The Chain of Evacuation of The Royal Army Medical Corps
A man's chances of survival depended on how quickly his wound was treated. Modern warfare was now producing vast numbers of casualties requiring immediate treatment at the same time. This necessitated an efficient system that could immediately address a patient’s critical injuries close to the Front and then evacuate him to a medical unit in a safer zone. This network is known as the Medical Chain of evacuation or evacuation chain.
The secret of success in treating large numbers of casualties was rapid evacuation.
“All through the chain of Medical Units from the Front to the Base the wounded man is kept the very minimum of time to attend to his wounds, and then he is moved on, and kept on moving, until he reaches either the Base or Home..... The reason for rapid evacuation is twofold. Firstly, it is very bad for morale if troops see wounded men lying about in large numbers; and, secondly, unless Medical Units are cleared they lose their mobility, and also cannot deal with a fresh influx of wounded that might come in quite unexpectedly - e.g. from a surprise counter-attack.”
[Lt/Col T B Nicholls R.A.M.C. ‘Organization, Strategy and Tactics of The Army Medical Services in War’]
The rapid and successful evacuation of any casualties, whether on a battlefield or in civilian life, depends on three interdependent factors - time, space and transport.
Time involves how quickly wounds receive first aid so infection does not set into the wound, and/or the casualty does not bleed to death. It also involves how quickly the casualty can get to someone with specialized knowledge or with specialist equipment. Abdominal wounds, for example, need to be operated on within six hours in order for the patient to survive.
Transport involves what type of equipment can be used and/or is readily available to transport the casualty away from danger and to an appropriate medical facility. This process could involve the soldier walking or being transported on stretchers, horses, cars, trains, barges or ships.
Space involves what is happening in the immediate area such as: how close can emergency services get without becoming casualties themselves? What is topography and how does it help or hinder? Is there enough space to set up a large medical facility close by or is there only enough room for a small one?
With the above in mind, other factors had to be considered:
• Mobility: All medical field units needed to be able to move at a moments notice. This was essential to ensure the fighting units had medical support during an advance or retreat. The procedure for a significant advance was for each medical unit to move forward to one already up and running in front of them. Therefore, the Regimental Aid Post would move forward in line with the fighting soldiers. An Advanced Dressing Station would then move forward to a Regimental Aid Post. The Main Dressing Station would move forward to an Advanced Dressing Station. A Casualty Clearing Station would move forward to a Main Dressing Station, and a Stationary Hospital would move to fill the gap between the Casualty Clearing Stations and the General Hospitals near the ports. In a retreat the procedure would be same but in the opposite direction. This was achieved by a small ‘light section’ of each unit moving forward immediately. They would provide care for the serious cases still housed in the unit ahead who were unable to be moved. The rest of the unit would then evacuate less serious cases, then would close, pack up and move.
• Distances between medical units: Sometimes the nature or physical features of the area (due to unsuitable topography for motor transport, bad weather, or deteriorated land due to heavy shelling) prevented medical units from getting optimally close. In these situations Relay and/or Collecting Posts were set up where patients could be collected and transported by horse drawn ambulances. (These will be explained further in the Field Ambulance and Casualty Clearing Station sections)
• Overlapping areas: During a major offensive, the front Line might cover some 5 to 6 miles with many Corps/Brigades/Regiments involved, all of which would have had their own pre-allocated medical support. In situations where the areas of advance were narrow, it was inevitable that their medical support would overlap. In these cases medical units from different Divisions would either work together as one, or perhaps two or three different medical units would set up in one specific location.
• Co-Operation: It was imperative that the medical evacuation chain did not hinder the fighting troops going into action or prevent them from getting to their ammunition, and vise-versa. Also the Medical Services was reliant on other branches of the army to supply materials to build Dressing Stations, construct roads, railway sidings, and/or provide telephonic communications.
• Before the start of any major offensive the Directors and Assistant Directors of Medical Services (DMS and ADMS) who were appointed to oversee in the offensive held a conference to discuss all the above factors before setting up the evacuation chain for that sector.
Collecting Zone: Regimental Aid Posts and Field Ambulances
Regimental Aid Post. [RAP] and the role of the Regimental Medical Officer [RMO]
“I should not advise anyone with any desire to practice their surgical or medical skill to take on the job of medical officer to a battalion, but from the point of view of seeing the war, understanding military methods and the spirit of the men it is the best post open to a medical man..... The only diseases the M.O. is called upon to treat are slight sprains, myalgia, and last, but not least, diarrhea.... Sanitation is, perhaps, the most important work that the M.O. is called upon to perform.”
[Lt A Noel Garrod R.A.M.C. ‘Notes on the Existence of a Regimental M.O. - At the Front’]
Duties of the RMO: During the war every fighting unit (infantry battalion, artillery brigade or cavalry regiment) had it’s own doctor [or RMO]. He was RAMC but came under the commanding officer of the fighting unit he was attached to. The doctor’s role was not only to attend to medical matters but also matters of hygiene, which meant water supply, the preparation of food, and the supervision of sanitary areas all came under his control. The doctor’s daily routine usually began with him doing an inspection of the sick. He then inspected the camp or billets, and the cook houses. The rest of the day would be taken up with the training and supervision of water cart orderlies and stretcher-bearers. To assist him in his duties he would have had an RAMC Sergeant or Corporal attached to him and perhaps 1 or 2 RAMC Privates. When away from the Front Line, the doctor’s post was known as the Camp Reception Station [CRS] or Medical Inspection Room [MI Room] and contained 2 - 6 beds for short term holding for those needing rest but was not sick enough to be evacuated back.
