From Battlefield Medicine to Civilian EMS

A Look into Military Innovations that Shaped Pre-hospital Care

Our brothers and sisters in arms have made significant contributions to pre-hospital care since the dawn of civilization. From transportation of the wounded in ancient battles to driving ambulances through heavy fire and across unknown terrain, and innovations in evacuation to instantaneous care on the frontline, medics are a crucial part of military success the world over.

Battlefield Medicine to Civilian EMS looks at the influence military medicine has had on civilian pre-hospital care since the Napoleonic Era (c.1800), which generally marks the start of “modern” military medicine in ways we would recognize today and continues on a journey through major US conflicts over the past 150 years focusing on some of the most influential innovations that have crossed over to civilian EMS.

As with each generation of soldiers, once one retires or discharges from military life – a new life in the civilian world waits. Many military medics continue on in civilian medicine, through service in emergency squads, hospitals, and clinics, and in so doing bring their military training with them creating a unique bond between battlefield medicine and civilian medical services.

Napoleonic War (1803-1815)

The Birth of the Ambulance & The Start of Triange

Baron Dominique Jean Larrey, Surgeon to Napoleon’s Imperial Guard, developed the modern method of army surgery, field hospitals, and an ambulance system. He was inspired by the speed of the French flying artillery as they made their way over the battlefield. He created “les ambulances volantes” (the flying ambulances) in the fall of 1792 in an effort to bring prompt relief to the wounded on the battlefield.

These ambulances would provide a shelter for emergency amputations and transport for the wounded to a hospital to recover under the supervision of a trained nursing corps.

Larrey also created the “triage” process where wounded were treated in the order of need, regardless of rank or nationality. As part of patient triage, he also expedited amputations and the cleaning of wounds to improve overall survival. Larrey is considered to be the first modern military surgeon.

Triage

While the concept of triage has been around since the Napoleonic Wars, a modern version in the civilian environment exists to this day. Triage is defined as a systematic sorting of patients based on need and their priority of treatment and transportation to the facility best suited to meet their needs. Triage is now performed at the point of injury or illness by the medic and continues through the emergency department, surgery, and to a hospital bed.

American Civil War (1861-1865)

Formation of the Ambulance Corps & Pre-hospital Care

By the time the War Between the States broke out, Larrey had successfully demonstrated the importance of the flying ambulance corps in France. In June 1862, as the Army of the Potomac cobbled together forces, Maj. Johnathan Letterman took up a post as the Union’s medical director. Often, soldiers were left in agony for days on the battlefield in various states of injury. His primary task: save as many soldiers from illness and injury as possible.

He created and implemented the “Letterman Plan.” This plan included an organized ambulance corps, created standardization in medical tools and supplies at field dressing stations, it emphasized evacuations to field hospitals where emergency surgeries could take place, and also included larger hospitals away from the battlefield which had facilities for long-term care.

His plan proved necessary on the bloodiest day of the American Civil War: Antietam on September 17, 1862. His more efficient treatment plan, while not perfect, was immensely successful and included the removal of 17,000 wounded soldiers within 24 hours of the battle.

Many Northern ambulances started as two-wheeled carts that easily became bogged down in the swampy fields of the Southern battlefields – a new more effective design was needed. Based on the buckboard wagon of the day, these new ambulances had 4 wheels and enough room to transport up to four patients with dedicated medical staff treating the injured en route to a field hospital, decreasing battlefield casualties.

Civilian Ambulance Corps

After the American Civil War, New York City’s Department of Charities and Corrections asked Dr. Edward Dalton to develop a civilian version of the ambulance corps he initiated while a surgeon in the Army of the Potomac. Dr. Dalton’s ambulance included an enclosed area for the patient and a suspension system to minimize shocks from uneven roads.

On June 30, 1869, the Medical Board of Bellevue Hospital in New York City held the first examination for ambulance surgeons, and the nation’s first municipal ambulance service was inaugurated. Each ambulance was staffed by a driver and a surgeon. The surgeons were usually were doctors who were fresh out of medical school.

