CHAPTER FIVE
Evacuation of Patients From Overseas

EVACUEE REPORT CARD

Information on evacuees becomes necessary whenever their numbers are large. This information is needed to plan for hospitalization in the United States, as well as for evaluating evacuation policies, and evacuees. During World War II, more than one-half million evacuees were, admitted, with 50,000 received in the peak month. Army regulations (12) in effect at that time contained standby provisions for submission of evacuee report cards (MED-75) by hospitals in the United States which received evacuees for definitive treatment. When the number of evacuees decreased markedly after World War II, submission of the report card was discontinued. With the outbreak of hostilities, in Korea and consequent increased demands on available hospital capacities in the Far East Command and in the United States, the requirement for submitting the evacuee report card was reinstituted in September 1950.

Accordingly, a record was prepared on each evacuee patient from overseas admitted to a hospital in continental United States beginning in September 1950. The evacuee report card was prepared by the first hospital in the United States to which the evacuee patient was admitted initially for definitive treatment. Hospitals were required to

¹ Includes a few U.S. Navy patients.
² Includes some cases originating at sea.

prepare the card. within 7 days of the date of admission and forward it to the Army Surgeon General at the end of the following report week.

These data cover 55,382 evacuee patients received in the United States during the period 2 September 1950-31 December 1953. The inclusiveness of this period encompasses the complete duration of the Korean War, July 1950-July 1953. Since evacuees were received from other overseas areas as well as from, Japan-Korea, total counts are given in table 63 by category of personnel and by area of origin. Approximately 95 percent (52,613) of the 55,382 evacuee patients were U.S. Army personnel, of whom 73 percent (38,515) were evacuated from Japan-Korea. The mode of transportation was specified as being ship or plane, or both, for 55,163 evacuee patients. For U.S. Army personnel, the number was 52,424, of whom 38,347 were from Japan-Korea. The percentage distributions by mode of transportation are presented in table 64.

EVACUATION POLICY AND DAYS BEFORE EVACUATION

Aside from any limitations which might be dictated by the condition of the patient or by the availability of transport, one of the chief determinants for defining parametric values of the order of magnitude of evacuees is the length of the evacuation policy. At the beginning of the war, the evacua-

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tion policy was 21 days for hospitals in Korea and 120 days for hospitals in Japan. By September 1950, the evacuation policy for Japan was reduced to 60 days and, for a short period, to 30 days, returning to 120 days in October 1950. Because of the Chinese Communist intervention and the resulting influx of casualties from Korea, the evacuation policy was again lowered to 60 days in December 1950 until 19 January 1951, when it returned to 120 days and remained at that level throughout the war. In Korea, during the early period of heavy casualties, evacuation was determined, to a large extent, by the availability of beds and the number of wounded being received. Subsequently, the evacuation policy was increased to 30 days and, later, to 60 days. The evacuation policy for all other overseas areas was 120 days.

The evacuee patients received in the United States from 2 September 1950 to 31 December 1953 spent, on the average, 35 days in overseas medical facilities before evacuation as did U.S. Army personnel from all overseas areas. U.S. Army personnel originating from Japan-Korea, however, averaged about 32 days, slightly less than the overall average for all patients from all overseas areas, but markedly lower than the 42 days averaged by U.S. Army personnel from all other overseas areas, excluding Japan-Korea. These differences reflect the influence of the early days of the Korean War, when large numbers of wounded created a heavy pressure on the available bed capacity in Japan. It was necessary, in the last quarter of 1950 and in the first months of 1951, to evacuate many of the less seriously wounded Patients with minor wounds to make room for the more seriously wounded nontransportable cases. Consequently, a higher proportion of the less seriously wounded was evacuated rapidly upon entering the chain of evacuation and the number of days elapsed before evacuation was low, averaging 17 to 19 days for patients received from Japan-Korea in September and October 1950 and not exceeding 30 days until April 1951.

Another factor which contributed to the lower elapsed time before evacuation from Japan-Korea is the possibility that the duration of hospital stay, before the decision to evacuate the patient, may have been considerably lower for wounded patients than for patients hospitalized for disease conditions. Since all wounded patients originated in Korea, this factor, in itself, would diminish the time spent before evacuation for patients from Korea.

