical support will be required. Might an air-cushion landing craft be capable of adaptation as a beach line initial casualty staging and treatment facility, while also serving an ambulance function? Will new forms of ambulance craft such as medical catamaran transports need to be developed?
Clearly, the phenomenon that characterized historical wartime medical care adaptation was a willingness on the part of operational commands to deviate from standard practices and innovate in response to operational need. Will future leaders be prepared to conceive of, and then develop, such "out of the box" adaptations and make the necessary tradeoffs?
The unpredictable nature of war frequently compels us to modify goals and courses of action, as well as to adjust the techniques for implementing those changes. It is ultimately the ability to adapt, and not the capacity for developing a flawless grand operational plan, that provides an operational commander with his greatest test.
Captain Smith is a professor of urology at the Medical College of Georgia in Augusta. He also is adjunct professor of surgery and military and emergency medicine at the Uniformed Services University School of Medicine in Bethesda, Maryland.