U.S. COMMAND AND GENERAL STAFF 
COLLEGE,SCHOOL OF LOGISTICS 
AIR EVACUATION AND ITS EFFECT 
ON THEATER AND ZONE OF INTERIOR 
HOSPITALIZATION REQUIREMENTS Table of Contents 
Analytical Study Tab A 
Annex 1, Hospital!»ation and Evacuation Tab B 
Annex 2, Comparison of Ueans of Evacuation Tab C 
Chart 1, Percentage Distribution of Evacuees 
Debarked in the United States Tab D 
Bibliography Tab E COMMAND AND GENERAL STAFF' COLLEGE 
SCHOOL OF LOGISTICS 
ANALYTICAL STUDY SUBJECT NO. 3-2 
SUBJECT* Air Evacuation and ita effect on theater and zone of 
interior hoepitaliaation requirements. 
DATS* 13 October U7 
PURPOSE* Compare the use of air evacuation and the use of surface 
means of evacuation to develop the most efficient evacuation policy 
and means of evacuating casualties* 
SCOPE: Assume a typical overseas theater of operations. Using 30, 
60, 90, and 120 days evacuation policy compare the effects of air 
evacuation with surface means of evacuation with respect to the 
following* a. Keans required overseas, means required in the zone 
of interior, means required for transportation, 
b. The percentage of fixed beds required overseas and in the 
zone of interior based on an admission rate of 1 per 1000 per day 
for disease and non-battle, and the same rate for battle casualties, 
based on above evacuation policies. 
c. Develop answers to the following questions* (l) that sav- 
ings will there be, and how much, in medical manpower, in engineer 
construction effort, in money, in outgoing tonnages and in days lost 
from duty? 
(2) Will treatment of patients be improved? 
(3) What impact will be made on theater replacement require- 
ments? Make specific recommendations on the evacuation policy and 
the transportation means (all air, all surface, mixed air and surface) 
to be used for most efficient operation from a logistical viewpoint. RESTRICTED 
3, Heconanendations. 
a. Recommend that a 60-day evacuation policy be adopted by 
the Department of the Army and used in the development 
of all plans for medical support in future wars. 
b. Recommend that air evacuation be considered the primary 
method of evacuation and that maximum use be made of 
this means when ever and where ever possible. 
c. Recommend that the Air Force be requested to develop air 
craft with flight cv'aracteristic similar to present 
liaison aircraft but having an increased carrying capac- 
ity of three litter patients. 
/s/ Carlyle W, Arey 
/t/ Carlyle W, Arey 
Major, Inf. 
Annexes: 
1. Hospitalisation and Evacuation, 
2. Comparison of Means of Evacuation, 
RESTRICTED RESTRICTED 
Fort Leavenworth, Kan. 
26 May I9I48 
ANALYTICAL STUDY SUBJECT NO. £-2 
SUBJECT s Air evacuation and its affect on theater and zone of 
interior hospitalization requirements* 
1. Problem*—To compare the use of air evacuation and the use of 
surface means of evacuation to develope the most efficient 
evacuation policy and means of evacuating casualties. 
2. Discussion* 
a. Air evacuation provides the only practical means of imple- 
menting a shorter evacuation policy. (See Annex 1, par 3) 
b. The advantages obtained by utilization of air evacuation 
in conjunction with a shorter evacuation policy are* 
(1) Provides a substantial savings in medical manpower and 
skilled specialists. (See Annex 1, par 5) 
(2) Provides a substantial savings in construction effort 
and construction materials in the theater of oper- 
ations. (See Annex 1, par 3) 
(3) Provides better medical treatment and Improves troop 
morale. (Sea Annex 1, par 6) 
(ii) Reduces fixed bed requirements in theater of operat- 
ions. (See Annex 1, Par 6) 
(5) Provides for better use of equipment and at the same 
time reduces the load that surface evacuation norm- 
ally places upon surface lines of communication. 
(See Annex 2) 
c. The only disadvantage resulting from the utilization of air 
evacuation in conjunction with a shorter evacuation policy 
is that theater replacement requirements will be increased. 
(See Annex 1, par 7) 
d. Aircraft used in air evacuation are adequate for all echelons 
except that performed within the combat *.one. (See Annex 1, 
par 8) 
RESTRICTED RESTRICTED 
Annex 1. Hospitalisation and Evacuation. 
1, General. The primary purpose of any study of the effect 
of air evacuation on the evacuation policy and the hospitalization 
requirements is to determine the policies and procedures which 
would be most advantageous to the armed forces in thb event of 
another global war. Future warfare will undoubtedly differ from 
past wars, however, a study of some of the medical aspects of past 
wars provides the only logical approach to the developmen t of sound 
policies and procedures for the conduct of the medical service in 
future warfare. The following paragraphs review some of the defin- 
itions used in connection with medical service and attempt to 
analyse the pertinent features of the evacuation and hospitalisation 
service. 
a. Definition. "Air Evacuation" as employed herein is 
used to designate the service provided the sick and wounded in trans- 
porting them by military aircraft to hospitals where medical treat- 
ment is available contrasted to surface evacuation, that is by 
ambulance, hospital train or ship. 