Figure 10 shows that, after April 1951, the average days elapsed before evacuation from Japan-Korea exceeded the average for the entire period, except for the months of September, October, and November 1951. As wounded admission rates declined and bed capacities in Japan were built up, sufficient capacity was on hand to return the less seriously wounded in Japan and return them to duty without draining away manpower through evacuation. Once the usual criteria for evacuation could be applied, the average duration before evacuation rose. For example, the average before evacuation was 19.6 days in 1950, 30.8 days in 1951, 39.1 days in 1952, and 46.4 days in 1953.

TYPE OF SPECIALIZED TREATMENT REQUIRED

The type of specialized treatment required for evacuee patients in hospitals of definitive treatment in the United States is shown. in table 65 for all evacuees received and in tables 66 and 67, in more detail, by category of admission, for U.S. Army evacuee patients. The three largest categories of specialized treatment were general surgery, general medicine, and neuropsychiatry. Excluding cases with type of specialized treatment not specified, approximately 36 percent of all evacuee cases from all overseas areas required general surgery. When amputations, hand surgery, neurosurgery, ophthalmologic surgery, orthopedic surgery, plastic and maxillofacial surgery, thoracic surgery, and vascular surgery are included, the percentage of cases requiring surgery increased to 59 percent, a condition to be expected considering the high proportion of wounded-in-action cases included. Cases requiring neuropsychiatric care comprised 11 percent of all evacuee cases with slightly more than half of the cases requiring closed ward care.

The cause of admission, whether for disease, nonbattle injury, or wounded in action, determines markedly the type of specialized treatment required. The more detailed data, as previously noted, are presented in tables 66 and 67 for U.S. Army evacuee patients by category of admissions. The former table is in terms of numbers of cases; the latter is in terms of percentages of type of specialized treatment required by category of admissions. This latter distribution provides, in effect, a probability table of the expected type of specialized treatment likely to be required among a given

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hundred evacuees by category of admission, when the "not specified" cases were excluded.

The variation in type of specialized treatment required according to category of admission is readily apparent from table 67. Of each 100 wounded evacuees, approximately 64 required general surgery, and about 97 required some type of surgery. Among each 100 Army nonbattle injury evacuees, 47 required general surgery and 85 required some type of surgery. But, among each 100 disease evacuees, only 15 required general surgery, and only 26 required some type of surgery.

Roughly, 9 percent of the nonbattle injury evacuees required specialized treatment for cold injury, largely frostbite. Of each 100 disease cases, 21 were evacuated to the United States to receive specialized treatment for neuropsychiatric conditions.

The wounded evacuees reported its requiring certain types of specialized treatment for disease conditions, such as arthritis (two cases), neurosyphilis (one case), general medicine (456 cases), neuropsychiatry (40 cases), dermatology (two cases), and tuberculosis (seven cases), presumably represented cases hospitalized for wounds and for disease concomitantly, with the disease condition being reported as the primary cause of evacuation although

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the case was classified as a battle casualty on the basis of the primary cause of admission. The same comment is applicable to the 18 wounded cases reported as requiring specialized treatment for cold injury.

The classification by type of specialized treatment, however, does not provide a count of the number of cases of certain categories of considerable special interest; namely, the amputees, the paraplegics , the blind, and the deaf. Some cases of blindness are included under the category blindness," but some might be classed elsewhere; for example, in a case where a penetrating wound resulted in loss of an eye and also in some brain damage, the specialized treatment might be classified as "neurosurgery" rather than "blindness." Likewise, amputees ordinarily would be reported by specialized treatment as "amputations," but some small number might have been included elsewhere; for example, as general surgery cases. This is also true of the evacuees suffering from deafness. Paraplegics cannot be separately identified by consideration of specialized treatment alone.

Because of the difficulty in identifying certain of these groups from any distribution by type of specialized treatment, cases that fall into these particular categories must be identified separately, taking into account the actual diagnoses and operations reported. Among the 52,613 U.S. Army evacuees reported to The Surgeon General for the period 2 September 1950-31 December 1953 were 1,354 major amputations of one or more of the upper and lower extremities, 111 hemiplegics, 247 paraplegics, 178 blindness involving both eyes, 1,325 blindness involving one eye only, 314 deafness involving both ears, and 299 deafness involving one ear only (154 of these cases also had defective hearing in the other ear). These disabilities totaled 3,828 and involved somewhat less than 3,800 individual patients.

