Between Flesh and Steel (44 page)

Four major innovations in military medical care were introduced during the Korean War. Among the most important was the introduction of the mobile army surgical hospital (MASH) units, an outgrowth of the mobile field surgical detachments first introduced in World War II. A typical MASH unit had from sixty to two hundred beds and was staffed with special teams of surgeons. The unit was not positioned within the normal vertical medical evacuation chain; instead, it was placed next to the regimental collecting station and the division clearing station. The idea was to provide high-level surgical care as close to the battlefront as possible. The most serious surgical cases were filtered out of the normal vertical chain of evacuation and moved laterally to the MASH unit for immediate emergency surgical care. After treatment, it moved casualties directly to the evacuation hospital for further treatment and evacuation disposition.
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With its complement of twenty-four medical officers and surgeons and forty-one nurses, MASH units sometimes served as many as twelve thousand surgical admissions a month.
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The army transported most of the wounded by vehicle. Curiously, U.S. forces ran short of proper ambulance vehicles throughout the conflict. The most common form of frontline casualty transport was the litter-jeep, which was capable of carrying four patients and was first used in World War II. Its virtues lay in its availability in sufficient numbers and its low profile, which made it a less inviting target on the
roads. A major innovation was using the helicopter in medical evacuation for the first time, although the military's critical shortage of these machines prevented the helicopter from playing a major role. The early helicopters were light and could carry no more than two casualties in external pods attached to the landing skids. In normal practice these machines transported the seriously wounded from the regimental and division clearing points to the MASH units. They also carried cases requiring more sophisticated treatment to the evacuation hospitals. In only a few instances did helicopters pick up casualties on the battlefield, a practice that became common during the Vietnam War. The medical evacuation system in Korea worked relatively well. Fifty-eight percent of the wounded received medical care within two hours of being wounded, and 85 percent were treated within the first six hours. The median time between wounding and treatment was only 1.5 hours.
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Fifty-five percent of the wounded were hospitalized within the same day of being wounded.
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A major medical advance arrived when battle surgeons could treat vascular injuries on a routine basis. Arterial repair was first tried in 1910, and the Russians reported their first large-scale series of attempted vascular repairs in the Balkan Wars of 1912–1913. In World War I, the Germans sought to undertake vascular repair in military hospitals, but the severity of the shrapnel wounds and the high infection rates halted progress in vascular surgery.
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The increased use of high-speed projectiles and shrapnel in World War II produced a sharp rise in the number of arterial wounds. Arterial wounds accounted for only 0.29 percent of the wounds during the Civil War and only 0.4 percent in World War I. The rate of these wounds doubled in World War II to 1.0 percent and doubled again during the Korean War to 2.4 percent.
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Small numbers of vascular surgeons served during World War II, when the standard treatment for injuries to the major arteries was ligation (tying the artery itself in a small knot). But this technique produced only marginal results, with 49 percent of the ligated patients contracting gangrene and requiring eventual amputation. Thirty-six percent of the patients upon whom arterial repair was attempted had to undergo eventual amputation. Taken together, 62.1 percent of cases of arterial injury to the lower extremities eventually needed amputation.
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When vascular surgeons first regularly operated in the frontline hospitals in Korea, they saw a dramatic drop in the amputation rate. In the early days of the war, the amputation rate from vascular injuries remained at the World War II rate of 62 percent. During the last eighteen months of the war, however, the amputation rate dropped to 17.7 percent and, finally, to 13 percent.
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Yet another advance in medical treatment was the great improvement in the management of shock. The ready availability of blood and transfusion helped greatly. Still, soldiers suffering from crushing injuries or prolonged shock often died of renal insufficiency while appearing to recover from their wounds. Doctors recognized this phenomenon during World War II, but no satisfactory treatment was available until the Korean War. A number of special medical units designed to treat acute renal insufficiency were placed near the MASH hospitals. The results of proper medical treatment were dramatic, and deaths due to renal failure declined by 50 percent.
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Between 1965 and 1970, 133,447 American wounded were admitted to medical facilities for treatment, of which 97,659 were admitted to a hospital.
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In Vietnam, small arms automatic weapons fire produced about a third of the injuries, while fragmentation missiles—often from booby traps—produced most of the rest.
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Burn injuries were frequent. Some resulted from explosions inside armored vehicles and bunkers, but more than half the burn injuries were accidental. Burn injuries were often accompanied by inhalation injuries, and wounds of this type produced 70 percent of the total burn fatalities.
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The official hospital wound mortality rate for the Vietnam War was 2.6 percent compared to 2.5 percent for Korea and 4.5 percent for World War II. These statistics are misleading, however, for they do not take into account how the excellent medical evacuation system successfully moved to hospitals seriously wounded men who would have died on the battlefield or at the battalion aid station in previous wars. A better way of understanding the medical care provided to the American soldier in Vietnam is to examine the “deaths as a percentage of hits ratio,” that is, the number of wounded men who survived. Viewed from this perspective, in World War II this ratio was 29.3 percent, in Korea 26.3 percent, and in Vietnam 19.0 percent. Stated another way, in World War II for every soldier who died, 3.1 survived their wounds. In Korea, the figure was 1 to 4.1 and in Vietnam 1 to 5.6.
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The nature of counterinsurgency warfare in Vietnam produced a war of small units widely scattered over inhospitable terrain, a situation that forced a rethinking of the casualty evacuation system. The classic pattern of ground evacuation of casualties while passing them through five echelons of medical care could not work rapidly enough to save the wounded in Vietnam, where distance and terrain slowed ground evacuation to a crawl. The helicopter permitted the greatest flexibility of movement
in evacuating casualties, and the complete control of the air by U.S. forces made it possible for helicopters to land very close to where the casualty was wounded. Once the casualty was aboard a helicopter, the pilot could bypass the battalion and regimental aid stations and take the casualty directly to a hospital equipped for major surgery. Casualties were routinely transported directly to a field hospital, evacuation hospital, or even a hospital ship offshore.
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Hospital ships were used most often for surgical treatment of U.S. Marine casualties since the Marines came under the jurisdiction and control of the navy medical corps. Shipboard evacuation to hospital ships offshore for treatment of Marine casualties had been established during World War II when Marine units were used to assault Japanese positions on Pacific islands. Corpsmen at the battlefront first treated the wounded Marines, who were then transported to battalion aid stations on the beach. From there boats took them to medical facilities located on ships offshore.