This contribution to more efficient medical service was in the 
embryo stage at the beginning of World War II (WW II), however, 
during the period of 19U2 to 19U5 it was developed to a high state 
of efficiency. In spite of the high state of development many auth- 
orities on the subject have implied that all the advantages and 
benefits afforded by air evacuation are not sufficiently appreciated 
on an army wide basis to realise the maximum benefits therefrom, 
b. Echelons of air evacuation. Air evacuation is separated 
into two broad geographical echelons—that which is performed in the 
theater of operation and which is performed in zone of 
interior. In the theater this has been subdivided into evacuation 
performed within the combat zone and evacuation within the commun- 
ication zone. The zone of interior has likefise been divided into 
RESTRICTED RESTRICTED 
that performed between the theater and the zone of interior and 
1 
that performed within the zone of interior# 
c. Evacuation and Hospitalization Requirementa, The 
responsibilities for provision of hospitalisation and evacuation 
service as established in FM 100-10 are as followst 
The evacuation and hospitalisation system is based on 
the principle that it is the responsibility of rearward 
units to relieve forward units of their casualties promptly. 
This principle extends from the responsibility of the zone of 
interior to evacuate and hospitalise all long term casualties 
from the theater of operations to responsibility of the bat- 
talion medical section to evacuate casualties from the 
companies or batteries of the battalion. 
Air evacuation within the combat zone is accomplished 
by the use of liaison aircraft, helicopters, or light trans- 
port planes. The aircraft are operated and maintained by 
theater airforce units, (i.e, a liaison squadron), but are 
placed under the control of the army surgeon,3 
Where transport aircraft are used for the evacuation of 
patients from the combat zone to the communication zone, air 
transportation, and the care of the patients in flight are 
the responsibility of the theater air force commander,** 
Air evacuation to the zone of interior rests with the 
air force as a major responsibility, but the communication 
zone must arrange for the delivery of patients to the air- 
field and for their proper care until they are actually 
placed aboard the aircraft, 5 
Hospitalization is accomplished with installations of increas- 
ing size from forward areas to rear that permit rapid sorting, 
treatment and disposition of patients dependent upon the nature of 
the casualty. Hospitals used within the theater are classified as 
mobile and fixed. In general, the hospitals used within the com- 
munication zone are of the fixed type while those used within the 
combat zone are of the mobile type. General hospitals, usually 
1000 bed units of the fixed type, are organized and equipped to 
provide definitive treatment for all types of casualties which 
occur within the theater. Station hospitals are relatively fixed 
installations ranging in size from 25 bed units to 900 bed units 
designed to provide hospitalization for areas where troop popula- 
tion is limited. These hospitals do not normally receive patients 
1 FM '!-35, par 103, p.190 
2 FJf 100-10, par 1005, p. 157 
3 Ibid, par 1110, p. 162 
U TbI3. par 1012, p. 161* 
5 Ibid, par 1015, p. 166 
RESTRICTED restricted 
from the combat zone. Field hospitals are mobile type hospitals 
designed and equipped to furnish hospitalisation in areas or at 
installations where it is impractical to establish station hosp- 
itals. These hospitals may be used in the combat zona on missions 
similar to those assigned to evacuation hospitals. 
The mobile type hospitals include evacuation, mobile surgical, 
and convalescent hospitals and are organised and equipped to 
support specific tactlfial units by providing hospital service for 
the sick and wounded personnel of the Army, corps and division, 
pending their recovery or further evacuation to general hospitals 
6 
in the communication zone. In addition to the hospitals already 
mentioned there is need for medical holding battalions which are 
units designed to transport and hold patients at air heads, rail 
heads, and ports while awaiting further evacuation. 
The majority of hospitalization service provided in the zone 
of interior is of the fixed type such as general, regional, station 
and convalescent hospitals. These hospitals are of a more perm- 
anent nature and afford better facilities and treatment. The need 
for the mobile type hospital in the zone of interior is relatively 
small and is usually limited to those which are being organized or 
trained for service in the theater of operations. 
In a typical overseas theater evacuation of the sick and 
wounded is performed by litter bearers, ambulances, liaison air- 
craft, transport aircraft, helicopter, hospital trains, troopships 
and hospital ships. The utilization of any combination of these 
means depends upon the facilities available and the military 
situation. Evacuation in the combat zone -fas normally performed 
by litter bearer to the forward limit of vehicular traffic or 
airstrips and from there to the evacuation hospitals by motor 
ambulance or liaison aircraft. The helicopter is ideally suited 
for this echelon of evacuation, Evacuation to the communication 
6 FU 100-10, par 1002 a, p. 1$6 
RESTRICTED RESTRICTED 
was effected by hospital trains and transport aircraft and where 
the distances were not excessive by motor convoy. 
In the zone of interior evacuation is performed by troop ship, 
hoepltal ship, hospital trains, and transport aircraft. Extensive 
use is also made of the motor ambulance where ever changes in the 
mode of transportation is required. The majority of evacuation 
from the European theater was accomplished by use of returning 
troop ships during the early phases of WW II, However, the increa- 
sed use of air transport and hospital ship during the latter part 
reduced the percentage evacuated by troop ship appreciably. (Sec 
Tab D) Within the zone of interior evacuation is accomplished by 
hoepltal trains and transport aircraft in distributing the patients 
received at debarkation hospitals to general and convalescent hosp- 
itals throughout the zone of interior. 