Nearly all of these cases originated in Japan-Korea; for example, 1,306 amputations, 98 hemiplegics, and 227 paraplegics were evacuated from the Far East Command (Japan-Korea). With respect to blindness, 1,253 of the cases involving one eye and 161 of those involving both eyes were evacuees from Japan-Korea. Unlike the other disabling conditions, it substantial proportion of the evacuees with deafness originated in areas other than Japan and Korea, although 193 of the 314 evacuees with deafness involving both ears, and 161 of the 209 involving one ear originated in Japan and Korea. Of the 161 cases of deafness, 67 also had defective hearing in the other ear. A total of 3,399 disabilities of those special categories were reported for almost the same number of individual patients evacuated from Japan and Korea.

CATEGORY OF ADMISSION

For U.S. Army evacuee cases, table 68 shows the respective category of admission (disease, nonbattle injury, and wounded) for all overseas areas, for Japan-Korea, and for all other overseas areas excluding Japan-Korea. Disease cases accounted for 49 percent, nonbattle injury for 14 percent, and

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wounded in action for 37 percent of all Army evacuees for all areas combined.

All of the wounded evacuees, of course, originated from Japan-Korea; of each 100 U.S. Army evacuees from the Far East Command, 51 were wounded cases, 34 were disease cases, and 16 were nonbattle injury cases.

As one should expect, the flow of wounded evacuees fluctuated with the tactical situation. This may be seen graphically from the data included in figures 11 and figure 12. The greatest number of wounded evacuees were received in September and October 1950 and again in December 1950 at the time of the Chinese Communist Intervention (fig. 11). During the first 2 months, three of each four evacuees received in the United States were wounded patients. In December 1950, one of each two evacuees received was wounded. Throughout most of 1951, the majority of all evacuees received from Japan-Korea were wounded. Nonbattle evacuees exceeded battle evacuees in January and February 1951, when the number of nonbattle injury evacuees included increased numbers of cold injury cases.

Reflecting the start of truce talks in July 1951, the proportion of wounded evacuees dropped in August and September, but even in these months, such cases comprised about 40 percent of all Army evacuees from Japan-Korea (fig. 12). The number of wounded evacuees rose precipitously during October 1951 at the time of the U.N. offensive to secure Line JAMESTOWN on the western front.

The situation was reversed throughout the first 6 months of 1952, when the number of wounded evacuees dropped each month to a low of 94 in June 1952. The predominant cause of evacuation was then related to nonbattle causes and the number of wounded evacuees was as low as 21 percent and rose no higher than 40 percent in the first, 9 months of 1952. In October 1952, the Chinese Communists launched their largest attack of the year on the western and central fronts, increasing the proportion of wounded evacuees to 52 percent in the last quarter of 1952. During the first 6 mouths of 1953, wounded evacuees never exceeded 40 percent. However, their number increased to 48 percent in July and reached a peak at 58 percent in August, reflecting the last two enemy offensives in June and July 1953, before the signing of the Armistice agreement at Panmunjom.

SURGICAL OPERATIONS PERFORMED OVERSEAS

Data On the number of surgical operations performed overseas before evacuation are also presented, in table 68. Operations as defined for the purposes included, here do, not include all surgical procedures, such as debridement of wounds and transfusions. They do, however, include most other major and minor surgery. An operation was recorded, even though only one step of the operation (as in the ease of a surgical amputation) may have been performed overseas.

Approximately 18,925 Army evacuees required surgical operation overseas before evacuation to

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U.S. hospitals of definitive treatment. This total represents an impressive overseas surgical workload since approximately 36 percent of all Army evacuees from all overseas areas required some surgical procedures before evacuation. In Japan-Korea, 45 percent of all evacuees were subjected to some surgical procedure before evacuation from overseas as contrasted with 10 percent requiring prior operation Overseas among evacuees originating in all overseas areas other than Japan-Korea.

The high proportion of operations performed in Japan-Korea reflects the influence of the wounded evacuees who originated from this area. The proportions of disease cases requiring operation before evacuation in Japan-Korea and in all other overseas areas are notably consistent. The proportions requiring operation for nonbattle injury, however, are markedly higher for Japan-Korea. Of 19,465 wounded evacuees, 13,335 (69 percent) required some surgical procedure before evacuation to the United States.

