The Medical Lessons of War

On April 21, 1944, Sgt. Ed Hladovcak, a U.S. Army Air Force pilot, was flying three wounded British soldiers to safety when his small reconnaissance aircraft was shot down behind enemy lines in Burma. Huddled on a rice paddy surrounded by Japanese snipers, the men were stranded and cut off from conventional rescue channels.

There remained one possibility for a rescue attempt. Six hundred miles away in Lalaghat, India, the First Air Commando Base housed a nascent contingent of military helicopters. Pilots had been trained to fly the first generation of military helicopters only six months earlier at the Sikorsky aircraft plant in Bridgeport, Conn. The military, still trying to figure out how and where to employ the new YR-4B, used the helicopter for observation missions and light transport.

But on the day Hladovcak was shot down, the landscape started to shift for the helicopter. Commanders had discovered a sandbar near where the plane was downed that could serve as a makeshift airstrip. If the wounded men could be ferried there by the helicopter, they could be picked up and flown to safety. A message was telegraphed to Lalaghat: “Send the eggbeater in.”

The two-seater YR-4B, dubbed “the flying shoebox with windows,” was made of Plexiglas panels and canvas-covered steel tubes balanced on two undersized wheels and looked more like a child’s toy than a reliable mode of transportation. The underpowered piston-driven, 200-horsepower engine could barely provide enough lift for a full load and was prone to breakdowns. Lt. Carter Harman, a 5-foot-7, 125-lb. music-critic-turned-pilot, was tagged to fly the 600 miles to the crash site and evacuate the soldiers.

Uncertain of what lay ahead, he piled four cans of gasoline into the copilot’s seat and loaded a stretcher before takeoff. The fact that Harman coaxed the YR-4B through a series of short hops across the continent all the way to Aberdeen, Burma, was a feat in and of itself that took several days. Harman worried the entire time about how the helicopter would perform once he arrived. The hot, humid jungle air would reduce lift even more, and he was going to need every bit of power he could muster.

After Harman reached the crash site and loaded the first wounded soldier, he found out what his eggbeater could do. The YR-4B vibrated and redlined on takeoff but made it to the sandbar. Harman returned to the crash site and brought out a second victim, but when he landed on the sandbar this time, his overworked engine seized and wouldn’t start up again. Harman was forced to spend the night on the sandbar, hoping his engine would start the next morning after cooling off, and it did. Harman made two more runs to pick up the last injured soldier and the pilot.

Harman flew another 15 rescue missions in the region before extensive damage to his helicopter grounded him, but in those few weeks he managed, for the first time, to demonstrate the helicopter’s value in evacuating the wounded.

Overview

When we think of war, our minds immediately leap to the cost in lives, limbs and futures lost, but along with the toll of human carnage, some good emerges. The fact that soldiers are wounded and die day after day serves as a powerful motivator spurring military personnel to develop better equipment and techniques to treat them. Wartime is exactly the place to make these advances because of the concentration of injuries.

This has been true at least since the Civil War, a conflict that produced more than 281,000 wounded and 140,000 traumatic deaths on the Union side alone and an unknown number of Confederate wounded and dead. In 1862 a forward-thinking surgeon general, William Hammond, insisted that medical officers submit case reports, surgical specimens and autopsy reports, data that was collected for the first time and published in a six-volume, 4,883-page work, The Medical and Surgical History of the War of the Rebellion (1861–65). This invaluable resource was our nation’s first large-scale compilation of trauma data.

In World War I 204,000 more casualties added to the accumulated expertise treating the wounded. World War II added 670,000 more, and the Vietnam War another 153,000 wounded soldiers. The total number of wounded from the American Revolution through Desert Storm (1775–1991) added up to an estimated 1,430,290 casualties. With this astounding number of trauma victims, it’s no small wonder that in every modern war since the Civil War, medical advances have emerged that not only improved the care of wounded soldiers but also filtered over to the care of injured civilians and drove the advances that resulted in today’s state-of-the-art trauma centers and systems.