The foregoing methods were common practice in the European 
theater during 1W II, however, in the jungle areas encountered in 
the Southwest Pacific and in the China-India-curma theater where 
communication facilities were almoet non-existent other methods 
had to be employed. This handicap was largely overcome by the 
7 
utilisation of air transport, 
2, Evacuation Policy. "The evacuation policy indicates the 
length in days of the maximum period of non-effectiveness for 
patients who are to be held In the thqater for treatment, and is 
established by the Department of the Army upon recommendation of 
the theater commander. Patients who in the opinion of the resp- 
onsible medical officers cannot be returned to duty status within 
the period prescribed are returned to the zone of interior by the 
first suitable transportation provided the travel required will not 
aggravate their disabilities. In conformity with the theater evac- 
uation policy, major subordinate commanders establish evacuation 
policies subject to the approval of the theater commander, indicat- 
' 8 
ing the maximum period that patients may be held in their area," 
Maj Oen Norman T Kirk, "Air Evacuation of the Wounded", Mil Review, 
vol X3BVI, No. 10, Jan 1*7, p. 28. 
° FM 100-10, par 1003, p. 157 
RESTRICTED RESTRICTED 
"The evacuation policy announced by theater headquarters 
determines what classes of casualties are to be treated in the 
theater of operations and what classes are to be sent to the 
sone of interior. The established policy has a great Influence on 
the medical activities and requirements of the communication sone 
and effects particularly the hospitalisation projects of this sons 
9 
as well as that of the sone of interior*” 
3. Effect of Air Evacuation, In analysing the effect of air 
evacuation on the evacuation policy and hospital requirements the 
medical service has to be divided into that which is performed 
within the theater and that which is performed in the sone of 
interior. It is desired to consider the various facton such as 
transportation, construction effort, and medical manpower as they 
effect the medical service in the theater and in the zone of interior, 
a. The European theater has been selected for the study 
of the effect of air evacuation on the evacuation policy and hospital 
requirements in the theater. The average strength of the STO during 
the period January 19U5 to June 191*5 ( incl ) approximated 2,9U6,?25* 10 
The dally admission rate in the ETO averaged 1.9 per 1000 per day for 
non-battle casualties and 0,1*7 per day per 1000 for battle 
Based on the above criteria it could be assumed that the average number 
of casualties for a one month period would approximate 162,000 non-battle 
casualties and 1*1,5U8 battle casualties. The disposition of the battle 
12 
casualties based upon experience factors of WW II would be as follows: 
1*$ (1662) die after reaching the hospital. 
15$ (6232) recover in 15 days, 
19$ (7891*) recover in 30 days, 
17$ (7063) recover in 60 days. 
11$ (1*570) recover in 60 to 90 days, 
20$ (83OO) recover in 90 days. 
H*$ (5820) invalided home. 
9 Medical Service- Communication Zone, Subject 1*308, Adv Sheet, 
par 8, p, 12 
10 Historical Review, WWII, Apend P, p, $8 
11 FM 101-10, Chap 5, par §13 c and d, pp, 55-56, 
12 Ibid, par d, p,56 
RESTRICTED RESTRICTED 
While no figures are available to indicate the disposition of 
non-battle casualties in the ETO such figures are available for the 
Mediterranean theater and by substitution of these figures for the 
non-battle casualties in the ETO the expected disposition of the 
13 
non-battle casualties would be as followst 
0.2% (336) die after reaching hospitals. 
IuO% (6720) were evacuated to the ZI, 
9$,85t (I609UU) returned to duty within the theater. 
Average itay in hospitals for non-battle casualties in 
the theater of operation — 19 days. 
Average stay in hospitals for non-battle casualties 
in both the ZI and the theater — 25 days. 
Assume further that a 15 day evacuation policy was in effect 
in the combat sone. By referring to the disposition expectancy 
for battle casualties on the proceeding page it will be noted that 
8ljt (33*650) of these battle casualties would require evacuation 
to hospitals in the communication sons. 
Based on the assumption that 2/3 (110,000) of the non-battle 
casualties will require evacuation from the division or correspond- 
ing areas and require hospitalisation in the communication sone 
the magnitude of the hospitalisation and evacuation service can be 
lit 
realised. 
The theater evacuation policy will have very little effect on 
the numbers to be evacuated to the communication sone but would 
have effect on the distance that patients would require evacuation. 
If the average distance from the evacuation hospitals in the combat 
sone to the general hospitals in the communication sone approxlsmted 
300 miles the requirements for evacuation of the battle casualties 
would be represented by one of the following means: 
No Bat Cas 
Unit Loads 
Units required 
Hours Per 
Per Month 
Per Month 
Per Month 
Trlp 
Hosp 33,6$U 
110.2 
18,3 
120 (1 trip ea 5 day) 
Train 
C-82 33,65U 
960.0 
16,0 
(2 trip per day) 
A eft 
X3 FM lOl-lO, Chap S, 
par 2l3 c. 
U* Ibid. 
RESTRICTED RKSTRIC TED 
iloepital requirements for the non-battle and the battle casualt- 
ies for this number of casualties based on Accumulation Tables 1, 2, 
3 and 1* at 120 days for the various theater evacuation policies would 
be as follows! 