CAUSATIVE AGENTS

Analysis of the 19,465 evacuee cards for wounded cases by causative agent (table 69) shows that, as in World War II, explosives and fragmentation weapons accounted for more than half the cases; in this instance, 59 percent.

However, this proportion for wounded evacuees is somewhat smaller than the 66 percent shown in table 40 for all nonfatal wounds of both World War II and the Korean War.

Shell fragments of unspecified explosive projectile shells alone accounted for approximately one-fourth of all wounded evacuees. The specified explosive projectile shells, (artillery, mortar, and bazooka) caused another 17 percent of the casualties, so that the two categories combined, specified and unspecified explosive projectile shells, were the causative agents for roughly 41 percent of the battle casualties evacuated. This compares to explosive projectile shells of 58 percent for the overall World War II distribution of nonfatal wounds and 51 percent overall for Korea. Other types of explosives and, fragmentation weapons accounted for 18 percent (the balance for this group), including grenades (6 percent) and land mines (5 percent) for wounded evacuee patients. A similar distribution for all nonfatal wounds, for World War II, was 9 percent for the balance, including 2.5 percent for grenades

and 3.4 percent for land mines. For Korea, the remaining distribution for fragmentation weapons was 15 percent, of which 9.0 percent was grenades and 3.5 percent was land mines.

The proportion of battle wounds caused by small arms weapons among the evacuees is considerably higher than the 20 percent experienced in World War II, and even surpassed the 27 percent for small arms included in the overall distribution of nonfatal wounds for the U.S. Army, Korea. This difference, however, reflects partly the comparative lack of enemy aerial activity in support of enemy ground troops; thus, bombs, or other air-launched explosives, were not so significant a factor as a cause of casualties among U.S. Army personnel during the Korean War.

Another and more decisive factor for differences between the World War II and the Korean War small arms totals is the relative weight from evacuees incurring wounds in the earlier fighting in Korea; that is, before the buildup of Communist artillery.

Also of some interest is the fact that only 0.3 percent sustained burns from incendiaries and other chemical warfare agents serious enough to require evacuation. It is entirely probable that some battle casualty evacuees whose primary diagnoses involved

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any of the other types of causative agent also sustained burns. These additional diagnoses and causative agents are not, of course, included with these data. However, an indication that burns are not a major factor may be derived from the fact that only 0.4 percent of the total traumatisms among wounded evacuees were evacuated because of burns.

Another item of interest in table 69 on causative agents is the proportion (3.3 percent) who were evacuated because of wounds caused by use of our own instruments of war. Included in this group of causative agents are explosions of weapons and ammunition and handling of weapons and ammunition.

TYPE OF TRAUMATISM AND ANATOMICAL LOCATION OF WOUND

Of all traumatisms among the 19,465 U.S. Army wounded, evacuees, 90 percent fell into the two main categories of fractures and wounds. Compound fractures represented approximately 50 percent of all traumatisms while wounds of all types were about 35 percent. The distribution, by type of traumatism is shown in, table 70.

Table 71 shows the number and percent distributions by anatomical location of wound for U.S. Army wounded evacuees for the complete period, 2 September 1950-31 December 1953, and for seven elected periods. If one compares the two periods before the peace talks began in July 1951 with the four periods after that date ending in June 1953, it will be observed that the proportion of wounds involving the head, face, and neck increased while the proportion of wounds involving the upper extremities decreased. Wounds of the trunk area, (thorax, abdomen, pelvis, and spinal cord) and of the lower extremities remained relatively unchanged.

The increase in the proportion of head wounds, as previously noted in the section on "Anatomical Location of Wounds and Tactical Operations" included in chapter three, resulted from the change in the character of fighting from a mobile combat situation to defense of fortified lines. This, of course, required the individual soldier to expose his head more often than any other part of his body.

TIME FROM WOUNDING TO FIRST MEDICAL CARE

Table 72 presents a cumulative percentage distribution of the elapsed time from wounding to first medical care.

This period of time is defined as extending from the time of wounding as recorded in the diagnosis space on the Emergency Medical Tag (WD AGO Form 8-26) (4) to the time shown on that same record as "hour tagged," usually the time of admission to an aid station.

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The data in table 72 are based on the records of 9,549 of a total of 19,465 Army wounded evacuees received in the United States on whom the time wounded and the time first admitted to medical care were specified. The remaining 9,916, or 51 percent, of the total battle casualties received in the period 2 September 1950-31 December 1953 did not have one or both of the time periods specified on their evacuee report cards.