“A good M.O. to a battalion was a privileged and important officer. He was usually on intimate terms with his colonel, a friend to all his brother officers, and friend and confidant as well as doctor to the rank and file. Often and often I noticed that a battalion with a first-class M.O. was always a first-class battalion, had the smallest sick parade, fewer men falling out on a long march and the lowest quota of casualties from trench foot.”
[Capt Philip Gosse R.A.M.C. ‘Memoirs of a Camp-Follower’
Function of the RAP: When in the trenches the doctor’s post was the RAP. The objective of the exercise was to patch up the wounded and either return them to their duties in the line or pass them back to a Field Ambulance. The RMO had the same staff as mentioned above but this became augmented by a designated number of Stretcher-Bearers. These Regimental Stretcher Bearers came from the fighting unit the RMO was attached to, usually the regimental bandsmen. When under pressure, the RMO could be further assisted with bearer teams from a Field Ambulance. Every soldier had a special pocket in his uniform for his issued ‘First Field Dressing.’ It contained antiseptic pads and two bandages (one for entry wound, one for exit) in a waterproof cover. This dressing was applied by a regimental stretcher-bearer, a comrade, or by the wounded soldier himself, if he was able, in the firing line. If the wounded man was unable to walk, he was carried back via hand or wheeled stretcher to the RAP. The regiment stretcher-bearers had then fulfilled their duty, and it became the RMO’s responsibility for receiving the wounded man, and treating him by checking the dressing, overseeing the splinting of fractures, and ensure everything was being done to stop the patient going into shock. If morphine was given or a tourniquet applied, the soldier’s forehead was marked with a “M” or “T”. If required he would undertake an emergency amputation but large operative treatments were discouraged so close to the fighting and danger. The RMO also completed a Field Medical Card for each patient and fixed it firmly to the patient—generally attaching it to a button by its attached string. This card included the soldier’s name, rank, and unit, a diagnosis, and any special treatments (like operations) performed. As the patient moved down the evacuation chain, the Field Medical Card remained with him so that information could be added to it and his full treatment could be known. The patient was then taken to a designated collecting area to be picked up by stretcher-bearers of the Field Ambulance.
Equipment: According to Dr John S G Blair “The basic MO’s drug box in 1914 included phenacetin for headaches, Adrenaline in injectable form, 0.0003gm, one dose to be used as a stimulant.... Dover’s powders for colds, Bismuth salicylate for the stomach, cough medicine, a light aperient calomel, and a strong one, unspecified; quinine sulphate, 2gr (60mg) as a tonic, lead and opium tablets to be made into a lotion as an application for sprains or as an anti-diarrhoeal and, for the doctor to hold safely, morphine sulphate gr 1/4 or grl 1/2 (15 or 30mg). Morphine was to be given “under the tongue or by injection.” There were also methylated spirits, iodine, boric lotion and carbolic acid 1 part in 60 as antiseptics for wounds, Lastly there was sal volatile, to be given for ‘fainting, a few drops in water’.”
[Dr John S G Blair ‘Centenary History of The Royal Army Medical Corps].
Equipment at the RAP was supplied by the Field Ambulances and normally consisted of a primus stove and a beatrice stove, along with an acetylene lamp, anti-tetanus serum, assorted bandages, blankets, Boric ointment, cotton wool, first field dressings, plain gauze, shell dressings, Sulphur ointment and a vermoral sprayer. There was also reserve boxes of all of the above, and a hamper containing medical comforts such as brandy, cocoa, bovril, oxo, biscuits etc.
Site (time and space):
Location requirements: The site of the RAP came under the concern of the officer commanding the fighting unit. It was ideally situated a few metres behind the front line, but near the regiment’s headquarters so the RMO could be provided with early information about the tactical situation. It was also to be located central so it could be easily accessed from any part of the front line in which the regiment is engaged by the wounded. Also in a place that was sheltered to protect all from enemy fire, and easily accessible to the field ambulances who were next in the line of evacuation.
Typical facility: RAP’s were usually situated in a dugout, in a communication trench, a ruined house, or a deep shell hole. In areas where constant fighting had occurred over a long period of time, such as Ypres, there was very little cover left so a RAP might have been set up behind a burnt out tank. RAP’s had no holding capacity for the wounded. If the engagement was successful then the RMO moved forward and searched out another area which would come into the above criteria. A yellow flag was put up so that the wounded could find it and runners might be expected to run back to advise the ADMS and the Field Ambulances of the new location.
Transport: The RMO was equipped with a horse for his personal use, and a Maltese Cart (a two-wheeled cart suitable for conveying a lying patient) and driver. Alternatively these might have been a light motor van and a small motor-car or a motor-cycle combination. As noted above the RAP would have stretchers for hand carriage and/or wheeled stretchers.
The Field Ambulance (of infantry divisions)
To be continued.....