Svac Policy 
No Fix Bed 
% Decrease 
£Decrease 120-day 
120-day 
209300 
— 
— 
90-day 
195850 
6.5 
— 
t60-day 
172970 
13.5 
16.8 
30-day 
128967 
38.U 
It may be noted from the above that the fixed bed requirements 
decrease with any decrease in the evacuation policy. The require- 
ments of the 60-day policy call for some >6000 less beds which 
corresponds to 36 general hospitals. This in turns would reduce the 
outgoing tonnages by 23U,000 measurement tons representing about 2l* 
shiploads of equipment which would not be required in the theater, 15 
Also a savings in construction effort of 5»5>08,000 man hours (1377 
2ngr Bn days) would be effected. The savings in medical manpower 
resulting from the utilisation of air as the principal means of evac- 
uation would approximate $% of the medical personnel in the theater, 
(See par 5) 
b. Mo accurate figures are available which show the medical 
support provided by the *one of interior for the army forces in the 
European theater separated from other theaters. However, by using 
the average ETO strength figure and applying the 21 evacuee factor 
contained in the accumulation tables 1 to U, the approximate medical 
17 
support can be obtained. These figures will bo slightly higher 
than the actual requirements as indicated in accumulation table 5, 
which is based on an evacuation policy of 120-days. 
101-10, Chap 5> par 532 e, p. 122 
10Ibid. par 528 b, p. 166 
17FM 101-10. Chao 5. did# 58-60 
RESTRICTED RESTRICTED 
21 Fixed Requirements for Support of Overseas Theater 
Strength-2946725—120 days accumulation 
iSrac 
Fix Bed 
% Increase froa 
% Increase froa 
Policy 
iiequireaents 
Precded Policy 
120-day Policy 
120 
35600 
90 
1*7300 
33 
— 
60 
70900 
50 
99 
30 
111*700 
62 
222 
It is noted by an examination of the above table of fixed bed 
requirements that the 90-day policy will Increase fixed bed require- 
ments in the 21 by sane 33* over the requirements for the 120-day 
policy. The 60-day policy will increase the requirements by 50* 
when compared to the 90-day policy and 99* when compared to the 
120-day policy. The extreme is reached with the 30-day policy 
which would increase the requirements 222* over that required by 
the 120-day policy. 
To obtain some idea of the evacuation requirements, assume 
the distance casualties were evacuated from the KTO to debarkation 
hospitals in the 21 to be an average of 3000 miles. The following 
table shows the required ants for the various means evacuation for 
each of the various policies. 
Means Required for Evac to 21 
£vac 
Pol 
Bat 
Gas 
Hoep Ship 
Required 
troop Ship 
Required 
c-5u Aeft. 
Required 
C-7l* Acft. 
Required 
120 
5820 
15.1 
U*.5 
10.7 
3.5 
90 
li*020 
36.U 
3U.9 
25.*9 
8.5 
60 
18590 
1*8.2 
1*7.5 
3U.U 
11.3 
30 
2S63S 
66.5 
61i.O 
1*7.1* 
15.6 
Hote: 1, Hosp ship ii 500 per trip round trip every 39 days or 
average of 385 patients per aonth. 
2. Troop ship tt 540 patients per trip, round trip every 
39 days for average of U00 patients per aonth, 
3. C-54 Airplane tt 36 patients per trip, round trip every 
2 days for average of 540 patients per month, 
ii. C-71* Airplane fi 109 patients per trip, round trip every 
2 days for average of 1635 patients per aonth, 
4. Ratio of Fixed Bed Requirements. One of the many problems 
confronting logistical planners and medical support planners is the 
RESTRICTED determination of the correct ratio of fixed beds in the sone of 
interior to the overseas theater. Such requirements arc based 
upon the evacuation policy, dally admission rates, accumulation 
18 
factor and the dispersion factor. The length of time required 
for the selection of sites, procurement of construction materials 
and the actual construction of the hospital faculties, both in 
the overseas theater and in the zone of Interior, makes advance 
planning vital to a successful hospitalisation program. As a guide 
\ 
in determine the effedt of air evacuation on the ratio of fixed 
beds in the theater and in the sone of interior the following table, 
based on the same assumptions used in paragraph 3* will be used. 
RESTRICTED 
Fixed fled Requirements - Overseas Strength 2,9Ut.725 
Svac 
Pol 
% In 
ZI 
Oversea* Requirement* ZI Requirements 
io Beds % Strength Ho Bed* % Strength 
Total 
120 
il*.5 
209300 
7.0 
35600 
1.2 
21*1*900 
90 
19.U 
1958SO 
6.6 
1*7300 
1.6 
21*31*0 
60 
29.2 
172972 
$.8 
70900 
2.1i 
21*3870 
30 
U7.2 
128970 
U.3 
111*700 
3.9 
21*3670 
The requirements in the ZI during 1W II was baaed upon XjC of troop 
strength plus 0,7% for overseas The KTO share based upon 
these percentages and the average troop strength would provide approximately 
50,000 beds in the tone of interior. This would represent sufficient 
beds for either the 120-day policy or the 90-day policy but would not 
accomodate patients accumulated under the 60-day or 30-day policies. 
It should be noted that the fixed bed requirements are about the same 
for all of the policies. As has been pointed out previously, the employ- 
ment of air evacuation favors the shorter evacuation policies which in turn 
increases the ratio of fixed bed requirements in the ZI and decreases the 
requirements in the theater, 
5. Conservation of Medical Manpower. Figures compiled and published 
in the "Statistical Review, WW II," indicate that the overall requirements 
for medical personnel to staff hospitals, medical installations and perform 
the required medical service during the past war reached a peak of 697,5iil 
f* 
in October This shortage in specialists and other medical personnel 
resulted 
18 FM 100-10, par 1002 
19 Subject L-U305, Apend 1 to advance sheet, p, ll* 
RESTRICTED RESTRICTED 
in units being shipped overseas short T/0 personnel. To alleviate 
this shortage strict controls were initiated in the United States 
in the summer of I9hh, however, in spite of this strict control the 
20 
shortage continued until shortly before the end of the war in Europe. 