At the peak of ground operations during the Tet Offensive in 1968, American troops received aeromedical support via 116 air ambulance detachments, each with five to seven UH-1E (“Huey”) helicopters capable of transporting six to nine patients at a time. Each division had aeromedical helicopters organic to its medical detachment.
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These medevac helicopters had trained medics aboard to provide in-flight advanced first aid to the casualty. The average medical evacuation flight from point of wounding to a hospital was only thirty-five minutes. The more seriously wounded usually reached a major surgical hospital within two hours of being wounded. Of the wounded who were still alive when they reached the hospital, 97.5 percent survived.
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The medical regulating officer controlled helicopter evacuation by designating assignments of medevac flights within his area of coverage. The call for a helicopter initially came from the combat unit's medic. Helicopters already in flight were diverted depending upon the seriousness of the wound. In planned battle operations, helicopters hovered near the site of the action, ready to land at a moment's notice. If no helicopter was in flight, machines of the aeromedical evacuation ambulances stood by on the ramp and upon receiving a call took to the air. Once on the landing zone (LZ), it took less than a minute to load the casualties and for the machine to become airborne again.

The medic aboard the helicopter contacted the radio controller, who had a direct “hot line” to the MRO. The MRO then designated the hospital destination depending upon the seriousness of the wound, the availability of expertise in a given
hospital to treat the specific injury, and the time to transport the casualty to the hospital. Distance was always less important than time. If the helicopter commander questioned the decision to divert to a specific hospital, a physician was consulted by radio. The inbound helicopter then informed the receiving hospital of the number of patients aboard and their respective wounds; this information allowed the hospital to make any special necessary preparations. Usually within minutes of arrival, the patient was on the operating table.
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The medevac crews' heroism in landing their machines on “hot LZs” is testified to by the fact that in a two-year period 39 crew members were killed and 210 wounded while flying medical evacuation missions. They flew 13,004 missions in 1965, and they increased to 76,910 in 1966, to 85,804 in 1967, and peaked in 1969 at 206,229.
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In addition to evacuating casualties, the medical helicopters also transported blood, supplies, and medical personnel throughout the medical evacuation system.

The Vietnam War saw the repair of vascular injuries become routine, and vascular surgeons were present at every major medical installation. The overall success rate of vascular surgery approached 75 percent by war's end. During World War II, division-level medical facilities used almost no whole blood, relying instead on stored plasma as the primary agent to prevent shock. In Vietnam, 14 percent of all blood transfusions were done at division level, mostly with whole blood that could be stored safely in a new Styrofoam blood box.
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The forward units' liberal use of whole blood was a major factor in reducing death by shock. Further, medical personnel found that the blood types stamped on the soldiers' dog tags were incorrect in approximately10 percent of the cases, so blood typing became routine practice in surgical hospitals.
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To reduce blood transfusion reactions, a decision was made in 1965 to send only type O universal donor blood to the war zone. Between 1967 and 1969, 364,900 blood transfusions were accomplished with less than a thousand reactions of all kinds.
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For the first time in U.S. military history, military personnel, their dependents, and civilian employees at military installations donated free of charge every unit of whole blood used for casualties.
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The military introduced disease control programs early in the war, and these prevention programs did much to reduce troops lost to sickness. The major diseases affecting U.S. troops were malaria, viral hepatitis, diarrheal diseases, skin infections, fevers of undetermined origin, and venereal diseases. The average annual disease admission rate in Vietnam was 351 per 1,000 men compared with 611 per 1,000 in
Korea and 844 per 1,000 in the Pacific theater in World War II.
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The encounter with a resistant strain of malaria resulted in a malaria rate of 26.7 percent, more than double the rate of 11.2 percent for Korea.
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1
. An excellent overview of the major contributions of military physicians in the early twentieth century is found in William H. Crosby, “The Golden Age of the Army Medical Corps: A Perspective from 1901,”
Military Medicine
148, no. 9 (September 1983): 707–11.

2
. The racial theorists of this period argued that the slaughter of war was actually beneficial to the genetic health of the population because it weeded out “the unfit.”

3
. Rayne Kroger,
Good-bye Dolly Gray
(London: Cassell, 1960), 167.

4
. Rice, “Evolution of the Military Medical Service,” 149.

5
. Peter Lovegrove,
Not Least in the Crusade: A Short History of the Royal Army Medical Corps
(Aldershot, UK: Gale and Polden, 1951), 26.

6
. Redmond McLaughlin,
The Royal Army Medical Corps
(London: Leo Cooper, 1972), 22.

7
. Lovegrove,
Not Least in the Crusade
, 27.

8
. Ibid.

9
. McLaughlin,
Royal Army Medical Corps
, 22.

10
. Edward H. Benton, “British Surgery in the South African War: The Work of Major Frederick Porter,”
Medical History
21 (July 1977): 277.

11
. Garrison,
Notes on the History
, 192.