A New Mode of Transport

No one knew it at the time, but wartime necessity, in dictating the first helicopter evacuation of the wounded, had introduced a mode of transport that would change the care of the injured for decades into the future. The success of the helicopter would be demonstrated on a larger scale during the Korean War when 11 H-13 Sioux helicopters evacuated 17,700 casualties in a setting of rugged terrain and a lack of road and bridge infrastructure.¹  

Despite the promise of helicopter evacuation, design shortcomings often plagued the smooth evacuation of casualties. The H-13 was underpowered and could barely lift a full load consisting of a pilot, copilot and two casualties, and there was no armor to protect the crew. These early helicopters had no radios, internal lights or instruments and were ill-equipped to fly at night or in bad weather. They broke down frequently and were out of service while replacement parts were on order or scavenged. The design shortcoming that raised the most alarm, however, was the fact that there was no room inside the helicopter for a stretcher, requiring that the wounded be carried on exterior litters mounted to the side of the aircraft. Not only were injured men exposed to the elements and possibly enemy fire outside the cabin, but they could not be monitored or treated in flight.

Still, the helicopter had some definite advantages over ground transport in terms of speed. The craft could be airborne within 3–10 minutes and deliver a wounded soldier to a mobile army surgical hospital (MASH) within an hour, while ground transport could take hours to days depending on weather and road conditions. Helicopter transport was also less traumatic to the injured than riding over rutted roads.

The message from the Korean experience was that helicopter transport was expensive and temperamental but well worth the trouble. The speed advantage resulted in a 2.4% mortality for soldiers who made it to treatment, versus 4.5% in World War II.² There was no arguing that the helicopter was saving lives that would otherwise be lost.

At the conclusion of the Korean War, the medical helicopter was in need of a champion, someone who would step up and take medical evacuation to the next level of safety and efficiency. That person was LTC Spurgeon Neel, MD, who proved to be a tireless advocate for medical evacuation.

“Casualties are a ‘perishable commodity,’” Neel wrote. “A man dies in so many minutes, not over a distance of so many miles.” He pointed out that any measure that could reduce the time between when a soldier was injured and when he reached definitive care would logically reduce morbidity and mortality. While this fact seems strikingly obvious now, during the Korean War the role of time in the outcome of injured patients was still not well defined. It would not be until the 1960s, when Dr. R Adams Cowley defined the “golden hour,” the critical hour immediately after injury during which treatment made the greatest difference, that trauma care would be built around this precept.³  

Neel urged the army to commission a helicopter that included optimum features for medical evacuation, and in 1954 the army held a competition for a new multipurpose helicopter. The result was the UH-1 Iroquois, aka “Huey,” produced by Bell Helicopter in 1956. This first-generation, turbine-driven, 800-horsepower Huey could lift 2,000 pounds and fly at a brisk 140 miles an hour for up to 115 miles. It had more than enough heft to carry a four-man crew and two patients inside the cabin.

Vietnam and Beyond

When the United States developed a presence in Vietnam four years later, the availability of a reliable multipurpose helicopter turned out to be extremely handy in fighting the enemy in mountainous terrain and thick jungles. But Vietnam offered new challenges to helicopter rescue in the form of landing zones under hostile fire, guerrilla warfare that constantly shifted the site of battle, and operational challenges in maintaining a dedicated fleet of medevac choppers.

Because of strong leaders like Maj. Charles Kelly, commander of the 57th Medical Detachment in 1964, medevacs, aka dustoff units, were moved closer to the action. Kelly promoted a mind-set of never refusing a rescue mission, no matter the danger presented by enemy fire or the weather. It was a mind-set that saved countless lives at the same time it put medevac crews directly in harm’s way. Kelly himself became a casualty on July 1, 1964 on approach to pick up wounded in a “hot” landing zone being pelted by enemy fire. The bullet traveled through an open door of the chopper, pierced Kelly’s heart and killed him on the spot. His legacy, however, endured and inspired new and vigorous support of the program. From 1962 to 1973 military pilots flew more than 496,000 medevac missions evacuating more than 900,000 wounded in Southeast Asia.