The scraping of the barrel so to speak in the last war should 
be sufficient warning to all concerned of the importance of conserving 
medical manpower. The extent of any reduction in personnel requirements 
resulting from the use of air ivacuation will be dependent upon many 
factors such as the tactical situation, evacuation means available, 
terrain and etc. The inherent difficulties connected with air evacuation 
such as the weather, adequate landing facilities together with the pre- 
requisite of air superiority precludes the possibility of air evacuation 
having the capability of performing lOOJt of the evacuation effort. It 
will always be necessary to have sufficient means such as ambulances, 
hospital ships, hospital trains and holding units to accomplish the 
evacuation mission when any of the above factors limit the air effort* 
This in turn will restrict the savings effected by use of air evacuation. 
To arrive at an approximate figure of the savings in medical manpower 
that could reasonably be expected from the utilisation of air evacuation 
in the combat aone, let us examine a hypothetical situation utilising 
0*1 
the "Type Meld Army (Proposed).* This organisation has an authorised 
strength of 353*97$ of which are medical personnel. In furnishing 
hospitalisation ami evacuation for a force of this sise, the communication 
zone would contribute the services of approximately 11,000 medical personnel 
also. The casualties Of such a force, based on a theater evacuation policy 
of 120-days, a daily admission rate of 1 per 1000 per day each for battle 
and non-battle casualties, and a 15 day evacuation policy for the combat 
zone, would approximate 21,500 per month. Of this total would be 
expected to die, 8> will have recovered and returned to duty within the 
month, and 7k% or 15,900 will require evacuation to general hospitals 
in the communication zone; Of this 
20Paraphlet, Type Field Army(Proposed) 
21 FM 101-10, Chap 5, par 613 (d), p, 56 
RESTRICTED RESTRICTED 
latter figure would require evacuation to the 21 for further 
hospitalization and evacuation within the 21 and possible separation 
22 
from the service. 
By an examination of the hospitalisation and evacuation effort 
required for this number of casualties and based on the assumption 
that these casualties are evacuated over qn average distance of 300 
miles it can be determined that a savings of 111*3 medical personnel 
one evacuation hospital could be achieved by making use of air 
evacuation. This would represent a $% savings in medical personnel 
and a 9% savings in evacuation hospitals. While it does not appear 
feasible to plan on performing all evacuation by air it doss appear 
that in order to effect the maximum savings air evacuation should be 
used when ever possible. 
Another factor contributing indiredtly to the conservation of 
medical manpower by utilising air evacuation results from the ability 
of quickly evacuating patients to hospitals where the services of 
specialists are available, Gen Kirk covered this phase of thd con- 
23 
servation of medical manpower as followsi 
It is quite apparent that there were not enough specialists 
in the army to bring the highly skilled doctors to the 
thousands of sick and wounded on the battle field but the 
chain of evacuation that was perfected to a high point of 
efficiency in all theaters performed a good job of moving 
the wounded to the various stations where they received the 
needed attention. 
These factors would apply equally well to the evacuation 
performed between the theater and the zone of interior as well as 
that performed within the zone of interior, The greatest savings 
in medical personnel would be effected by a reduction in personnel 
required to operate holding units, hospital trains, hospital ships, 
and by the conservation of the services of the skilled specialists. 
6, Treatment of Patients. Air evacuation offers several 
22 FM 101-10, Chap 5, par 613 d (b), p. $6 
23 tfaj Gen Norman T, Kirk, Surgeon Gener<|I, "Air Evacuation of 
the Wounded," Military Review, Vol, XJVI No 10, Jan 19U7, p.28 
RESTRICTED RESTRICTED 
dietinet advantages to patients thus transported, however, there 
are also some limitations as to the type of patients that may be 
safely transported by air. The following extract from instructional 
material issued at the C A CISC establishes the present thinking re- 
lated to the type patients that may be evacuated by airi 
Any patient who nay be classified as transportable, nay be 
transported by aircraft provided certain conditions are net. 
These conditions are (l) limitation of altitude not to exosed 
3500 feet, (2) oxygen therapy availability, and (3) trained 
medical attendants present. The first condition was satis- 
factorily net in most theaters of operation by judicious choice 
of evacuation routes, . hen conditions cannot be satisfied, 
especially regarding altitude of flight, it is necessary to 
exclude certain typos of casualties. In general, najor surgical 
abdominal cases within seven dajs after surgery, pneunothor&x 
cases, and markedly severe anemias do not react favorably to 
altitudes exceeding 3500 feet. However, many patients of this 
type react unfavorably to any form of transportation. 
In aircraft converted for the transportation of casualties, 
considerable treatment can be administered enroute. It was normal 
in the past to provide a nurse and at least one medical technician 
for each airplane that was to be used for evacuation. This team 
afforded the patients treatment as needed for the readjustment of 
splints, adnInistration of stimulants, sedatives, plasma, and other 
medications, arrest of hemorrhage, treatment of shock, and most 
25 
important of all, administration of oxygen, when indicated. 
