Delivery of Medical Care on the Battlefield
The system for the delivery of medical care on the battlefield was based on the premise of providing a process of progressive treatment and evacuation. In practice this meant the sick and wounded would receive care from the infantry division’s medical units, such as aid posts, dressing stations and field hospitals. The purpose at each stage was to provide enough treatment in order to stabilize the patient and prepare him for transportation to the next level of medical care: the evacuation hospital. The system diagram below illustrates how this progressive sequence of treatment and evacuation led from medical units near the front line to the evacuation hospitals at the corps and army levels and then on to base hospitals in the rear, via hospital trains.
The purpose of the evacuation hospital, as first conceived of in 1916, was to support the infantry division field hospitals by receiving their patients when they moved to new locations. However, as it turned out this would not be their role when deployed to France. What changed their medical mission was the experience acquired by the department in the summer of 1917. It was discovered that the intended purpose of the field hospital to be the “emergency hospital for the battlefield” failed because the unit was too small, to close to the front line and was expected to be mobile. The department recognized that instead of performing life saving surgery they had become a “magnified and improved dressing station rather than a hospital.” What was needed was a medical unit equivalent to the British Army’s Casualty Clearing Station that could treat up to 1000 patients per day.
The evacuation hospital evolved over the next year into a larger and more capable hospital unit. When developed in 1916 the evacuation hospital was planned to care for 432 patients through its staff of 16 medical officers and 179 men. Two evacuation hospitals were to be allocated to an infantry division. Although supplies were available to equip twenty-two hospitals, the army did not have personnel to staff them. By 1917 it was recognized hat they must solve how to deliver life saving surgery on the battlefield. The department re-thought the purpose and size of this new unit. It would be enlarged to treat up to1000 patients through a larger staff of 34 medical officers, 237 enlisted men and a complement of female nurses.
Although the size of evacuation hospitals varied, their function, general layout and location remained consistent throughout the war. Their purpose was to provide “with great rapidity” the best possible surgical care. But this was constrained by the number of casualties they could receive per day. In order to prevent congestion and over-loading of these hospitals, the army’s chief surgeon prepared a plan that deployed these hospitals and other medical units for each offensive. In the operations plan, he clustered the hospitals so they could support each other. Sites were chosen to facilitate both reception and treatment of patients and eventual evacuation to the rear area base hospitals. In practice, these hospitals were relay stations that provided significant treatment but did not retain patients any longer than necessary.
Evacuation hospitals were expected to be mobile, which meant they were housed in tents. "Mobile" was a relative concept. These units were barely mobile, and had little to no organic transport capabilities. To move one hospital unit required ninety 3-ton trucks or 30 rail cars. If possible they were placed in towns which provided buildings and access to fuel and water. They were located at 9 to 15 miles from the front on roads that linked them to forward medical units and on rail lines to connect them to base hospitals further in the rear area.
The hospital’s layout was designed to quickly treat a large number of admissions. The ground plan shown was for Evacuation Hospitals 6 and 7, located in 1918 at Souilly. The receiving rooms and evacuation wards were adjacent to a road and rail lines, to facilitate patient arrival and evacuation. In the center were the operating rooms, x-ray rooms, and adjacent hospital wards. These hospitals were organized into two services, administrative and medical. The former dealt with records, supply, personnel and administrative matters while the medical provided patient care as directed by the Chief of Surgical Service and Chief of Medical Service.
The Chief of Surgical Service supervised the:
- Receiving room
- Dressing room
- X-ray room
- Pre-operative ward
- Shock ward
- Operating room
- Post-operative ward
- Evacuation ward
The Chief of Medical Service supervised the medical and gas wards and assisted the Chief of Surgical Service in the receiving ward.
The process of sorting patients began with their examination upon arrival at a receiving room which would determine where the patient should be routed. At this point an important decision would be: Should he receive an operation or could it be delayed until he arrived at a base hospital? For example, a small perforated wound, flesh wound, or small bone fracture made one eligible for re-dressing in the dressing room and on to the evacuation ward to await a hospital train. This decision was likely if 1000 casualties were received in a day. These injuries were not deemed as serious as head, chest, and abdominal wounds, fractured femurs, head injuries, or multiple injuries.
The surgical service consisted of five wards and three rooms. There were the pre-operative ward, x-ray room, shock ward, operating room, post-operative ward. These were all close together, as shown by the diagram above, to reduce the distance a patient was carried and to efficiently use staff and resources.
The pre-operative ward prepared patients for surgery through another examination, undressing, bathing, morphine, shock prevention and sorting them into head, chest, abdominal, shock and fracture cases. If a patient was in shock or on the verge of it he was moved to the shock ward for resuscitation. If an x-ray was ordered, he was transported to that room.
The operating room was staffed by four teams using eight tables. Each team consisted of two surgeons, one anesthetist and two nurses. An experienced team could perform 35 to 40 operations per twelve-hour shift. By mid-1918 it was common during a major offensive operation for these teams to be augmented from quiet evacuation and base hospitals, expamding the service to as many as fourteen teams.
Surgical operations addressed different types and severity of injuries. A laparotomy was performed for abdominal wounds. Thoracotomies could be done for chest wounds, but simple placement of chest tube was the most common treatment. Wounds caused by bullets and shell fragments required debridement of devitalized tissue and foreign bodies. Debridement helped to prevent infection, especially gas gangrene caused by anaerobic bacteria. The wound, if there was a possibility of infection, was left open and packed or wrapped with gauze soaked in saline or Dakin's solution, in anticipation of using the Carrel-Dakin system to prevent or control infection (See Wounds and Injuries).
Fractures were set as well as repairs to the knee or elbow. If a limb was too badly damaged, it was amputated. Even though radiology was only in its second decade of existance, x-rays were very valuable in treating extremity and joint injuries.
Head wounds were a challenge because they required neurosurgical skills that might not be present. If an operation was performed it prevented an immediate evacuation. Therefore, the Chief of Surgical Service might recommend a delay and evacuate the patient to a base hospital.
Upon completion the surgeon recorded his findings, the procedure and whether the patient should be ‘detained’ or ‘evacuated’. Both categories were moved to the post-operative ward for recovery. If a patient was detained he was then moved to an appropriate ward of similar injuries. All cases, however, were not retained any longer than necessary which on average was 10 to 14 days. If a patient was identified for evacuation upon recovery he was moved to the evacuation ward to join those from the receiving ward or dressing room. Here he was prepared for evacuation by being classified as a sitting or stretcher patient and whether he was a surgical, medical, infectious disease or psychiatric case.
At this point the soldier passed to the next level of care, which was base hospitals in the rear areas, often via a hospital train. The coordination of this transfer was essential for the success of the entire patient management system designed by the Medical Department. It was entrusted to the Chief of Surgical Service who arranged with the army’s Regulating Officer for a hospital train to evacuate patients to their final destinations at the base hospitals.
Sources for Evacuation Hospitals
Jaffin, Colonel Jonathan H. Medical support for the American Expeditionary Forces in France during the First World War (Fort Leavenworth 1990)
Surgery in progress in an operating theatre suite at No 3 Casualty Clearing Station, July 1916, Creator Canadian Official photographer H E Knobel, Catalogue number co 157, Part of Canadian First World War Official Exchange Collection, Imperial War Museum, London
Volume VIII, Field Operations, The Medical Department of the United States Army in the World War (Washington, 1925)
Volume XI, Section I, General Surgery, The Medical Department of the United States Army in the World War (Washington, 1925)