The original ambulances were two horse-drawn vehicles designed by the Abbot-Downing Company. A bell was rung by a foot pedal as the warning system. The only warning device was a bell operated by a foot pedal on the floorboard of the ambulance. They also carried basic medical equipment, supplies, and pain management in the way of brandy and morphine. These wagons had the word “AMBULANCE” emblazoned on the sides and the rear, as well as on an arched roof sign in front.

In 1901 Dr. Emily Dunning became the first woman ambulance surgeon in the United States and rode out of Gouverneur Hospital in Manhattan.

World War I (1914-1918)

Wound Care in the Field & Motorized Transport

When World War I broke out in August 1914, no one knew what toll the ‘Greatest War’ would take on the world. Nor did anyone anticipate the rapid change in emergency medical care brought on by the inhumanity of war during the early 20th century. Many of the earlier innovations from war were perfected and modernized. Medical personnel utilized triage along with field hospitals in order to create faster and more effective means of treatment.

Historically, battle wounds came from swords/bayonets and bullets, but WWI was the first time that deadly gasses were employed as a weapon. These gasses were detrimental to skin, lungs, throats, and noses, and within a matter of moments, they could also paralyze and also cause death.

Not all injuries happened on the battlefield itself. WWI was fought in trenches. Soldiers lived and fought in them for weeks on end. Little more than muddy holes, trenches presented medical providers with an entirely new host of injuries to tend to. Infection and diseases were rampant. Some common diseases seen in soldiers included dysentery, trench fever, enteric fever (a form of blood poisoning), nephritis, shell shock, and influenza, to name a few. In addition, the trenches could harbor pests such as rats and lice.

Of all the innovations brought on during the war, for the first time, medics provided basic first-aid and medical care prior to transporting the patient. The Great War also saw the organization of a professional ambulance service which implemented levels of care from front line thru battalion aid stations to fully operational field hospitals. This all being possible because of the motorized ambulance and front-line litter bearers among the military ranks.

World War II (1939-1945)

Transportation by Land, Sea and Air

With Allied and Axis forces clashing around the globe, World War Two was truly a world war.

From the US Department of Defence’s Webpage, it’s noted that “from the bombing of Pearl Harbor, Hawaii, to the day Japan’s emperor signed the surrender, more than 400,000 U.S. service members were killed during World War II. About 70% of those were combat-related, and the rest were accidents or illnesses. More than 670,000 were wounded.”

New types of weaponry in the form of artillery and bombs were used in the war, which created even more horrific injuries for medical personal to treat. In addition to the previously mentioned triage technique, medics also had more medicines at their disposal to aid in both suffering and recovery. Having been discovered in 1928, penicillin allowed medics to battle disease and infection and a higher rate of success. Needles, surgical implements, and other medical equipment also were able to be sterilized in the fight against infections. Servicemembers were also inoculated against deadly diseases as well.

Aeromedical Transportation

Technological advances since the First World War also made mass transport a possibility and World War II saw regular use of hospital trains and hospital ships, as well as the introduction of fixed-wing aeromedical transportation. The Douglas C-47 Skytran, the Douglas C-54, and the Curtiss C-46 Commando Skymaster, cargo planes were utilized to carry the wounded out of the conflict areas. The benefit of these carriers was the speed at which they could transport the injured, and they were able to traverse long stretches of rough terrain. Nurses and surgical staff cared for the soldiers during these flight transports. Some of the injured, if they were able, were ambulatory, while others were carried on the planes on litters. Aeromedical transportation was utilized in every combat theater in the war.

Korean War (1950-1953)

MAS*H, EMT-A Training and Helicopter Evacuations

Often referred to as “The Forgotten War”, the Korean War set in motion the global political dynamics we live with today. In three short years, the Korean War also set up practices for modern EMS that shaped civilian practice in the decades to follow the conflict. Most famously, the Mobile Army Surgical Hospitals (MASH Units) were fully functioning hospitals that could move along with the frontline.