Another very important advantage in connection with the treatment 
of patiants afforded by air evacuation rests In the field of surgery, 
Gen Kirk has the following to say regarding this phase of medical 
treatment t 
Air evacuation of wounded, permitting prompt surgery, along 
with the administering of penicillin, the sulfas and blood 
plasma, has bean one of the outstanding contributions of this 
war in the care of the sick and wounded. This speedier link 
in the chain of evacuation was of far greater importance in 
the war against Japan, both because of the distances involved 
and the nature of the terrain over which fighting took place..,, 
£arly care is of the greatest importance in noth surgery and 
-K\ — .. 
4 Subject 1*308, "Medical Service in Communication Zone", Apend 1* 
to Adv Sheet, par 9, p.26 
H Fs* 8-35, par 102 f. 
&aj Gen Kirk, op. cit, pp. 27-29 RESTRICTED 
medicine and it is highly essential that skilled specialists 
start their work at the earliest possible moment, Army record 
of saving about 96> of wounded who reach a hospital is largely 
due to the fact that the skilled surgeons were able to admin- 
ister the proper care at an early stage in the chain of evac- 
uation. Early attention for those who are sick is also an 
important factor in the army's disease rate resulting in less 
than 1 death per 1000 per year... In the case of surgery the 
time element is always of prise importance. It often means the 
difference between the loss of an arm or leg or even can be the 
matter of life itself. 
Capt Grace H. Gtakeiuan, ANC, adds the following thoughts in 
27 
regard to the medical treatment of patients: 
i 
Experience in H I indicated that speed in evacuation and 
early treatment of wounds would lead to a lower mortality 
and morbidity rate. This was conclusively proved during the 
last war. Early In 19U2 air evacuation of the sick and 
wounded became a military necessity for us, and long before 
VJ day it was considered the method of choice 
Prior to the war, medical authorities here and abroad 
feared that patients with many different types of medical or 
surgical illness would be endangered by flight. Experiences 
of the past four years has not borne this out. Because of 
the necessity for experienced medical attendance in flight, 
nurses and enlisted men received special training for this 
work. Medical personnel who have received adequate instruct- 
ion in the care of patients while in flight have enabled the 
AAF to fly patients with almost any kind of disorder.,..In 
many discussions with ground force surgeons, surgeons who 
operated near the front lines, we agreed that it was probably 
better to do the surgery at the advanced hospitals, and then 
evacuate the patients back to the general hospitals for con- 
valescence, in view of the fact that if these patients were 
operated upon under the old system at these advance hospitals, 
they would have to remain there for a period of several days 
because transportation by ground was so difficult and tortur- 
ous and occupied a much longer period of time. 
In other theaters, front line portable hospitals were 
used corresponding to our evacuation hospitals, in the S70, 
and the surgeons at these hospitals told me they could do much 
better surgery and much more extensive surgery in the front 
line, knowing that the patients were going to be returned 
to a general hospital in very excellent condition.... 
The factor of morale of the combat troops is also favorably 
influenced by air evacuation. The knowledge that they can be 
evacuated oy airplane, if wounded, to hospitals where the best in 
medical treatment is available has a marked influence on troop 
morale, Gen Kirk covers this aspect of air evacuation with the 
28 
following remarks: 
There is one phase of this air evacuation subject that I have 
not covered. It is of an intangible nature, I can give no 
figures. let it is recognized by army authorities as a very 
important by-product of this system of transporting the dis- 
abled by air. That is the matter of morale. Unless you have 
Capt Grace R Stakeman, ANC, "Medical Care of Casualties in 
tong Distance Evacuation (Air)," The Journal of Aviation 
Medicine, Vol 18, Ko, 2, April p.192, 
aj Jen kirk, op, cit, p. 33 
RESTRICTED R2STRICT3D 
been thousands of niles away fro® hone under circumstances such 
as coiifront troops in battle you will never know how comforting 
the thought Is that if you should be wounded air-transport couli 
take you hone in a matter of few days. Also important to a man 
fighting in a jungle or isolated area is the thought that if an 
emergency deveiopes, army planes can pick hi* up and get him the 
best possible medical care. It is realised that morale is a big 
factor in the winning of battle and it has been proved that this 
air evacuation system played an important part in morale. 
7, Replacement Requirements. Prior to I* II a replacement 
system worthy of the name had not been developed. This matter had 
received considerable study before and during the early stages of 
WW TT and as a result of these studies, the War Department directed 
In May 19l*li, the establishment of centralised and uniform replace- 
ment systems in each of the theaters, and announced the basic 
29 
principles which should govern the operation of this system. 
The part of this system that is of concern during this study 
is that which deals with the hospital returnees* One of the main 
principles regarding evacuation is that a patient is evacuated no 
further to the rear than his physical condition requires or the 
military situation dictates. Strict adherence to this principle 
will restrict some of the benefits and advantages afforded by air 
evacuation. There should be very little argument over the fact 
that a patient will receive much better treatment in hospitals deep 
in the communication zone or in the zone of interior than that 
afforded him in evacuation hospitals in the army area where the 
situation is not so favorable. 
