Interwar Years

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Aeromedical Evacuation

 

Although the conflict in Europe had ended in 1918, Great Britain retained extensive global interests. Military forces were involved in containing a number of local rebellions during the 1920's and 1930's. The extreme distances involved in conducting expeditionary military operations in the Middle East led to consideration of the use of aircraft for casualty evacuation. The first recorded instance of aircraft being used by British forces was for the evacuation of sick from the Kurdistan column in Iraq in April 1923.

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Some 200 cases of diarrhoea and dysentery were evacuated from an inaccessible mountain region back to Baghdad (1). This became a standard technique for casualty evacuation at the frontiers of the British Empire. As experience developed further, the Army and the Royal Air Force developed working relationships for the command and control for the movement of casualties by air between land medical units (2).

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EVACUATION:

 

Army and RAF interoperability is a key element of casualty evacuation

 

The Spanish Civil-War

 

The civil war in Spain was seen by many as the pre-cursor to the European conflict of World War II. It was this experience that enabled the Germans to develop many of the detailed tactics needed to support the strategy of ‘Blitzkrieg’. Volunteers from overseas extensively supported the medical services on both sides (3). Jolly (4) described the medical experience of this war in a book published in 1940. He highlighted the importance of time as the key determinant of outcome in the management of war wounds: ‘in Spain it was shown that the reduction of the time-lag for the gravely wounded necessitates a reorganisation throughout the system of Forward Hospitals and Casualty Classification Centres. The interval cannot be reduced merely by increasing the number of surgical teams working in Casualty Clearing Stations’.

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Fig 1. Diagram of Three-Point Forward System

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He proposed a concept for the organisation of military medical services called the ‘Three Point Forward System’. This is shown diagrammatically in Figure 1.

 

This system divided the Casualty Clearing Station (CCS) into its component functions of an Evacuation Hospital (5) and established each as a separate unit. The Casualty Classification Centre, with trained classification (triage) teams, was placed in advance of the furthest forward hospital and acted as the pivot for the remainder of the system. The No1 Hospitals (‘Hospitals of the First Urgency’) were sited so that the time-lag from wounding to operation was reduced to under 5 hours. A dedicated shuttle of ambulances was established between the classification posts and the No1 hospitals.

 

The No2 hospitals took the remaining casualties prior to their onward move to evacuation hospitals. If the time-lag at both the No1 and No2 hospitals rose above the permissible limits and the evacuation road between these and the classification post was good then it was advised that the siting of the classification post and the means of evacuation to the classification post should be examined. If the time-lag between the classification post and one of the hospitals became extended then the hospitals should be moved.

 

Jolly noted that the conditions of the ‘total war’ experienced in Spain challenged many of the pre-existing assumptions. The extensive use of airpower had largely removed the imperative for the siting of surgical units at the limit of effective range of the enemy’s artillery as all military units had now become vulnerable to enemy action.

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In addition, towns and cities had become targets, negating any protection that might have been afforded to civilians. Thus, medical units had to adopt the same principles of dispersion, camouflage and protection employed by combatant units. Large aggregations of transport or wounded men at hospital sites had the potential to become targets for aerial bombardment.

 

The treatment function depended on two separate elements, the field hospital, and the mobile surgical unit. The field hospital contained the core elements of a hospital, namely beds and nurses, administration, and infrastructure. This unit could act as a No 1 or No 2 hospital and so movement of medical services could occur by means of a leap-frog system of a pair of these units. The surgical capability was delivered by means of self-sufficient mobile surgical units consisting of 14 personnel (surgeon, assistant surgeon, 2 anaesthetists, 2 theatre nurses, 2 orderlies, 3 driver sterilisers, one electrician and 2 ward nurses). Their equipment was moved in a specially designed Renault truck (the auto-chir). This included a portable steriliser, a special wheeled and counter weighted theatre light, an electricity generator and sufficient medical materiel to support two operating tables. Although not capable of working independently from another medical unit, the mobile surgical unit could either be deployed to a field hospital to give it surgical potential or act as a nucleus of a hospital unit. The hospital unit could be established by the addition of a truck loaded with 20 beds, 2 marquees, ward furnishings, kitchen materiel, an ambulance with a triage officer, a clerk, 2 ward nurses, 4 stretcher-bearers and a cook.

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This combination of units allowed the chief medical officer of an Army Corps to provide a flexible medical service to support military operations.

 

TRIAGE: triage by destination.

SURGERY: creation of a specialist,

mobile Forward Surgical Hospital

 

Second World War

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Overview

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The Second World War was a considerably expanded conflict compared to the First World War, with military forces engaged in every geographic region around the world. The ‘Blitzkrieg’ of the Spanish Civil War expanded the violence and destruction of military technology. Military planners had visions of columns of mechanised warriors moving rapidly around the battlefield where the terrain and military situation allowed. However, most battles included the set-piece artillery barrage, infantry operating on foot and the close-quarter fighting reminiscent of World War One. Casualty evacuation still started with the hand-carry of the seriously wounded by stretcher. The organisation and design of surgical hospitals was adapted to meet the demands and constraints of each environment. Fortunately, gas was not used as a weapon, though the war ended under the shadow of nuclear weapons.

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In the British Army Medical Services, the surgery of wounds went through three phases. Treatment by closed plaster was the rule at the beginning of the War. In the second phase of the development of wound management, wounds were excised and drained, the limb immobilised in a padded plaster and closure by secondary suture or skin graft was undertaken as soon as the surface was covered by granulation tissue.

 

By 1944, ‘delayed primary suture’ was the authorised treatment. In this the wound was excised by the forward surgeon and the defect closed in the base hospital between the fourth and sixth days (6).The understanding of wound shock expanded considerably leading to the design of complete systems for the movement of blood and plasma to medical units. The development of antibiotics, sulphonamides initially and then penicillin, augmented the armamentarium of the surgeon in the management of war wounds – but this did not replace the dictum of wound excision learnt in the First World War.

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