When the war started in 1950, doctors were in short supply so a draft was enacted. Combat care consisted of a relay type system. The first system was organized around a battalion aid station and then a separate forward collecting station. They were triaged initially diagnosed here. The wounded would then be carried off-site to larger collection stations or MASH units for further care.

The mortality rate during the Korean conflict was cut in half from rates seen during World War II. Doctors began experimenting with vascular treatments which limited the numbers of amputations.

Rotary aircraft rescues were perfected during the Korean War. Helicopters allowed rescue and evacuation teams to fly low through the mountainous and uneven terrain and “drop” down to access the patient. However, the first generation of helicopters didn’t have room for a medic to care for the patient in transport. Drs. ‘Deke’ Farrington and Sam Banks brought military medical training to the Chicago FD in 1958 with the first civilian trauma training course; the EMT-A certification was born.

Vietnam War (1955-1975)

Radio Communications, the Birth of the ‘Para-Medic’ & ‘The Golden Hour’

By the time the US entered Vietnam, radio had become essential for communication in the military. From frontline movement to base operations, radio communications proved to be an efficient way to move troops and prepare for battle and movements. For medics, radio communications during patient transport ensured hospitals were prepared for the incoming patient and their injury.

Like other wars mentioned in this exhibition, Vietnam also presented its own host of different kinds of injuries soldiers faced due to changing warfare technologies. The guerrilla nature of the conflict saw military personnel with injuries ranging from gunshot, shrapnel, and exploded devices injuries. Many of the nurses who treated soldiers had little experience in these severe types of wounds and had to adapt and learn quickly. The utilization of the helicopter was vital in getting the injured out of the jungles of Vietnam quickly and efficiently in order to aid in better rates of survival.

Medical professionals also implemented and perfected techniques that not only aided those in Vietnam but are still used today. The use of topical antimicrobial chemotherapy was used for burns and other wounds was available for the first time in Vietnam. In addition, the use of the universal donor Type O blood was first used here too.

It was during this conflict that medics and corpsmen were now identified as para-medics armed with a wide array of life-saving protocols including IV use and shock resuscitation (among others) to be used prior to transport. These life-saving measures started prior to transport led to the idea of ‘The Golden Hour’ or the window of prime opportunity to save a patient’s life after traumatic injury.

SAM Splints

SAM (structural aluminum malleable) splints were created in the mid-1980s by former Vietnam War trauma surgeon Dr. Sam Schienberg. Schienberg found that field medics rarely utilized the military issue splints they were provided as they were bulky. Using his background in orthopedics and his work during the war, he created the SAM splint after playing with a foil bubblegum wrapper.

The splint is made from soft aluminum with a polyethylene coating and is used for immobilizing bone and soft tissue injuries. It can come in formats including rolls or flat strips, can be formed to fit a person’s body, but can become rigid and sturdy when bent and folded. They can be cleaned and reused as well.

The SAM splint can now be found all over the world in First Aid kits, trauma kits, ambulances, and in military medics’ supplies.

Operation Desert Shield and Desert Storm (1990-1991)

Tactical Combat Care

On August 2, 1990, Iraq’s Saddam Hussein ordered the invasion of Kuwait due to ongoing arguments over crude oil at the border of the two nations. In response, U.S. President George H.W. Bush condemned the invasion along with Britain and the Soviet Union. U.S. Troops were sent in on a mission called Operation Desert Shield. The U.N Security Council authorized the use of any means necessary against Iraq if they didn’t withdraw from Kuwait. Hussein and his army did not, so on the morning of January 17, 1991, the conflict was renamed Operation Desert Storm. The U.S., its NATO allies, Eqypt, and several other nations created the coalition which would fight Hussein.