For the cases with specified information, slightly more than 58 percent received medical care during the first 2 hours and slightly more than 85 percent during the first 6 hours after wounding. The median number of hours between the time of wounding and first, medical care was about 1½ hours; that is, half of the cases for which data are available obtained their first medical care within the first 1½ hours after being wounded.

TIME FROM WOUNDING TO FIRST HOSPITALIZATION

Another measure of the time elapsed from wounding to medical care is afforded by consideration of the number of days elapsed before hospitalization. Data were reported in this connection for 17,503 of the 19,465 Army, wounded evacuees received in the United States during the period 2 September 1950-31 December 1953. The necessary information was not specified for 1,962 of the cases, or about 10 percent of the total received.

In the entire period, 55 percent, of the Army wounded evacuees were hospitalized on the same day wounded, 30 percent were hospitalized on the first day following, 6 percent on the second day following, and 9 percent on the third day or later (table 73).

The method by, means of which this type of information was gathered wounded in action patients who became evacuees should be noted, however. Only the date, not the precise hour, was specified in reporting the length of interval between wounding and hospitalization. Thus, a patient, wounded late in a 24-hour day during one of the frequent Communist night attacks (for example, at 2100 hours), might be admitted to hospital only 4 hours after wounding (at 0100); yet he would be reported as having been hospitalized the day following wounding, not the same day wounded.

The overall percentages for the complete period are somewhat misleading. During the first months of the Korean War particularly, the fluid tactical situation sometimes interfered with early hospitalization of patients. Some clearing stations were used in a role other than their conventional one of evacuating patients to hospitals. The overall percentages for the complete period are, therefore, affected by heavy weighting of evacuees wounded in the first 9 months of the war (see table 74). Moreover, throughout the war, many patients were treated and returned to duty at echelons forward of the surgical and evacuation hospitals, particularly at the clearing station. Some patients temporarily held for treatment in forward installations undoubtedly were found to require evacuation.

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If time from wounding to first hospitalization is considered in intervals of 6-month periods, as in table 73, a considerably different picture is presented. For example, the percent hospitalized on the same day wounded rose from 34 percent for July-December 1950 to 76 percent in January-June 1952. Thereafter, the percent hospitalized the same day remained constant at about 72 to 73 percent.

The monthly fluctuations in the percentage of wounded in action cases hospitalized within specified numbers of days are shown in table 74. The percentages shown are cumulative within any 1 month, reading from left to right.

It will be noted that, beginning in April 1951, the percentage of wounded in action evacuees hospitalized on the day wounded at all times was at, or above, the average of 55 percent shown for the complete period.

Similarly, except for May 1952, the cumulative percentage hospitalized on the day wounded and

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the first day following wounding, from March 1951 on, exceeded, the average of 85 percent for the complete period. An explanation of the drop in the percentage hospitalized in May 1952 is not discernible; the number of cases involved, however, is small, and the percentage may only be indicative of chance variation.

The changed character of the war is, of course, reflected in the increasing proportion hospitalized on the day wounded and the day following. By March 1951, the United Nations Forces were again established north of the 38th Parallel. The campaign was becoming less a war movement and more fixed positional type warfare prevailed. Conditions were, therefore, more favorable to the rapid recovery and evacuation of wounded to forward hospitals.

In addition, the use of helicopters for evacuation of the seriously wounded in need of immediate surgical treatment markedly affected the percentage of those hospitalized on the day wounded or on the day following.

In September and October 1951 during heavy fighting for possession of "Heartbreak Ridge" and the, "Punchbowl," and the major offensive in October 1951 to secure Line JAMESTOWN, 93 percent and 97 percent, respectively, of all the wounded during these 2 months were hospitalized on the same day they were wounded or on the following day.

Furthermore, during August and September 1952 when bitter battles waged for "Old Baldy," "T-Bone," and "Bunker Hill," and during the following month of October 1952 when the Chinese Communists launched a major attack on the western and central fronts, the percentage of wounded hospitalized on the same day or the day following wounding was 99 percent during August, 96 percent during September, and 94 percent during October. During 1953, these percentages ranged from 96 to 100 percent for wounded hospitalized on the same day or the day following.