To Care Always Requires Organization

Oliver North on the "Angels" set.
In the 15th century there was an anonymous description of professional responsibilities, common among French surgeons but used by practitioners in all countries — “To cure sometimes, to relieve often, and to care always” — expressing the societal expectation of surgical care. Those who defend the homeland for fellow citizens have a claim on the society for the injuries sustained in the common defense.

The Flying Ambulance

From the earliest times surgeons were near the fight and the injured were brought to them when practical. A key change occurred in the nineteenth century as efforts to care for the soldier, sailor and Marine were systematized. Dominic Jean Larrey, surgeon to the Imperial Guard, took the first step in the Napoleonic armies. Like many surgeons before him, Larrey recognized that the important variable in providing successful care was the time that elapsed between being wounded and reaching the care of the surgeon. Larrey’s great insight was that it was not exclusively a matter of moving patients more efficiently — the surgeon could also move forward. He designed a surgical unit, called the "Flying Ambulance," which had organic transport, litter bearers, enlisted nurses, and surgical teams. He then got Napoleon’s approval to field the unit. The surgeons of the Flying Ambulance were seen far forward of other surgeons caring for the fallen members of the Guard and inspired imitation. Other surgeons in various armies for variously sized units achieved forward surgical capacity but there was no consistency and no doctrine until after mid century.

The Letterman System

In the American Civil War, Jonathon Letterman, Medical Director of the Army of the Potomac, introduced the second essential innovation in military surgical thinking; the surgeon is part of an organized system of care. Letterman introduced and organized a trained ambulance corps with dedicated assets under medical control and placed surgeons forward to operate early. He also instructed that they refer the patients to hospitals further in the rear and had the ambulance corps available to facilitate the transport. In doing so he built an echeloned care system in which only the necessary surgery was performed forward and the patients were evacuated for definitive care — an evacuation system. He also introduced a system of pushing supplies forward at need rather than accumulating supplies in the forward area that limited mobility. To assure that all the parts of the system worked effectively, he used a system of medical inspectors, senior officers charged with evaluating the functioning of the regulations. An evacuation system combined with an echeloned care system and a push supply system, with an inspection system all together under medical command and control formed the Letterman System.

The century that followed the Civil War saw the Letterman System adopted by every major army in the western world, in large measure as a result of the publication of the experience in the Medical and Surgical History of the War of the Rebellion, the first U.S. Army effort at Medical Lessons Learned. It also saw the development of surgical care as a scientific practice taking advantage of progress in bacteriology, physiology and the organization of patient care in hospitals with trained nurses in attendance.

The Forward Surgeon in World War I documented the value of surgical resuscitation and the control of shock by the transfusion of blood. The military surgeons established fully functional hospitals at the Division rear with doctors and nurses providing life-saving resuscitation within the range of the enemy guns. World War II saw further progress with antibiotic therapy and even greater surgical miracles. Plastic and reconstructive surgery made great strides as did neurosurgery, orthopedics and ophthalmology. War served as a presser function accelerating the research and training which had begun in peace time medical centers. The surgeons who provided this care were often members of small augmentation. The essential similarity was that they, like their World War I predecessors, were surgeon heavy and unable to hold patients without nursing facilities.

MASH: Mobile Army Surgical Hospital

The helicopter in Korea, and especially in Vietnam, replaced the World War II truck, just as the truck and jeep had replaced wagon ambulances, but the system remained the same. In the second half of the twentieth century, the airplane and the flight nurse replaced the train and the enlisted medical attendant, providing better care to sicker patients. This innovation — a professionally trained, non-physician attendant, who could modify the care of the patient in transit — was a major extension of the evacuation system; it reduced the need for massive hospital establishments close to the front. As intensive care medicine and nursing made strides in the late twentieth century, this capability was further expanded. By the time of Operation Just Cause (Panama, 1989), it was possible to transport the stabilized (requiring active management in transit) as opposed to the stable (not expected to require active management in transit) patient. The Korean conflict also saw the introduction of the MASH, the Mobile Army Surgical Hospital, in an effort to provide the needed nursing in association with the forward surgery. By the 1990s, the MASH had grown in both nursing and surgical capability so that it was no longer mobile, and the forward surgical team concept was reintroduced to get surgical care to the worst of the wounded in time to make a difference.

Flak Vests

The development of surgical science also made possible the study of fatal wounding and the development of more effective personal protection equipment. The vital organs are in the head, thorax and abdomen; obviously armoring these areas will reduce fatal wounds. Beginning with bomber gunners in World War II, flak vests (steel plates worn over the vital organs) began a continuing process of personal protective gear. By Korea, the USMC had infantry protective vests. Synthetic materials expanded their utility by reducing their weight. The modern Kevlar and ceramic personal protective vest is highly effective against penetrating rounds (bullets) but less so against blast injury and does not cover the extremities. The result is a reduction in the number of fatal bullet wounds to the vital areas and a statistical increase in the significance of blast injury and extremity wounds.

The Future

From World War II through Vietnam, the placement of sub specialist vascular surgeons forward had resulted in the reduction of extremity amputations. The expansion of the echelons of care made possible by flying intensive care units, and the increase in the proportion of extremity wounds will probably combine to increase amputations in Operation Iraqi Freedom for the first time in a half-century of military surgery. However, so far the data are anecdotal. Even if there is an apparent increase, it may be an artifact of progress rather than a real change in experience; statistical analysis of military medical experience remains extraordinarily difficult since it depends on the weapons, the tactical situation and the medicine.

What seems clear is that while we have not changed the "Died of Wounds" rate much in the last quarter century, we have reduced the proportion of "Killed in Action"; we have saved a lot of people with significant damage and we "relieve often." This progress requires an increase in our obligation to "care always" because there will be many amputees, an apparent increase in blind and deaf from blast injury, and a host of people with psychiatric sequels of the war experience. The challenge of matching the tactical and operational commitment with the medical and surgical capability, (within an overall system of evacuation and care) will remain a difficult balance. Real-time medical inspection and consultation is critical to assuring the system works to maximize patient care effectiveness. New technology will permit better evaluation and management during evacuation. Nursing, medical and other specialized providers are critical to assuring the most effective care in theater; while a long-term commitment to the care of those who were damaged will require revisiting our veterans affairs clinical commitments. The costs in well-trained people and targeted research will be significant.

A popular country song has the American soldier promise to be ready if the wolf growls at the door. The unanswered question is, will America continue to be ready with the bandages if the wolf bites him? So far, we always have been!

Dale C. Smith, PhD is a Professor & Chairman of the Department of Medical History at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.