Under the present replacement system it has been estimated 
that the hospital returnee, who has been determined fit for combat 
duty by the medical personnel assigned to the replacement depot in 
the communication zone charged with receiving and examining returnee's, 
will spend 6 to 7 days in the replacement stream before reaching his 
old outx it, In a situation similar to that encountered in WW U, 
this time spent in tho repl.acenient stream would increase to 
C-l Manual, Chap 3, par 3&-305 
Subject 1061, "Replacement Support, Communication Zone," 
advance Sheet, par 2 c, p.2 
ii i S T a I c T S D RESTRICTED 
approximately 100 days if the hospitalisation occurred in the tom 
of interior, i’he loss of manpower represented by the amount of 
tie* consumed in returning hospital returnees to the conuat zone is 
excessive and it is not conducive to a shorter evacuation policy. It 
would appear that this tine lag could be reduced by streamlining 
the replacement system in so far as it effects hospital returnees 
which would bs much more favorable to a shorter evacuation policy. 
\ i’o carry thia a bit further let us examine some experience 
32 „ 
figures of ffl II, during October of the strength in the 
BTO was 2,026,358, the annual admission rate during this month was 
693 per 1000, At this rate a total of 117,000 patients were 
admitted to the hospital during October, Of this numoer approx- 
imately 601 or 70,000 of these patients were evacuated to the com- 
munication sons. Approximately 2S% or 17,000 would have been 
evacuated to the zone of interior under an evacuation policy of 
120-days, some to be invalided home others to be returned to duty 
in the theater. Thia represents the loes of strength of one infantry 
division for over three months, which appears quite excessive. *hile 
It is within the capability of air evacuation and a short evacuation policy 
to perform the majority of hospitalization in the zone of interior, 
such a policy will definitely increase the replacement requirements. 
However| If the time spent in the replacement stream could be mat- 
erially reduced then the loes of man hours would not be as excessive 
and consequently less replacements would be required. Air evacuation 
would reduce thewe requirements somewhat by providing speedier trans- 
portation to the zone of interior where hospitalization and treatment 
could be started earlier. 
7. Future Warfare. Air evacuation will undoubtedly play an 
important and ever increasing role in future warfare. Any study 
concerning Any phase of future warfare must include the effects of 
such weapons and tactici as envisaged in atomic warfare, biological 
warfare and chacical warfare, when. Tinder what conditions and how 
these weapons might be employed against our armed forces or civilian 
“J1 
J Object 1092, “Personnel Distribution and Flour," Chart 1, Sec III 
ii Statistical Review, vr. IT, Apend P, p, 198 
Ibid. Apend ft, p. 230 
RESTRICTED RESTRICTED 
pppulation is a -natter of conjecture. One thing that appears relatively 
aertain at this time is that the implementation of this type of warfare 
will result, initially at least, in a tremendous number of casualties 
which in turn will result in overloading normal evacuation and Hospital 
facilities, Air evacuation with its greater flexibility, mobility 
and speed would offer the only practical solution to such a problem. 
Any war of the future appears certain to be one that will be 
fought on a global scale. This brings up the queation of effect 
that the various theaters of operation might have on employment 
of air evacuation, A brief study of the history of the employment 
of air evacuation in the last war will indicate that air evacuation 
performed admirably in all theaters. Sven more noteworthy was the 
demonstrated ability to perform its mission under the most adverse 
conditions, especially in the jungle areas of the Southwest Pacific 
and in the China-India-Dursna theater where other methods were extremely 
costly in time and effort or failed completely. 
8. Adequacy of Equipment. The present aircraft used in air 
evacuation, although not primarily designed for this purpose, are con- 
sidered adequate with respect to all echelons except that which is 
performed in the combat aone. It is believed that there is a definite 
need for the development of aircraft more suitable for use in evacuating 
patients from forward areas to army evacuation hospitals. The develop- 
ment of helicopter is progressing rapidly and should contribute materially 
to this echelon of evacuation in the future. The L-$ is handicapped by 
its limited carrying capacity (1 litter patient), the L-13 although 
slirhtly larger carries only one patient, and the L-15 is designed 
primarily for observation and has no provisions for litter patients. 
The helicopter with increased carrying capacity would be the best 
answer to this problem, another thought is the development of a small 
airplane with, similar flight characteristics to the L-f> but with the 
capability of carrying two or litter patients. 
RESTRICTED RESTRICTED 
Anns* 2. Comparison of Means of Evacuation. 
1, Performance of the various mdans of evacuation may be 
compared by the following methodst 
a. Time element of evacuation as established in Draft 
Fil 101-10, Chap 5, par $16, p. 61, 
"Ambulance, motor, during combat, in division area* 
5 miles and return in one hour. 
Aircraft: 
Dials on airplane (L-£)—$0 miles one way in one hour. 
Cargo airplane (0-4*7)—100 miles one way in one hour* 
b. In a pamphlet, "Patient Air Evacuation, “ published by 
the Office of the Surgeon, Air Transport Command, the claim is made 
that If C-$U airplanes per day will evacuate 6 times the number of 
patients that a hospital ship can with a savings of 3U# in medical 
personnel and at the same time will carry more than k$0 tons of 
high priority supplies back to the combat area on return trips. 
c. The average performance capabilities of the various 
means of evacuation represented in units of litter patients/Wiles 
per hour with each "Unit" represented as 1000 patient/miles. 
Im. 