With the efficacy of medical evacuation well established by 1966, the federal government offered matching funds for states that wanted to test the feasibility of civilian helicopter rescue. These programs proved successful, and by the 1970s the medevac concept was taking root in the civilian arena, where today over 272 air ambulance services across the country transport 650,000 patients a year.

Today, UH-60 Black Hawks transport wounded soldiers in Iraq and Afghanistan. They are faster and larger than the Vietnam-era Hueys and carry all the high-tech equipment a medic could dream of, including heart monitors, ventilators, electronically controlled litters, a built-in external hoist and an infrared system that can locate patients by their body heat.⁴ The time-to-treatment goal has been whittled down from the golden hour to the platinum 10 minutes. For the most severely injured, there is even the capability to bring a surgeon and a basic operating room to the point of injury through a program known as MERT (Medical Emergency Response Team) pioneered by military physicians from the United Kingdom. For casualties with severe injuries, MERT transport results in lower mortality.⁵

Life-Threatening Blood Loss

One of the main reasons time and rapid transport to definitive care are critical in treating the injured is because of the potential for life-threatening blood loss. Of the approximately 5 million people who die around the world from trauma every year, at least a third bleed to death.⁶ In the face of severe injury, not only can wounded soldiers bleed out and die in a matter of minutes, but they are susceptible to developing shock and a potentially irreversible state of organ damage.

Ninety percent of soldiers who die with potentially survivable wounds bleed to death. Early in the wars in Iraq and Afghanistan, military physicians found that most combat casualties died within 10 minutes (aka the “platinum 10 minutes” of resuscitation) of being wounded and usually from exsanguination.

At the outset of the war, tourniquets had been set aside in favor of direct compression to stop bleeding for fear of inducing ischemia in injured limbs. The Tactical Combat Casualty Care (TCCC) program, developed by medical professionals tasked with reviewing the principles of battlefield trauma care before the war, uncovered the potential value of tourniquets in preventing deaths and set about documenting their necessity in the field.⁷  

In 2004, Col. John B. Holcomb, MD, reviewed autopsy data and documented a 15% incidence of preventable deaths among special operations fatalities, including a number of deaths from extremity hemorrhage that might have been prevented with application of a tourniquet. Holcomb directed a comparative study of all commercially available tourniquets to find the most effective option. Ultimately the Combat Application Tourniquet (C-A-T), a tourniquet that can be deployed with one hand, and the Special Operations Forces (SOF) Tactical Tourniquet were chosen by the military for use on the battlefield. SFC Dom Greydanus trained special operations units in deploying the tourniquets. Initial results showed the tourniquets were effective in stopping bleeding with no loss of limbs. By 2011 the percent of combat fatalities from extremity hemorrhage had dropped from 7.8% to 2.6%, a 67% decrease.

The TCCC all-combatants course, designed to teach basic techniques of bleeding and airway control, has been so successful that its principles have been restructured and taught to law enforcement and civilians. The Bleeding Control for the Injured (B-Con) course was developed by the National Association of Emergency Medical Technicians (NAEMT) with the assistance of Dr. Peter Pons and Dr. Norman McSwain to train nonmedical personnel to respond to active shooter, IED (improvised explosive device) and mass-casualty events.⁸ The White House “Stop the Bleed” campaign, aimed at training bystanders, provides similar tools and knowledge required to stop life-threatening bleeding at the injury scene.