Tactical military efforts had grown by leaps and bounds since Vietnam and included the latest in technology. Some of these included stealth bombers, cruise missiles, “smart” bombs with laser-guidance systems, and infrared night-bombing equipment.

In 42 days of relentless air attacks, President Bush declared a cease-fire but by then, most of the Iraqui forces had fled or surrendered. Kuwait had been liberated. Out of about 697,000 U.S. troops who took part in the war, 299 lost their lives.

Many veterans of this war have suffered long-term medical complications from their service. Some common ailments seen at Veteran’s Hospitals are respiratory issues, psychological afflictions, skin troubles, and Gulf War Syndrome.

America’s War on Terrorism & Iraqi Freedom (2001 onward)

Telemedicine in the Field

After the tragic events of September 11, 2001, the world changed in many ways. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) commenced in October 2001 and May 2003, respectively, as part of the global war on terror. To go into great detail about this war would be akin to writing pages and pages in order to gain enough context to understand the complexities.

Briefly, America’s War on Terrorism, also known as Operation Enduring Freedom (OEF) was a direct response to the attacks on the United States on September 11, 2001. President George W. Bush authorized missile airstrikes targeting known terrorist groups al-Queda and the Taliban in Afghanistan. These attacks began on October 7, 2001, and was officially declared over by President Barak Obama on December 28, 2014.

In tandem with OEF was the creation of Operation Iraqi Freedom (OIF). President George W. Bush, whose father had faced Saddam Hussein’s regime in the 90s, believed that the leader was harboring weapons of mass destruction and that his government was a threat to the United States. Authorized by Congress, the President declared war on March 20, 2003. Both air and on-land tactical missions were part of this war. President Hussein was captured on December 13, 2003, and was later executed for crimes against humanity. The invasion and subsequent fall of Hussein’s government led to a new Iraqi constitution, government, and elections.

Over 50,000 Americans were injured as a result of these ongoing wars. This generalized number does not include those who died. Some of the injuries soldiers faced from both campaigns came from a variety of dangers. Suicide bombers, explosive devices, landmines, mortars, and bomb shrapnel, and of course, bullets, to name just a few. An article created by the Bureau of Veteran’s Affairs lists numerous types of procedures medics performed in the field and in hospitals. This article lists orthopedic (including amputations, joint reconstructions, ligament repairs), soft tissue injuries (wound closures, burns, debridement), vascular, thoracic, and head and neck injuries. Lasting wounds, both physical and mental, still plague some personnel today.

As US Forces embarked on campaigns around the world in these wars and soldiers found themselves in very inhospitable areas where medical evaluations are tricky at best. To ensure optimum survival rates with complex trauma, medics were able to telecommunicate with hospital-based doctors that could direct complex medical procedures in the field. This advance in technology allowed medical professionals to better treat and save more military personnel’s lives. One advantage of this new telemedicine process was the ability to bring telepsychiatry services to soldiers suffering from PTSD. This allowed professionals to better assess the soldier’s needs and to get them the assistance they required.

Tactical Combat Casualty Care

Tactical Combat Casualty Care refers to the standards of pre-hospital care given in combat arenas. The guidelines were developed by the U.S. Department of Defense Health Agency Joint Trauma System to ensure universal standards of care for military trauma support and to prevent deaths while maintaining operational success.

The three areas of care are:

Care Under Fire (CUF): involves care to injured personnel while still under active fire. The only goal in this scenario is to stop life-threatening bleeds until the injured can be moved to more secure locations
Tactical Field Care (TFC): involves more advanced care while still in the war zone. This area of care focuses on the MARCH acronym to assess hemorrhage, airway constrictions, respiration, circulation, and hyperthermia. In addition, medics can assess eye injuries, brain trauma, burns, splinting, wounds can administer pain relievers and antibiotics.
Tactical Evacuation Care (TACEVAC): involves areas of the TFC with the addition of getting injured evacuated out of the battlefield area.

Research and assessment of these operations have shown that these protocols are the most effective strategies for modern battlefield medicine and care.