Capacity 
MPH 
Units 
L-5 Airplane 
1 
90 
0.09 
R-U helicopter 
80 
0.16 
C-U7 Airplane 
2)4 
U*5 
3.U3 
C~U6 * 
2h 
165 
3.96 
C-82 • 
3k 
165 
5.61 
C-Sii 
36 
200 
7.20 
C-97 
33 
217 
18.01 
C-7U “ 
109 
211 
22.99 
Hosp Ship 
500 
20 
5.oo 
Hosp Train 
300 
10 
3.00 
Aaibulancet 3/1* ton 
1* 
15 
0.06 
RESTRICTED RESTRICTED 
?. Comparison of the efficiency with which an L-£ airplane, 
K-U helicopter and a 3/U ton ambulance can perform an evacuation 
mission of moving 20 litter patients a distance of 20 miles. 
Type 
No.* 
patients 
No. 
Trip# 
Total 
Miles 
MPH* 
Total 
Tine 
Gal 
Fuel 
Unite 
L-5 
1 
20 
800 
50 
20*00 
200 
0.002 
R-A 
2 
10 
Uoo 
50 
10*00 
150 
O.OQi* 
3 A ton Anb U 5 
* Draft Fit 101-10, 
•*» Ibid, par £16 
200 
par $15 
10 
20<00 
0.002 
3. Comparison of the efficiency with which transport type 
aircraft and a hospital train perform an evacuation mission of moving 
300 patients a distance of 100 miles. 
Type 
No. 
Patients 
No. 
Trios 
Total 
Miles 
MPH 
Total 
Tine 
Oal* , 
Fuel$ 
21U0 
Units 
C-U7 
2k 
12.5 
2500 
1U5 
23*30 
1.28 
C-U6 
2k 
12.5 
2500 
165 
22*25 
3800 
1.3U 
C-82 
3k 
8.8 
1761* 
165 
15*05 
2675 
1.92 
uoep Train 300 
1.0 
200 
10 
22 < 00 
2100 
1.36 
* Pamphlet, 
“Cargo Aircraft" 
Chart on page 
26. 
Rotei l£ minutes have been added to each trip for loading, 
unloading and refueling, 
2 hours added to train tine for loading and unloading* 
R * S T R I CTED K K 5 T H I C T S D 
U. Comparison of the efficiency with which transport type 
aircraft and a hospital ship can perform an evacuation mission 
of r oving 500 patients a distance of 1000 miles. 
# 
Ko. 
Tytxj Patient* 
3* 
Total 
Vile* 
mi 
Total 
Tiro 
Fual in 
Gallons 
Unit 
C-82 
Hi. 7 
29h 00 
16$ 
207 OS 
1*1*500 
2.1il 
C-& 36 
Ui.O 
26000 
200 
168x00 
£190$ 
2.98 
C-97 83 
6.0 
12000 
217 
67*20 
26$00 
7.1»3 
C-71* 109 
ii.6 
9200 
211 
S2jS0 
236OO 
9.kS 
Uosp Ship $00 
1.0 
2000 
20 
110100 
Uoooo 
k»$h 
* Draft FM 101-10, 
par $1$ 
Note: Two hoars added to time for each plane trip for loading 
unloading and refueling. 
Ten hours adddd to total time for hospital ship*a trip 
to allow for loading and unloading patients. 
5. ?uel consumption per hour for the various moans of trans- 
portation referred to above. 
Izss. 
Gal-per-hour- 
Im 
Oal-per-hour 
L-5 
10 
c-5U 
37$ 
R-4* 
1$ 
C-97 
1*80 
C-a? 
125 
C-7l* 
$1*0 
C-U6 
250 
Hosp Train 
120 (eet) 
C-82 
250 
riosp Ship 
200 (eat) 
Ambulance 
2.2 (eet) RESTRICTED 
Bibliography 
Draft FM 100-10. Field Service Uorjilations-AdcUnistration. 
Command ana uenoral Staff College, 1 January 191*8, 
Draft Fid 101-10. Staff Officer's Field nanual-Planning* 
Command and General Staff College, 1 September 19l*7, 
Rieid V-amal 3-39* Transportation of the Sick and £oundod. 
United States Government Printing Office, 19U9. 
G-l Manual (Tentative), Command and General Staff College, 
July 191*7, 
Historical Heview, acrid figr II » 
Pamphlet, Type Field Army (Proposed), Headquarters AOF, ?8 Mar 19l*7 ♦ 
Pamphlet, Cargo Aircraft, CooBaand and General Staff College, * 
Subject 1*309. "Evacuation And Hospitaliaation, Zone of Interior," 
Command and General Staff College, 191*7-191*8, 
Subject 1*308, "Medical Service, Communication Zone," Command and 
General Staff College, 191*7-191*8, 
Subject 1061, "Replacement Support, Communication Zone," Cosanand 
and Genera; Staff College, 191*7-191*8, 
Subject 1092, "Personnel Distribution and Flow,". Command and 
General Staff College, 1957-191*3. 
Major General Kirk, Nontan T,, Surgeon General, "Air Evacuation Of 
The Side and bounded." Military Reclew, Vol XXVI, Nc. 10, Jan 1*7, 
Captain Stake man, Grace H, ARC, "Medical Care Of The Sick and Wounded 
In Long Distance Evacuation (Air)," The Journal of Aviation 
Medicine, Vol 18; No, 2, April 191*7. 
* References Classified as "RESTRICTSD", 
IUSTRICIED