Aeromedical Evacuation

The U.S. armed forces had their first large-scale experience with aeromedical evacuation during World War II, in which 672,000 Americans were wounded—almost four times the number in World War I. Because incapacitating wounds or illnesses frequently occurred in areas remote from modern medical facilities, providing care to soldiers and airmen often required aeromedical evacuation. Even in western Europe, aeromedical evacuation offered both medical and logistical advantages. More than one million patients were successfully moved by air during World War II. Although most patients in the war still traveled by ground and water transport, aeromedical evacuation clearly showed a potential for expansion in future wars.

Early informal aeromedical operations began in the Pacific theater and in Asia. In 1942, U.S. and other Allied forces clashed with Japanese invaders in China, Burma, and the southwest Pacific region. If they existed at all, most sea and land routes from the fighting in those remote areas inhibited rapid medical evacuation. Cargo and troop carrier planes returning from the front were the only swift means of medical evacuation. The famous C–47 Skytrains often functioned as medical evacuation craft. Air evacuation routes that crossed mountain barriers and submarine-infested waters ended at general hospitals in New Caledonia, New Hebrides, and Australia.

Despite the successful inauguration of aeromedical evacuation in the southwest Pacific in 1942, in-theater aeromedical evacuation needed many improvements in organization, equipment, and training. In November 1942 at Bowman Field, training began for medics who would form AAF aeromedical squadrons consisting of several flight crews, each with a surgeon, nurses, and technicians. The squadron had no aircraft of its own, but its members boarded ATC aircraft when these were loaded with wounded returning from another mission. The first squadrons deployed in early 1943. Some went to the Pacific theater and some to North Africa, where the U.S. and Allied troops soon needed aeromedical evacuation.

Air evacuation became critical in mid-January 1943, when U.S. forces pushed eastward into southern Tunisia, where there were few hospitals, roads, or railways. Motor ambulances took twelve to fifteen hours to reach the nearest medical facility in Constantine, Algeria, and hospital trains took twenty to twenty-four hours; air evacuation took only one hour. Larger hospitals in Algiers and Oran were only ninety minutes away. In the last attack on Tripoli, almost all patients were evacuated by air. Patients seriously ill or injured departed on air ambulances, and patients with minor injuries left on transport planes. Although still new and imperfect in some respects,aeromedical evacuation quickly proved its worth.

As it had in the Pacific, the C–47 soon became the aeromedical workhorse in Tunisia. Most C–47 transports carried an evacuation kit containing blood plasma, oxygen, morphine, portable heaters, first aid medicine, and various bandages to control hemorrhaging. Flight surgeons selected patients for air evacuation but usually accompanied only flights with many serious or critical patients. The standard evacuation flight crew consisted of medical technicians and flight nurses, many of whom had been airline stewardesses before the war. The C–47 usually carried eighteen litter patients. Although many nonmedical personnel, especially transport and ground crews, were involved in aeromedical evacuation, the patients received excellent care. By May 29, 1943, the Twelfth Air Force had airlifted 15,000 patients from Tunisia, with only one death in flight.

Operation Husky, the invasion of Sicily, started on July 10, 1943, and air evacuation began four days later. Two-hour flights to North Africa continued nonstop until the operation ended with the capture of Messina on August 17. The total number of patients evacuated by air from the U.S. sector was 4,755. About one-half were litter patients. Ships also evacuated many casualties because a number of commanders and doctors still had concerns about the safety of aeromedical evacuation.

U.S. landings at Salerno on September 9, 1943, began Operation Avalanche, the invasion of the Italian mainland. The 802d Aeromedical Evacuation Transport Squadron began operations seven days later. U.S. aeromedical squadrons supported both U.S. forces fighting up the western coast of Italy and British forces moving up the eastern coast.

The Tunisian and southern Italian campaigns, supported by aeromedical evacuation squadrons of the U.S. Twelfth and Ninth Air Forces, conclusively demonstrated the safety of aeromedical evacuation. The method proved suitable for every type of patient except those in shock who could tolerate no movement at all. It was suitable day and night, barring those rare occasions when the Allies did not have air superiority in the combat region. Air Surgeon Grant wrote that

Many seriously wounded soldiers, while still under surgical anesthesia, were evacuated by air from the Anzio beachhead in Italy, but, thanks to expert nursing care, there were no deaths or ill effects in flight. In 1943, cargo and troop carrier planes stationed in the Mediterranean evacuated about 61,000 patients. Although about one-half of the evacuees were litter patients, only one patient died in flight.