Hemostatic dressings, used for compressible hemorrhage in body regions not amenable to tourniquet application, also emerged during the wars in Iraq and Afghanistan. Currently the TCCC recommends QuikClot Combat Gauze containing kaolin, an inorganic mineral that accelerates the body’s clotting ability.⁹ The XSTAT, the “medical version of Fix-a-Flat,” deployed by the military in 2016, is a syringe full of small sponge-like discs impregnated with a clotting agent that can be injected into an open wound like a bullet hole in the abdomen.10 The sponges expand to 10 times their size within seconds to plug the wound and internally compress bleeding sites.

In 2016 the United States Army started fielding the SAM junctional tourniquet designed to stop hemorrhage from injuries to the groin or armpit.11 The SAM straps on like a belt and includes two inflatable air bladders that can provide compression to a bleeding high leg or axillary injury caused by an IED blast or bullet.

The military has also adopted tools that work within the intravascular system to stop bleeding, including whole blood (documented to improve survival in the face of massive hemorrhage); recombinant factor VII (NovoSeven), which acts by activating the coagulation cascade; and tranexamic acid, an antifibrinoloytic that prevents clot degradation.

Conclusion

At the height of the wars in Iraq and Afghanistan, a combination of factors converged to improve outcomes for even the most severely wounded. Military surgeons were battling injuries with knowledge and expertise acquired from casualties treated earlier in the war. They were saving soldiers previously classified as unsalvageable. They had also accumulated data to drive their decision-making toward the best possible outcomes. And they had been able to ship even the most critically injured back to the United States using a critical care air transport team, a flying intensive care unit with individual stations staffed by physicians, nurses and respiratory therapists.

Our armed forces have made tremendous advances over this last decade of war, but even after the last gunshot has been fired and the last injured soldier released from the hospital, there will still be work to be done. Information about patient injury, treatment and outcomes must be collected and circulated just as it was after the Civil War. New techniques and devices must be transferred to civilian trauma centers and military medical expertise preserved so that victims of trauma, wherever they may arise, can benefit from the medical lessons of war.

References

1. Dorland P, Nanney J. Dust Off: Army Aeromedical Evacuation in Vietnam. Washington, DC: Center of Military History, U.S. Army, 1982, p. 11.
2. Whitcomb D. Call Sign–Dustoff: A History of U.S. Army Aeromedical Evacuation From Conception to Hurricane Katrina. Frederick, MD: Office of the Surgeon General, Borden Institute, 2011, p. 22.
3. Franklin J, Doelp A. Shock-Trauma. New York: St. Martin’s, 1980, p. 7.
4. Hale R. New MEDEVAC Helicopters Take Flight in Iraq. U.S. Army, www.army.mil/article/49856/New_MEDEVAC_helicopters_take_flight_in_Iraq.
5. Medical Corps International Forum. Forward Aeromedical Evacuation, www.mci-forum.com/forward-aeromedical-evacuation/.  
6. Kabaroff A. Stop the Bleeding. J Emerg Med Serv, www.jems.com/articles/supplements/special-topics/putting-clamp-hemorrhage/stop-bleeding.html.  
7. Butler FK. Military History of Increasing Survival: The U.S. Military Experience with Tourniquets and Hemostatic Dressings in the Afghanistan and Iraq Conflicts. J Spec Oper Med, 2015 Winter; 15(4): 149–52.
8. National Association of Emergency Medical Technicians. Bleeding Control for the Injured (B-Con), www.naemt.org/education/WhatIsB-Con.aspx.
9. QuikClot. What is QuikClot? Innovation in hemostasis, https://quikclot.com/About-QuikClot.  
10. Leopold T. Tool Can Plug Gunshot Wounds in Seconds. CNN, www.cnn.com/2014/06/02/tech/innovation/xstat-wound-treatment/.
11. Crown E. Soldiers Getting Junctional Tourniquet Designed to Save Lives. U.S. Army, www.army.mil/article/163229.

Catherine Musemeche, MD, is author of Hurt: The Inspiring, Untold Story of Trauma Care, from which this article is in part adapted.