The aeromedical evacuation flights, however, put many nurses and other medical personnel at great risk of death or injury. In November 12 1943, for example, a group of thirteen flight nurses and seventeen medical technicians in a transport plane went down in bad weather in German-held Albania and had to trek several weeks over snow-covered mountains before they were rescued on the coast of the Adriatic Sea.

When aeromedical evacuation was in its infancy during 1942, a shortage of long-range transport planes limited air evacuation to the United States. Air Surgeon Grant nevertheless made plans and arrangements for a transoceanic system. In June 1942, the War Department established the ATC to move equipment, cargo, and high-priority personnel between theaters. In September of that year, the command began to assign high priority to sick and wounded patients returning to the United States. The January 1943 participation of Army nurse Elise Ott in a pathbreaking trip with five patients from Karachi in India (now in Pakistan) to Bolling Field, Washington, D.C., proved the feasibility of global aeromedical evacuation.

New, more powerful C–54 Skymasters soon became available, making possible the first scheduled medical evacuations from the United Kingdom to the United States in the summer of 1943. By the end of the year, preparations were under way to set up a similar route from North Africa. The transoceanic system, however, was still experimental, and most of the relatively few patients evacuated by air from Europe or Africa in 1943 were mainly ambulatory cases needing little medical attention.

This was also true in the Pacific theater. The ATC moved a monthly average of twenty-one patients from Pacific regions to the United States starting in March 1943. Large-scale evacuation from the Pacific did not begin until late November and December of that year, when five C–54s evacuated casualties from the invasion of Tarawa in the central Pacific. ATC moved 3,260 patients to the United States and another 5,400 patients between theaters during 1943. The stage was set, however, for much larger transoceanic operations in 1944 and 1945. By September 1945, ATC evacuations to the United States accounted for about 5 percent of the total 1.34 million air evacuations made during the war.

U.S. operations in 1942 and 1943, both in the Pacific and in Europe, presented several challenges for aeromedical evacuation. Poor communications hampered aeromedical planning and patient regulating. Medical crews had trouble returning litters, blankets, and medical equipment to the front. Because litters were not standardized among the Allies, fixed litter mounts were inconvenient or unusable. Many airfields had no medical holding facilities. Heating, air conditioning, and food service were inadequate or unavailable on most cargo and troop carrier planes. Stationing and rotation of aeromedical evacuation crews was difficult to streamline. Fortunately, these problems were not insurmountable.

By the end of 1943, the AAF aeromedical evacuation system was ready to assume larger responsibilities in Operation Overlord. Medical planners were especially busy. The Normandy invasion and the concluding attack on Germany produced the largest, most intense aeromedical evacuation operations of the war. Total AAF aeromedical evacuations more than doubled during the assault on western and central Europe from June 1944 to May 1945. When European hospitals filled to capacity during the Battle of the Bulge in the winter of 1944–45, patients flew directly to Mitchel Field, New York, just three days after they were wounded.

When the war ended in September 1945, it was clear that air evacuation, despite its early problems, was at least as safe as ground and sea evacuation. The improvement in patient comfort and medical care was evident, and notable reductions in medical and logistical costs had been achieved. Airplanes saved sick or wounded patients many painful, uncomfortable hours en route to a hospital, and more rapid arrival at definitive medical care reduced deaths and speeded recovery. Ground transportation for nonmedical items and troops also became more efficient when patients traveled by air. Gen. Dwight D. Eisenhower, commander of the European Theater of Operations, thought that air evacuation was as important as other World War II medical innovations—sulfa drugs, penicillin, blood plasma, and whole blood—in reducing the fatality rate of battle casualties. He told the press, “We evacuated almost everyone from our forward hospitals by air, and it has unquestionably saved hundreds of lives, thousands of lives.”

After the war, the many advantages of aeromedical evacuation became apparent to the Army Medical Department and other defense officials. Secretary of Defense Louis B. Johnson recognized this lesson of the war in September 1949 when he announced that aeromedical evacuation was now the preferred means of transporting the sick and wounded, both in peacetime and in war.